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Tuesday, April 9, 2013

Health Care Reform Articles - April 9, 2013

Today's blog is catch-up day, and is therefore a little longer than usual.
-SPC

Where Does It Say the Supreme Court Has the Constitutional Power to Hike Medicine Prices to 5x Their Cost?

March 30, 2013  |  
The Supreme Court oral arguments on marriage equality deserved all the attention they received — but it’s another case heard this week that will affect even more people over the course of their lifetimes. And it could cost Americans millions in prescription drug bills.
The case falls within a sadly predictable continuum for the Roberts Court, which virtually always sides with the corporate litigant over the government or individual. This time, the arguments in FTC v. Actavis revolve around an insidious tactic common to the nation’s largest drug companies, and known as “pay for delay.” As a result of the likely ruling in this case, drug companies will be able to charge consumers as much as five times the potential cost of their products. And both government regulators and consumers will watch helplessly as pharmaceutical companies bribe generic drug makers to retain their exclusive holds on the lifesaving medicines we all inevitably require.
The first thing to know here is that U.S. pharmaceuticals get a very good deal from the federal government. For every new drug they produce, they get rewarded with long-term patents that grant them exclusive rights to market and sell the product for as much as 20 years – which guarantees them billions in profits and no competitors in the marketplace. Drug companies claim that they must be allowed to profit off of products they nurtured with expensive research and development. In reality, taxpayer-funded research from academia or the National Institutes of Health account for the vast majority of vital drugs brought to market every year, and R&D is a small fraction [2] of the overall drug company budget. What’s more, drug companies routinely use their monopoly power to jack up pharmaceutical prices, which cost far more in the U.S. [3] than anywhere in the world.
Congress tried to deal with this problem as far back as 1984. The Hatch-Waxman Act accelerated the FDA approval process for generic drugs, essentially copies of the brand-name products. Typically, generics sell at a much lower price – in most cases by 80-90 percent, which obviously makes them quite popular. So the introduction of a generic drug basically ends the profitability for the brand-name manufacturer, while delivering big benefits to the consumer. Under Hatch-Waxman, companies can sell generics before the expiration of the exclusive patent by successfully challenging the patents’ validity (and there are often grounds for such a challenge, as drug company lawyers often find every loophole imaginable to extend their patent life or acquire new patents for slightly different versions of the same drug).
http://www.alternet.org/print/drugs/where-does-it-say-supreme-court-has-constitutional-power-hike-medicine-prices-5x-their-cost


Using Medicaid Dollars for Private Insurance


By 

The Obama administration and Republican officials in several states are exploring ways to redirect federal money intended to expand Medicaid, the main public insurance program for the poor, and use it instead to buy private health insurance for Medicaid recipients. The approach could have important benefits for beneficiaries and for the future of health care reform. But the idea also carries big risks. Federal officials will need to enforce strict conditions before agreeing to any redirection of Medicaid dollars that were originally intended to enlarge the Medicaid rolls.
The Supreme Court ruled last year that the states could decide whether they want to expand their Medicaid programs to cover more of the uninsured; they can’t be required to do so, as the health reform law intended.
The law provides hugely attractive financial incentives for states to add more people. The federal government will pay 100 percent of the cost of caring for newly eligible enrollees for the first three years, tapering to 90 percent in later years. Even so, some state officials, mostly Republicans, are proposing that the very generous federal financing for expansion be used instead to pay the premiums of poor people on new electronic health care exchanges, created by the reform law, where people can shop for subsidized private insurance.
Private insurance obtained on the exchanges could help poor beneficiaries in several ways. They would be less vulnerable to disruptions every time their incomes fluctuated above or below the boundary line that determines whether they are poor enough to qualify for Medicaid, where they would see one array of doctors, or slightly better off and eligible for subsidized insurance on the exchanges, where they might see a completely different group of doctors. Providers would be paid the same amount whether treating a Medicaid recipient or a privately insured patient, potentially creating a wider network of doctors for Medicaid patients. And some poor residents of states resistant to expansion, who would otherwise be frozen out by a glitch in the reform law, could gain coverage through the exchanges.
But the main benefit would be political in that it could engage Republicans in the whole health reform effort, make it easier to carry out the law and reduce the appetite among Congressional Republicans to gut the law.
There are at least two big caveats. The switch would be likely to increase costs for the federal government, and ultimately state governments, because private insurance is almost always more costly than Medicaid. That could force a cutback in the number of people covered because the money won’t go as far. There is also a risk that poor people will end up with fewer benefits and higher cost-sharing on the exchanges despite regulations that should prohibit that.

Hospitals take on building projects despite MaineCare debt

By Jackie Farwell, BDN Staff
Posted March 31, 2013, at 6:44 a.m.
As drivers pass through Augusta on Interstate 95, Maine’s newest hospital comes into view just off Exit 113. Four stories of brick and gleaming glass now stand in what was once a grassy field, a $322 million project just months away from opening to patients as the Alfond Center for Health.
Just a few miles away, lawmakers continue a heated debate about how to repay Maine’s hospitals $484 million in overdue Medicaid bills dating to 2009. Hospitals have stressed the debt’s consequences — from layoffs to frozen wages to eliminated services — in pressing legislators to make good on the state’s long-standing IOU.
Yet a brand-new hospital still managed to be built in Augusta. Two of the state’s other large hospitals in Bangor and Portland also have embarked on multimillion-dollar construction projects.
All three hospitals have financed their projects without assuming that the state will repay the debt, as Gov. Paul LePage has vowed to do. Each pulled together enough capital and loans to get the projects off the ground, even as they’re waiting for Maine to pay up on tens of millions of Medicaid dollars.
Hospital executives say the projects represent needed upgrades that will better serve patients. Others question whether hospitals are being held accountable for all the growth, including employers frustrated by the higher costs that often follow.

