Dispute Develops Over Discount Drug Program
By ANDREW POLLACK
When a private oncology practice in Memphis formed a partnership with a nearby hospital in late 2011, the organizations proclaimed that the deal would “transform cancercare” in the region.
What they did not emphasize was that the deal would also create a windfall for them worth millions of dollars a year, courtesy of an obscure federally mandated drug discount program.
The program, known as 340B, requires most drug companies to provide hefty discounts — typically 20 to 50 percent — to hospitals and clinics that treat low-income and uninsured patients.
But despite the seemingly admirable goal, the program is now under siege, the focus of a fierce battle between powerful forces — the pharmaceutical industry, which wants to rein in the discounts, and the hospitals, which say they might have to cut services without them.
One issue is that the program allows hospitals to use the discounted drugs to treat not only poor patients but also those covered by Medicare or private insurance. In those cases, the hospital pockets the difference between the reduced price it pays for the drug and the amount it is reimbursed.
That is what happened in Memphis. When the West Clinic teamed with Methodist Healthcare, the huge volume of chemotherapy drugs used by the clinic suddenly qualified for the hospital’s discount, while reimbursement remained the same.
In a report issued on Tuesday, pharmaceutical industry trade groups say that some hospitals have gone overboard in using the program to generate revenue, straying from the original intent of helping needy patients. The report, which was supported by groups representing pharmacies, pharmacy benefit managers and oncology practices, called for the discounts to be more narrowly focused.
Some senior Republicans in the House and Senate are investigating the program, which they say has suffered from murky rules and lax enforcement.
Study Points to Shorter Treatments for Prostate Cancer
By ANDREW POLLACK
Men with high-risk prostate cancer treated with only 18 months of hormone therapy live just as long as those treated for a more standard 36 months, a new study has found.
If the study results are applied in practice, it could mean much shorter treatment, sparing men months of unpleasant side effects, researchers said Tuesday.
“This may well change the standard of care,” said Dr. Bruce J. Roth, a prostate cancer specialist at Washington University in St. Louis. “Three years of hormonal therapy was almost picked randomly, and there’s nothing magical about that duration.”
Dr. Roth was not involved in the study, but he moderated a news conference for the Genitourinary Cancers Symposium, which will take place starting Thursday in Orlando, Fla., and is where the results will be presented.
Hormone therapy is essentially chemical castration, in which drugs are used to block the body’s production of testosterone, which fuels prostate tumor growth.
The side effects, including hot flashes, loss of sexual desire, fatigue and the weakening of bones and muscles, make life “quite miserable,” said Dr. Abdenour Nabid of Sherbrooke University Hospital Center in Sherbrooke, Quebec, who was the lead investigator.
The study involved 630 patients with localized but high-risk prostate cancer who were treated with radiation therapy and hormone therapy. While that description fits only a small portion of the 240,000 new cases of prostate cancer diagnosed each year in the United States, the results would still apply to thousands of men, researchers said.
After a median follow-up of about six and a half years, 77.1 percent of the men who received 36 months of therapy were still alive, as were 76.2 percent of the men treated for 18 months.
Government says it recovers billions in health fraud crackdown
The Obama administration says it recovers $4.2 billion, a one-year record, from Medicare providers and others who falsely billed the government.
By Noam N. Levey, Washington Bureau
7:22 PM PST, February 11, 2013
The 2012 tally — which surpassed the $4.1 billion the government reclaimed the previous fiscal year — extends a years-long trend and reflects efforts by the Obama administration to crack down on healthcare fraud.
The president's healthcare law includes new initiatives to weed out fraudulent medical providers and bar them from receiving Medicare reimbursements.
"Our historic effort to take on the criminals who steal from Medicare and Medicaid is paying off: We are gaining the upper hand," Health and Human Services Secretary Kathleen Sebelius said in a statement.
Over the last four years, enforcement efforts have yielded $14.9 billion, up from $6.7 billion over the previous four years, the administration said.
The Justice Department, which is working closely with the health agency to reduce fraud, also reported that 826 people were convicted of crimes related to healthcare fraud last year, another record.
Despite the stepped-up enforcement, independent analyses continue to find holes in the federal government's anti-fraud efforts.