Moving forward without MaineCare money

LePage wants the state to pay its $186 million share of the Medicaid debt, which would trigger a federal match of $298 million.
The debt piled up as hospitals served patients covered by MaineCare, Maine’s version of the Medicaid health insurance program for the poor, without being fully reimbursed by the state, which splits the bill for the program with the federal government.
While LePage and lawmakers remain at odds over how to repay the MaineCare debt, there’s no debate that the state has run up a hefty tab. Hospitals also are giving away more charity care and racking up additional losses from patients who can’t pay their medical bills.
Still, hospitals have managed to stay open and in many cases expand. Maine hospitals employed about 36,000 full- and part-time workers in 2011, a jump of about 2,400 from 2007, according to a January report by the American Hospital Association.
As the state fell short on its MaineCare payments, hospitals shifted the burden of those unpaid medical bills to people with private health insurance — namely, Maine’s employers, said Wayne Gregersen, who oversees employee health benefits at The Jackson Laboratory in Bar Harbor.
That “hidden tax” on employers has kept Maine’s hospitals out of debt, he said.
“When they get those overdue hospital payments, they’re just going to be floating in money. … As far as I’m concerned, they’re getting paid twice,” Gregersen said.


Posted March 30, 2013, at 1:22 p.m.
Gov. Paul LePage stirred up Twitter Wednesday afternoon when he pledged to give up his pension if Democrats in the Legislature had the hospital bill on his desk by Saturday. It’s unclear how serious LePage was about this pledge, considering he ended the tweet with “Ya mon,” a reference to his current trip to Jamaica, but it’s certainly not the first time the governor has made waves with a surprising or controversial comment. Here’s a selection of some of LePage’s ‘greatest hits’ from his time in the Blaine House and during his campaign for governor.
• March 1, 2013: “I don’t care if it’s my bills. I’ll veto my own bills.” — LePage promises to veto any bill that comes across his desk until the Legislature passes his plan to repay $484 million owed to the state’s hospitals.
• January 2013: “ You guys, you’re idiots and you’re just as bad if not worse than those other guys.” — LePage comparing independent lawmakers to Democrats during a meeting with three independent legislators on alternate approaches to balancing the state budget.
• Nov. 9, 2012: “ If you want a good education in Maine, and I get criticized by my opponents because I’m hard on education, but if you want a good education, go to an academy. If you want a good education go to private schools. If you can’t afford it, tough luck. You can go to the public school.” — LePage discusses school choice during an “Eggs ‘n Issues” talk at York County Community College.
• July 12, 2012: “ The Holocaust was a horrific crime against humanity and, frankly, I would never want to see that repeated. Maybe the IRS is not quite as bad — yet.” — LePage compares the IRS to the Gestapo during an interview with Seven Days, an alternative weekly newspaper in Burlington, Vt. He later apologized for his remarks.
• March 31, 2012: “That [criticism] is coming from a little spoiled brat from Portland. He’s very fortunate that his granddad was born ahead of him.” — LePage on Sen. Justin Alfond, D-Portland, when asked about Democratic calls for an investigation of the Department of Health and Human Services.
• March 15, 2012: “The press. Reading newspapers in the state of Maine is like paying somebody to tell you lies.” — LePage to a student who asked him what he didn’t like about his job during his appearance as keynote speaker at a Career Conversations event at Waterville Junior High School.
• March 25, 2011: “ I’d laugh at them, the idiots. That’s what I would do. Come on! Get over yourselves!” — LePage when asked what he would do if people formed a human chain to block the removal of the mural from the state Department of Labor.
• February 2011: “The only thing that I’ve heard is if you take a plastic bottle and put it in the microwave and you heat it up, it gives off a chemical similar to estrogen. So the worst case is some women may have little beards.” — LePage saying he has yet to see enough science to support a ban on BPA, a common additive to plastics that some research suggests may interfere with hormone levels and could cause long-term problems.
• Jan. 14, 2011: “ Tell them to kiss my butt.” — LePage to reporters in response to suggestions from NAACP members and others that his decision not to attend ceremonies honoring Rev. Martin Luther King Jr. was part of a negative pattern.
• September 2010: “As your governor, you’re going to be seeing a lot of me on the front page, saying ‘Governor LePage tells Obama to go to hell.’” — LePage telling a crowd of fishermen that, if elected, they could expect to see him stand up to the Obama administration.

A.D.H.D. Seen in 11% of U.S. Children as Diagnoses Rise


By  and SARAH COHEN

Nearly one in five high school age boys in the United States and 11 percent of school-age children over all have received a medical diagnosis of attention deficit hyperactivity disorder, according to new data from the federal Centers for Disease Control and Prevention.
These rates reflect a marked rise over the last decade and could fuel growing concern among many doctors that the A.D.H.D. diagnosis and its medication are overused in American children.
The figures showed that an estimated 6.4 million children ages 4 through 17 had received an A.D.H.D. diagnosis at some point in their lives, a 16 percent increase since 2007 and a 41 percent rise in the past decade. About two-thirds of those with a current diagnosis receive prescriptions for stimulants like Ritalin or Adderall, which can drastically improve the lives of those with A.D.H.D. but can also lead to addiction, anxiety and occasionally psychosis.
“Those are astronomical numbers. I’m floored,” said Dr. William Graf, a pediatric neurologist in New Haven and a professor at the Yale School of Medicine. He added, “Mild symptoms are being diagnosed so readily, which goes well beyond the disorder and beyond the zone of ambiguity to pure enhancement of children who are otherwise healthy.”
And even more teenagers are likely to be prescribed medication in the near future because the American Psychiatric Association plans to change the definition of A.D.H.D. to allow more people to receive the diagnosis and treatment. A.D.H.D. is described by most experts as resulting from abnormal chemical levels in the brain that impair a person’s impulse control and attention skills.
While some doctors and patient advocates have welcomed rising diagnosis rates as evidence that the disorder is being better recognized and accepted, others said the new rates suggest that millions of children may be taking medication merely to calm behavior or to do better in school. Pills that are shared with or sold to classmates — diversion long tolerated in college settings and gaining traction in high-achieving high schools — are particularly dangerous, doctors say, because of their health risks when abused.
The findings were part of a broader C.D.C. study of children’s health issues, taken from February 2011 to June 2012. The agency interviewed more than 76,000 parents nationwide by both cellphone and landline and is currently compiling its reports. The New York Times obtained the raw data from the agency and compiled the results.

Small Firms’ Offer of Plan Choices Under Health Law Delayed


By 

WASHINGTON — Unable to meet tight deadlines in the new health care law, the Obama administration is delaying parts of a program intended to provide affordablehealth insurance to small businesses and their employees — a major selling point for the health care legislation.
The law calls for a new insurance marketplace specifically for small businesses, starting next year. But in most states, employers will not be able to get what Congress intended: the option to provide workers with a choice of health plans. They will instead be limited to a single plan.
The choice option, already available to many big businesses, was supposed to become available to small employers in January. But administration officials said they would delay it until 2015 in the 33 states where the federal government will be running insurance markets known as exchanges. And they will delay the requirement for other states as well.
The promise of affordable health insurance for small businesses was portrayed as a major advantage of the new health care law, mentioned often by White House officials and Democratic leaders in Congress as they fought opponents of the legislation.
Supporters of the law said they were disappointed by the turn of events.
The delay will “prolong and exacerbate health care costs that are crippling 29 million small businesses,” said Senator Mary L. Landrieu, Democrat of Louisiana and the chairwoman of the Senate Committee on Small Business and Entrepreneurship.
In the weeks leading up to the passage of the health care legislation in 2010, Ms. Landrieu provided crucial support for the measure, after securing changes to help small businesses.
The administration cited “operational challenges” as a reason for the delay. As a result, it said, most small employers buying insurance through an exchange will offer a single health plan to their workers next year.

Low-Cost Drugs in Poor Nations Get a Lift in Indian Court


By  and 

NEW DELHI — People in developing countries worldwide will continue to have access to low-cost copycat versions of drugs for diseases like H.I.V. and cancer, at least for a while.
Production of the generic drugs in India, the world’s biggest provider of cheap medicines, was ensured on Monday in a ruling by the Indian Supreme Court.
The debate over global drug pricing is one of the most contentious issues between developed countries and the developing world. While poorer nations maintain they have a moral obligation to make cheaper, generic drugs available to their populations — by limiting patents in some cases — the brand name pharmaceutical companies contend the profits they reap are essential to their ability to develop and manufacture innovative medicines.
Specifically, the decision allows Indian makers of generic drugs to continue making copycat versions of the drug Gleevec, which is made by Novartis. It is spelled Glivec in Europe and elsewhere. The drug provides such effective treatment for some forms of leukemia that the Food and Drug Administration approved the medicine in the United States in 2001 in record time. The ruling will also help India maintain its role as the world’s most important provider of inexpensive medicines, which is critical in the global fight against deadly diseases. Gleevec, for example, can cost as much as $70,000 a year, while Indian generic versions cost about $2,500 a year.
The ruling comes at a challenging time for the pharmaceutical industry, which is increasingly looking to emerging markets to compensate for lackluster drug sales in the United States and Europe. At the same time, it is facing other challenges to its patent protections in countries like Argentina, the Philippines, Thailand and Brazil.
“I think other countries will now be looking at India and saying, ‘Well, hold on a minute — India stuck to its guns,’ ” said Tahir Amin, a director of the Initiative for Medicines, Access and Knowledge, a group based in New York that works on patent cases to foster access to drugs.
In trade agreements — including one being negotiated between the United States and countries in the Pacific Rim — the drug industry has lobbied for stricter patent restrictions that would more closely resemble protections in the United States.

A Prescription for Frustration


By ABIGAIL ZUGER, M.D.