Last month, the Health and Human Services Department's inspector general reported that an initiative designed to identify waste and abuse in Medicare's drug benefit program and Medicare Advantage had managed to find just a handful of cases. About a quarter of Medicare beneficiaries receive their benefits through Medicare Advantage, which allows private insurance companies to contract with the government to administer benefits.
http://www.latimes.com/health/la-na-health-fraud-20130212,0,5850022,print.story
Tax help comes with health insurance advice
H&R Block is using customers' 2012 returns to advise them of their options under the Affordable Care Act and possible penalties they can face without insurance.
By Chad Terhune, Los Angeles Times4:21 PM PST, February 11, 2013
Derrick Bean filed his income taxes at an H&R Block office in Los Angeles this month, and the 26-year-old left with something unexpected: a price quote on federally subsidized health insurance.
Using the information from his 2012 return, a tax advisor told the actor and waiter that he would qualify for significant government help and pay only about $65 a month in premiums under the federal healthcare law. If he skips coverage, H&R Block warned him, he faces a $95 tax penalty next year and $356 the following year.
"I was surprised to hear all that," Bean said. "It's good to finally see some concrete evidence that this is happening."
Quiz: Test your healthcare knowledge
As tax season kicks into high gear across the country, millions of Americans are getting their first taste of the biggest change to health insurance in nearly half a century. Many of the changes in President Obama's Affordable Care Act take effect in January, when most Americans will be required to buy coverage or incur a penalty.
The individual effects and consequences of the nation's healthcare overhaul in 2014 are far from certain, but insurance companies, tax consultants and other financial planners are starting to offer cost estimates for next year and describe the penalties for inaction.
For many consumers, their 2012 tax returns will offer some of the first clues on what financial aid may be available and what coverage may cost.
"Your 2012 tax return is key to determining if you're eligible for any financial assistance on health insurance," said Meg Sutton, senior advisor for tax and healthcare services at H&R Block. "This law represents sweeping changes for how the middle class will get insurance."
The Internal Revenue Service and state insurance exchanges will rely primarily on 2012 federal tax returns, officials say, to verify people's income and household size and to help determine what premium subsidies are available. By October, exchanges in California and other states are slated to open for enrollment and allow comparison shopping of health plans.
In California, individuals earning up to about $15,000 will qualify for an expansion of Medi-Cal, the state's Medicaid program for the poor and disabled.
Beyond that, people and households earning up to 400% of the federal poverty level are eligible for subsidies. For instance, a family of four earning about $93,000 in modified adjusted gross income may be eligible for a monthly credit of $445 and pay $742 a month for health coverage. In 2014, the penalty for not having coverage is $95 per adult or 1% of household income, whichever is greater. The penalties grow in subsequent years.
An estimated 2.6 million Californians would qualify for premium subsidies, and nearly 800,000 of them are in the Los Angeles area, according to state data.
At an H&R Block Inc. office on Wilshire Boulevard in Los Angeles, Cindy Salcedo Bravo, 35, flipped through a stack of drugstore receipts on a recent Friday morning as her 8-month-old son, Fernando, bounced on her knee.
She rattled off dollar amounts to her tax advisor, who tallied them for a potential deduction on medical expenses. Then they sorted through W-2 forms, investment statements and other paperwork.
As they wrapped up, tax advisor Blanca Chavez began the company's free health insurance review by asking the Northridge mother whether her family of six had health coverage.
http://www.latimes.com/business/la-fi-tax-return-health-20130212,0,2349104,print.story
Do you really need an annual physical? Benefits are hard to prove
Posted Feb. 13, 2013, at 9:48 a.m.
My husband hasn’t seen a doctor in at least five years. His last visit came when I insisted on taking him to the emergency room for help extracting a shard of wood he’d accidentally stepped on. Dave, a former athlete in his early 40s, is a fit, healthy nonsmoker. He’s never had an annual physical, and he doesn’t see any need to start now.
Once upon a time, an annual physical was just something you did if you cared about your health (and had the insurance to pay for the exam). But a recent review by researchers at the Nordic Cochrane Centre in Copenhagen suggests that my husband’s “wait for a reason” approach may be perfectly wise.