Time spent in hospitals brings out the inner Chekhov in some doctors, the inner Che in others. Then there are the occasional hybrids, the storytellers who secretly plot revolution and the revolutionaries who wind up telling fairy tales.
One might argue that Dr. Leana Wen and Dr. Joshua Kosowsky belong to the latter group. At least, their impressive “When Doctors Don’t Listen” is a manifesto motivated by very active imaginations, not that this necessarily diminishes the book’s importance.
The authors, both emergency room physicians at Brigham and Women’s Hospital in Boston, do a fine job of sorting through most of the serious problems in American medicine today, including the costs, overtesting, overprescribing, overlitigation and general depersonalization. All are caused at least in part, they argue, by the increasing use of algorithms in medical care.
Algorithms are flow charts, created by groups ranging from individual hospitals to large professional organizations, dictating what tests doctors should order and what medications they should prescribe in hundreds of different situations. Deployed throughout medicine, the algorithms are perhaps used most frequently in emergency rooms, where any single word a patient utters may set off a long cascade of programmed activity.
Thus, people who say “fever” and “cough” are likely to find themselves being evaluated and treated according to a “pneumonia” algorithm; a mention of chest pain will land them on a “heart attack” algorithm. And such is the power of these decision trees that even if you are a circus employee and Jumbo the elephant has just stepped on your chest, the chances are that once you say “chest pain” you will wind up on that heart attack pathway, just in case.
There are good reasons behind this kind of rote decision making. The great river of suffering and complaint that churns through E.R. doors demands some kind of quickly imposed external order. Algorithms help standardize medical care and ensure that no life-threatening conditions are accidentally overlooked.
But doctors who use too many algorithms practice what is commonly disparaged as “cookbook” medicine — you combine ingredients like blood tests and CT scans, and out pops a diagnosis. (Or, more often, the absence of one: “Well, at least we know it wasn’t a heart attack!”) Even dummies can do it.
Group pushes for vote on single-payer health care in Colorado
By Michael Booth The Denver Post The Denver Post
Posted:
DenverPost.com
Even as state officials scramble to put in place major health reforms for 2014, a new proposal to guarantee medical care as a human right and create a single-payer system for all citizens is moving toward a Colorado vote.
Health Care for All Colorado and a current board member of the budding state health insurance exchange are pushing a citizen initiative to scrap the private insurance system.
The effort is separate from Sen. Irene Aguilar's bill proposing a statewide referendum on a "cooperative" that also would be a single-payer system, whose passage with a two-thirds majority is seen as having a slim chance.
The citizens group wants to press on, bypassing requirements for a legislative super-majority to directly test state sentiment on revolutionary fixes for gaps they say were left by 2010's national health reform.
"Access to health care is a human right, it's not something that should be bought and sold as a commodity," said Donna Smith, executive director of Health Care for All Colorado.
Skeptics and critics abound, even within the same progressive movement. Aguilar wonders why the organizers are competing with her effort, while conservatives deride universal coverage as an even worse idea than current big-government health reforms.
"Wait, I thought Obamacare fixed the health care system!" said Linda Gorman, health care analyst for the libertarian Independence Institute. The European and Canadian single-payer systems "are unbelievably expensive for what you get," Gorman said.
"They eliminate treatment and physician choice, make everyone wait for care, degrade the infrastructure needed to diagnose and cure disease, and result in widespread denial of care to those who are seriously ill," she said.

U.S. to boost rather than cut payments to health insurers

By , Published: April 1

The Obama administration reversed itself Monday, scrapping plans to cut by 2.2 percent the rates paid to health insurers that take part in the Medicare Advantage program.
The insurance industry and more than 100 members of Congress had objected to the cut in the per capita growth rate, which was proposed in February. They argued that the administration was using faulty methodology. The insurers mounted a vigorous campaign, using television ads and phone banks, to persuade lawmakers to oppose the reduction.
On Monday, the Centers for Medicare and Medicaid Services (CMS) announced that it was changing its method of calculating reimbursement rates. Instead of cutting payments for Medicare Advantage plans, it will increase them by 3.3 percent.
“The policies announced today further the agency’s goal of improving payment accuracy in all our programs, while at the same time ensuring program stability and preserving beneficiary choice,” Jonathan Blum, the CMS’s acting principal deputy administrator, said in a statement.
Twenty-seven percent of Medicare beneficiaries — about 13 million people — get their benefits through the private health insurers that make up the Medicare Advantage program, according to the nonpartisan Kaiser Family Foundation.
The cut would have been one of several directed at the Medicare Advantage program. The plans still face payment reductions and a new tax under the 2010 health-care law.
“Today, CMS rightly acted to reverse course and implement a responsible rate that will preserve choices and ensure continued access to top-notch quality and affordable care for beneficiaries enrolled in the popular Medicare Advantage program,” Sen. Orrin G. Hatch (R-Utah) said in a statement.


A little-known loophole in President Obama’s landmark legislation enables health insurers to extend existing policies for nearly all of 2014.
A new fight is brewing over health insurance companies letting millions of Americans renew their current coverage for another year — and thereby avoid changes under the federal healthcare law.
That may offer a short-term benefit for certain consumers and shield some of those individual policyholders from potentially steep rate increases. But critics say this maneuver could undermine government efforts to remake the insurance market next year and keep premiums affordable overall.
At issue is a little-known loophole in President Obama’s landmark legislation that enables health insurers to extend existing policies for nearly all of 2014. This runs contrary to the widespread belief that all health insurance must immediately comply with new federal rules starting Jan. 1, when most provisions of the law take effect.
“Insurers are onto this, and the big question is how many will try to game the system,” said Timothy Stoltzfus Jost, a law professor and health policy expert at Washington and Lee University.
Some of the nation’s biggest health insurers are looking to take advantage of this delay, and Arkansas officials are encouraging companies to do this by resetting customers’ renewal dates for the end of December. There’s also concern that some insurers and agents could rush to sell more individual policies before year-end so they could be extended in 2014.
Some policy experts are expressing concern about this practice for fear that insurers will focus on renewing younger and healthier policyholders and hold them out of the broader insurance pool next year. Their absence could leave a sicker and older population in new government insurance exchanges, driving up medical costs and premiums there.
“This could undermine the Affordable Care Act, and it opens the door for exacerbating potential rate shock in the exchanges,” said Christine Monahan, a senior analyst at Georgetown University’s Health Policy Institute. “The health insurers can cherry-pick some healthy people and it raises prices for everyone else.”

Dementia Care Cost Is Projected to Double by 2040


By 

The most rigorous study to date of how much it costs to care for Americans with dementia found that the financial burden is at least as high as that of heart disease orcancer, and is probably higher. And both the costs and the number of people with dementia will more than double within 30 years, skyrocketing at a rate that rarely occurs with a chronic disease.
The research, led by an economist at the RAND Corporation, financed by the federal government, and published Wednesday in The New England Journal of Medicine, provides the most reliable basis yet for measuring the scale of the problem. Until now, the most-cited estimates of the condition’s cost and prevalence came from an advocacy group, the Alzheimer’s Association.
Although some figures from the new research are lower than the association’s projections, they are nonetheless staggering and carry new gravity because they come from an academic research effort. Behind the numbers is a sense that the country, facing the aging of the baby boom generation, is unprepared for the coming surge in the cost and cases of dementia.
“It’s going to swamp the system,” said Dr. Ronald C. Petersen, who is chairman of the advisory panel to the federal government’s recently created NationalAlzheimer’s Plan and was not involved in the RAND study.
If anything, Dr. Petersen said of the study’s numbers, “they’re being somewhat conservative.” Dr. Petersen, the director of the Alzheimer’s Disease Research Center at the Mayo Clinic, is part of another team collecting data on dementia costs.
The RAND results show that nearly 15 percent of people aged 71 or older, about 3.8 million people, have dementia. By 2040, the authors said, that number will balloon to 9.1 million people.
“I don’t know of any other disease predicting such a huge increase,” said Dr. Richard J. Hodes, director of the National Institute on Aging, which financed the study. “And as we have the baby boomer group maturing, there are going to be more older people with fewer children to be informal caregivers for them, which is going to intensify the problem even more.”
The study found that direct health care expenses for dementia, including nursing home care, were $109 billion in 2010. For heart disease, those costs totaled $102 billion; for cancer, $77 billion.
The study also quantified the value of the sizable amount of informal care for dementia, usually provided by family members at home. That number ranged from $50 billion to $106 billion, depending on whether economists valued it by the income a family member was giving up or by what a family would have paid for a professional caregiver.

Over 7,000 March to Demand Return of Stolen Health Benefits

By: Kay Tillow Thursday April 4, 2013 9:43 am
 16 arrested in Charleston, WV
Charleston,West Virginia. April 1, 2013.  They boarded buses and cars before dawn, some the night before, coming from the coalfields of Illinois,Pennsylvania,Kentucky,Virginia,Ohio,Indiana, and all acrossWest Virginia.  By10:00 AM over 7,000 had packed into the giant Charleston Civic Center to voice their support for the 23,000 miners and their families who face the loss of their lifetime health benefits in a bankruptcy scam.

In a series of mergers and deals, Peabody Energy and Arch Coal transferred their contractual health benefit obligations to Patriot Coal.  InSt. Louis,Missouri, in March, 2013, Patriot Coal filed in bankruptcy court seeking to terminate the United Mine Workers (UMWA) contract and set up instead a Voluntary Employee Beneficiary Association (VEBA) for the retirees and families. 

Patriot seeks to put only a pittance into the VEBA, vastly underfunding it.  UMWA President Cecil E. Roberts has said this plan would “put thousands of retired coal miners, their dependents or their widows on the path to financial ruin, worsening health conditions or even death.”

The UMWA pioneered in healthcare benefits and pensions when they battled coal operators and the American Medical Association to establish the UMWA Health & Welfare Fund.  John L. Lewis and the union defied accusations of socialized medicine to set up miners’ clinics and built the miners’ hospitals that serve today as the backbone of health care in Appalachia.  The UMWA won early retirement with family coverage for miners who retired before they were 65.  These achievements of the miners’ struggles are under attack by Patriot, Peabody, and Arch.  Most unions, following the lead of the UMWA, have negotiated early retirement with employers picking up the cost of health care until Medicare kicks in.  The attack on UMWA retirees is a snapshot of what employers have in store for union negotiated early retirement plans.
Last chance
If ACA fails, single payer is next
First Published Mar 30 2013 01:01 am • Last Updated Mar 30 2013 01:01 am
The Patient Protection and Affordable Care Act should be seen as what it is: One last opportunity for the private health insurance market to prove that it can offer a service that covers the millions of Americans who were previously left out, at a cost that we — as individuals, employers and taxpayers — can afford.
If that is a goal beyond the grasp of the existing system, then it needs to be finally swept aside in favor of something that will meet those needs.
The most valid critique of the law, better known as Obamacare, is that it does not do enough to reduce, or even retard, increases in the cost of health care across the board. That, in furtherance of its humanitarian goal of catching up to every other industrialized nation by providing near-universal health care, it does too much to increase the cost of that coverage to individuals, employers and taxpayers.
This has been illustrated locally, by the Granite School District’s decision to duck an expected $14 million jump in costs by reducing the hours of hundreds of part-time workers. That way, the district, and its taxpayers, can avoid the ACA mandate that employees who work 30 or more hours a week have to be included in an employer’s health care plan.
And it has been illustrated nationally, by a study that estimates health care insurance claims that are paid may jump by as much as 32 percent per capita as millions more Americans enter that system. Of course, a law that requires health insurance outfits to put actually insuring the health of their customers ahead of their own profits is going to increase the amount of money those companies spend on actual care.
These cost projections, if the ACA works as intended, should be mitigated by other provisions of that act. Health insurance companies should, for example, be limited in how much of the increased cost they can pass along to customers by the provision that at least 80 percent of what an insurance provider spends must be for care, not overhead and profit.
Other factors that could help include increasing access to preventive care now and avoiding more expensive emergency or chronic care later, or moving low-wage workers off their employers’ plans and onto subsidized plans or Medicaid.
http://www.sltrib.com/sltrib/opinion/56079343-82/care-health-insurance-cost.html.csp