Researchers examined the most rigorous studies they could find (14 in all) comparing people who received so-called general health checks and those who didn’t, some 182,000 people in all. Their analysis found that routine medical exams failed to reduce overall deaths, disease-related deaths, hospitalizations or costs.
The Cochrane review isn’t the first to question the effectiveness of the annual exam. A 1979 Canadian panel convened by the government concluded that “the routine annual physical examination should be discarded in favour of a selective plan of health protection packages appropriate to the various health needs at the different stages of human life.” The U.S. Preventive Services Task Force does not advise for or against annual exams; instead, it makes age-specific recommendations about which screening tests you need and when, says Michael L. LeFevre, a physician at the University of Missouri and co-vice chair of this independent group of national experts.
Even without formal recommendations, many Americans continue to see their doctor once a year, whether they have symptoms or not. The 2009 National Ambulatory Medical Care Survey showed that general medical exams were the No. 1 reason people visited their doctors.
The annual physical became popular, in part, because it seems so logical that a regular exam might catch medical problems before they get out of hand, says Ateev Mehrotra, a health policy researcher and physician at the University of Pittsburgh School of Medicine. But given the lack of evidence that the yearly ritual improves health, he says, “my own view is that the medical community should no longer encourage patients to receive an annual physical.”
It’s not just that these exams are unlikely to help the patient, Mehrotra says. They come with potentially serious downsides, too.
For patients, the negatives include time away from work and possibly unnecessary tests. “Getting a simple urinalysis could lead to a false positive, which could trigger a cascade of even more tests, only to discover in the end that you had nothing wrong with you,” Mehrotra says.
There’s also potential for false assurance that everything is okay, which may lead people to ignore or minimize new symptoms. “You may come in and have a completely fine bill of health, and three months later you develop leukemia,” says physician Christine Laine, editor of Annals of Internal Medicine. “Unfortunately, we can’t prevent that from happening.”
Study: No link between readmitting hospital patients and saving lives
Posted Feb. 13, 2013, at 9:52 a.m.
Some hospitals with high readmission rates say they’re saving lives by bringing patients back at the first hint of trouble. The evidence for this is that a handful of hospitals with high readmission rates also have extremely low death rates among Medicare patients.
But a study published Tuesday finds that there’s no major link between hospitals with high readmissions and those with low mortality rates. The findings come as Medicare ramps up financial penalties for hospitals with higher readmission rates in an effort to improve quality and contain costs.
Writing in the Journal of the American Medical Association, researchers found no relationship between readmissions and mortality rates for Medicare patients who had heart attacks or pneumonia between 2005 and 2008. The paper did find a “modest” inverse relationship between readmissions and death rates for heart failure patients, where hospitals with low death rates tended to have somewhat higher readmission rates. But that was only for a small portion of hospitals and not strong even then.
“I feel we’ve dispelled the notion that your performance in mortality will dictate your performance in readmission,” said Dr. Harlan Krumholz of Yale University School of Medicine, the lead author of the study. “This result says they appear to be measuring different things, they’re not strongly related to each other and you can clearly do well on both.”
Krumholz does work for the Centers for Medicare & Medicaid Services (CMS) in developing and assessing measures of hospital quality, including the ones for readmissions and mortality.
His study has not quelled the debate among researchers, including ones from the Cleveland Clinic, who previously suggested that higher readmission rates might be the consequence of successful care.
Dr. Bruce Lytle, chairman of The Cleveland Clinic’s heart and vascular programs, said he considered the Krumholz’s finding about heart failure readmissions more significant than Krumholz gave it credit for. “He got very similar results from what we noted,” Lytle said. “He tends to feel it’s not a big inverse association. But big and small are a matter of interpretation.”
Medicare data released last year showed that two hospitals, Beth Israel Deaconess Medical Center in Boston and Olympia Medical Center in Los Angeles, had higher than average readmission rates for all three conditions that Medicare tracks publicly: heart attack, heart failure and pneumonia, but lower rates of mortality within 30 days of discharge for patients with those three conditions. Thirty-one hospitals other than Israel and Olympia had low mortality for heart failure patients even though they had high readmission rates.
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