3 big providers exploring health alliance

By Robert Weisman

Health care merger fever spiked Wednesday when the leaders of two major teaching hospitals and the state’s largest physicians organization told employees they are in preliminary talks to form an alliance that could create one of the largest medical systems in Massachusetts.
The discussions involve Beth Israel Deaconess Medical Center in Boston, Lahey Health of Burlington, and Atrius Health, a Newton-based consortium of Harvard Vanguard Medical Associates and five other doctors groups. Also taking part are the in-house physicians groups at Lahey Clinic and Beth Israel Deaconess.
In memos to employees and associates, obtained by the Globe, presidents of the parties that are negotiating said they are committed to “spend a few months exploring new possibilities to benefit our patients and the communities we serve.” They offered no details of the type of partnership envisioned or the scope of services being considered.
The potential impact on patients is not clear. They could gain access to a broader range of medical expertise from the three providers, but Beth Israel Deaconess, Lahey, and Atrius are expensive health care providers in Massachusetts. Combining them might have the potential to drive up costs, just as state officials focus on health care affordability.
Representatives of Beth Israel Deaconess, Lahey, and Atrius declined to comment.
If they agree on an alliance — especially one that includes an outright merger of Beth Israel Deaconess and Lahey — it would dramatically alter the competitive landscape.
Combining the Beth Israel Deaconess and Lahey Health networks, which include community hospitals from Needham to Beverly, would create a 1,577-bed system, including Jordan Hospital in Plymouth, which agreed in January to be acquired by Beth Israel Deaconess. That would be topped only by Partners HealthCare System, with 2,400 beds, and Steward Health Care System, with 2,096 beds in Eastern Massachusetts.

LePage supporters’ hospital debt ad ignites political firestorm

By Robert Long, BDN Staff
Posted April 04, 2013, at 7:33 p.m.
AUGUSTA, Maine — A new television ad from Maine People Before Politics, a group that supports Republican Gov. Paul LePage, inflamed partisan hostilities in Augusta and across Maine’s political spectrum Thursday.
The ad criticizes LePage’s predecessor, Democrat John Baldacci, for leaving behind a Medicaid “welfare” debt to the state’s 39 hospitals and encourages Mainers to urge their legislators to support LePage’s plan to repay the balance of that Medicaid debt. A release accompanying the ad directs people to an online petition at www.NoHospitalDebt.org.
BDN blogger and former Democratic state senator Ethan Strimling reported that Maine People Before Politics will pay $41,775 to air the ad statewide beginning Thursday.
Baldacci, who has said he would consider another run for governor in 2014, responded to the ad with a statement Thursday. He also plans to make himself available to the media at 9:15 a.m. Friday at Gracie Theatre on the Husson University campus in Bangor.
“Gov. LePage prefers to fight rather than govern,” Baldacci said in the statement. “There’s bipartisan agreement on the need to repay the hospitals, but the governor can’t take ‘yes’ for an answer. The governor should be focused on the state budget, where his plans would raise property taxes, cut education and hurt the economy. It’s so bad, Republicans can’t support it as it is.”
Maine’s hospital debt, which now stands at roughly $484 million, with a state share of approximately $186 million, began to accumulate before Baldacci’s governorship, which ran from 2003 to 2011. Democrats consistently emphasize that point and the fact that Baldacci made efforts to begin reducing state government’s debt to Maine hospitals.
In 2006, Baldacci struck a deal with the Maine Hospital Association that put hospitals first in line for any surplus funds at the end of a budget year. Baldacci and hospital officials expected the arrangement would yield $82 million in state funds by 2010 that could be leveraged into a $221 million Medicaid debt paydown with federal matching funds included.
Four years later, LePage made a campaign issue of paying back the state’s hospitals, and, during his first months in office in 2011, he negotiated a supplemental budget that included $66.8 million in state funds for the hospitals, which translated into a $247 million total payment with federal funds. That payment brought Maine’s debt current through the first half of 2009. The existing debt dates to mid-2009.
In Thursday’s release, Baldacci rejected the ad’s suggestion that his administration’s failure to pay the full hospital debt forced layoffs.
“At the height of the worst recession since the Great Depression, Democrats and Republicans came together on a bipartisan plan that put the hospitals first in line,” Baldacci said in the prepared statement. “We did it to ensure that Maine people would have access to the care they needed and to prevent hospital layoffs.”
Maine Lawmakers Reconsider Health Insurance Reforms
04/04/2013   Reported By: Patty B. Wight

State lawmakers today considered a package of bills that would undo aspects of a Maine healthcare reform law passed two years ago. Public Law 90 sought to deregulate the health insurance market, increase access and lower premiums. But some Democrats say it's created inequity, and unfairly raises prices for rural Mainers. Patty Wight has more.
Democratic Sen. Geoff Gratwick, of Penobscot County, says Public Law 90, or PL 90, is the very reason he became a lawmaker. When he's not at the State House, Gratwick is a practicing physician. 

"I think that PL 90 was geared toward trying to save money for young people, and people who lived in big metropolitan areas, and it was at the expense of rural Maine," he says.

Under PL 90, insurers have been allowed to charge consumers different health insurance rates based on where they live. Gratwick's bill would require insurers to use one geographic area - the entire state - when establishing rates for individual and small group health plans. 

"The concept of insurance - my concept - is that we're all Mainers we're all Americans, we're all in this together," Gratwick says. "And your health and well-being is, in the last analysis, very important to me as an American and as a Mainer."

There are a total of six bills sponsored by Democrats that tackle two aspects of PL 90. There's a fair amount of overlap between them: Two focus on geography, four would reinstate advance review and approval of rate increases. 

Mitchell Stein from Consumers for Affordable Health Care says a year before PL 90 was enacted, Maine's insurance commissioner used that approval process to deny a request to increase rates by 9 percent, and instead only increased them by 5 percent. 

"That's different from what happened last year when there was a rate increase request of 9-and-change percent. And because of the rules in effect at the time, it went through without any public hearing and public comment," Stein says.

But the spokesman for the House Republican office, David Sorensen, says while Democrats focus on process, they're ignoring the big picture of what PL 90 has achieved.

TV ad backs LePage hospital payback plan

By Steve Mistler smistler@pressherald.com
Staff Writer
(Continued from page 1)
"Gov. LePage prefers to fight rather than govern," Baldacci said. "There's bipartisan agreement on the need to repay the hospitals, but the governor can't take 'yes' for an answer. The governor should be focused on the state budget, where his plans would raise property taxes, cut education and hurt the economy. It's so bad, Republicans can't support it as it is."
He added, "This type of partisanship and attack politics might get Gov. LePage's base excited, but it's no way to govern."
Maine People Before Politics began as the organization that helped fund the governor's transition to office. Initially, it disclosed its donors, which included corporations and trade groups such as the Maine Hospital Association.
It's now unclear how much each organization has given to Maine People Before Politics. The group is a nonprofit organization, so it doesn't have to fully disclose its donors.
The Maine Democratic Party described the group as a "Super PAC," a reference to the "dark money" groups that have operated at the national level and tried to influence elections.
LePage was asked about the ad after a speaking event for Augusta Kiwanis at the Senator Inn. He said he was unaware that the ad was running and looked to his spokeswoman, Adrienne Bennett, for an explanation.
"You know more than I do," he said to Bennett, laughing. "How come I'm always the last one to know?"

Support wanes for upfront payment for Maine liquor contract

The upfront payment of $200 million to repay hospitals has now fallen out of favor with Democrats and Republicans.

By Jessica Hall jhall@pressherald.com
Staff Writer
AUGUSTA — As legislators debate the future of the state's liquor contract, the idea of an upfront payment by a liquor contractor, which could be used to pay money owed Maine hospitals, has fallen out of favor with both Democrats and Republicans.
Opposition to an upfront payment, which had been proposed in a bill sponsored by Sen. Seth Goodall, D-Richmond, was voiced Monday by Rep. Peggy Rotundo, D-Lewiston.
"We're all in agreement that the hospitals need to be paid back. We are interested in getting the best value for the state. In looking at the nonpartisan figures, it became clear that the upfront payment doesn't make sense," Rotundo said in a telephone interview.
An analysis by the nonpartisan Office of Fiscal and Program Review outlined three possible scenarios for a liquor bill. None of the scenarios directly aligned with the two liquor bills on the table that have been proposed by Goodall and Gov. Paul LePage.
The state's 39 hospitals are owed about $484 million in reimbursement for services to patients covered under MaineCare, the state's version of the Medicaid program for low-income residents. The state owes about one-third of the amount but must pay its share before the federal government will release matching funds.
The Veterans and Legal Affairs Committee plans to propose its own bill, which would repay the debt to the hospitals using a revenue bond. The bond would be secured by the revenues from the state liquor business over the next 10 years.

April 3

Maine Medicaid debate: Cost vs. benefits

Backers and skeptics make their cases on a bill seeking to have Maine cover more people under Obamacare.

By Steve Mistlersmistler@pressherald.com
Staff Writer
Department of Health and Human Services Commissioner Mary Mayhew said that for about 41,000 parents who were part of the 2003 expansion, the federal government would maintain its current reimbursement rate of 61.5 percent. The remaining cost is paid by the state, amounting to $57.6 million in the next two-year state budget, and that cost won't decrease if the state joins the latest expansion, she said.
She said the state's population of about 10,000 childless adults -- non-disabled people earning up to $11,490 a year -- also would receive the lower federal reimbursement.
Some of the administration's estimates directly conflicted with data compiled by Maine Equal Justice Partners, an advocacy group for low-income Mainers that belongs to Cover Maine Now!, a coalition of businesses, doctors and health care advocacy groups.
Equal Justice's Sara Gagne-Holmes told lawmakers that the childless adult population could qualify for 100 percent federal reimbursement. She cited a recent rulemaking by the Obama administration.
The conflict over reimbursement rates was upstaged at Tuesday's hearing by health care advocates and Medicaid recipients who argued that increasing coverage was a matter of life and death.
Some Medicaid recipients slated to lose coverage following recent legislative changes to decrease eligibility also testified.
Patricia Kidder, from Sanford, said she and her husband recently lost their coverage.
“Low-income adult individuals, ages 22 through 64, need you to accept the federal funds and expand MaineCare," Kidder said. "We need it to stay alive.”
Amy Madden, a doctor representing the Maine Medical Association, said health care costs were high, but limiting coverage wouldn't help.
"When we limit access, such as rejecting these expansion funds and continuing the status quo, we do not eliminate the need for health care," Madden said. "We just allow individuals and families to fall into debt and bankruptcy, and we continue to shift costs onto those who provide and have health insurance."
A recent Harvard study found that expansions of Medicaid coverage were associated with improvement in a state population's overall health status and a significant reduction in death rates.
Nonetheless, skeptics argued that the success of expansion was contingent on the federal government keeping its funding promise.
http://www.pressherald.com/politics/Lawmakers-begin-vetting-Medicaid-expansion-bill.html?pagenum=1


Michaud, LePage spar on Medicaid

The posturing between the congressman and governor could hint of the 2014 gubernatorial race.

By Kevin Miller kmiller@mainetoday.com
Washington Bureau Chief
WASHINGTON – Democratic U.S. Rep. Mike Michaud and Republican Gov. Paul LePage offered dueling views Wednesday on whether Maine should expand its Medicaidprograms, in what could be an early skirmish in the 2014 gubernatorial race.
Without naming LePage, Michaud released a statement Wednesday morning urging the state to go along with the Medicaid expansions in the federal Affordable Care Act.
Expanding MaineCare, the state’s Medicaid program, would provide health coverage to more than 50,000 additional lower-income Mainers. LePage is among the governors nationwide who have yet to agree to the expansion, which will be entirely funded by the federal government for three years and then funded at 90 percent.
“This is an issue that directly impacts the health of Mainers and the health of our economy,” Michaud after meeting with affected Mainers at the Bangor office of the Maine People’s Alliance, a progressive organization.
“The state should accept this federal funding that has been set aside for Maine so that we can further reduce the uninsured population. Doing so could help expand and maintain health care for over 69,000 Mainers and provide a boost to our state’s economy.”
Hours later, LePage issued a statement whose second sentence notes that Michaud is considering running for governor in 2014. The governor, who is expected to seek re-election, said declining federal Medicaid reimbursement rates have created a “massive financial hardship for Maine” and the federal government cannot guarantee it will fully fund the expansion.
“The federal debt has more than doubled since Rep. Michaud has been in Congress,” LePage said. “Unlike the career politicians in Washington, D.C., the Maine Governor has to balance the budget.”

Bills look to roll back Republican insurance reform

By Scott Thistle, Sun Journal
Posted April 05, 2013, at 12:38 p.m.
AUGUSTA, Maine — Seven bills that would roll back controversial health insurance reform passed in 2010 began their journey through the Maine Legislature this week.
Members of the Insurance and Financial Services Committee on Thursday began taking testimony on the bills offered by Democrats that would, according to rival Republicans, gut the health insurance reforms collectively known as Public Law 90.
The law created a high-risk insurance pool and a $4 monthly fee on all health insurance policies to fund it.
The bill also set up a private, nonprofit corporation to administer that pool and eliminated requirements that insurance-rate hikes of less than 10 percent be reviewed in a public process by the state’s Bureau of Insurance.
Supporters of PL 90 say it’s driving down insurance rates, especially small-group and individual market rates in younger and more urban parts of Maine. They argue that will create bigger pools of healthier people that will eventually lead to lower rates for all Mainers.
One of the bills heard Thursday would require all insurance-company-proposed rate increases — no matter the size — to go to public hearings. Current law says only rate hikes above 10 percent need public review. Increments smaller than that can be processed, with oversight from only the Bureau of Insurance.
Other bills would make public the meetings and records of the Maine Guaranteed Reinsurance Association, which administers the high-risk pool for companies offering health insurance in Maine.
That pool is funded to the tune of $20 million a year by the $4 monthly fees paid on the policies of everyone with privately funded health insurance in Maine.
That pool, according to supporters of PL 90, is a big reason insurance-rate increases in other markets in Maine have slowed dramatically, compared to years past.
But the committee heard a long list of complaints about how the law had sent insurance rates skyrocketing, especially for older and more rural Mainers.
Elizabeth McSwain, a small-business owner in Boothbay Harbor, said group rates for her six-person company shot up 34 percent in 2012 after they shot up 26 percent in 2011.
“We’ve been repeatedly slammed by rate increases,” McSwain said.
Rep. Nathan Libby, D-Lewiston, an author of one of the bills that restores the public review and prior approval provisions in the old statute for small groups, said some people might be benefiting from PL 90.
“We can all agree it lowered health insurance premiums for many Maine people but drastically spiked premiums for some Maine people,” Libby said.

Maine Medical Center sues federal official over nearly $3 million in unpaid medical claims

By Jackie Farwell, BDN Staff
Posted April 04, 2013, at 5:21 p.m.
PORTLAND, Maine — Maine Medical Center has sued U.S. Department of Health and Human Services Secretary Kathleen Sebelius over nearly $3 million in unpaid medical claims for patients with government health insurance.
The outstanding bills date back a decade and cover treatment that the Portland hospital provided to patients covered by both Medicare and Medicaid.
The suit is unrelated to the current debate over $484 million owed to Maine’s hospitals under the Medicaid program, debt that dates back to 2009.
In the suit filed Tuesday in U.S. District Court in Portland, MMC said it was never fully paid for services provided to patients eligible for both Medicare and MaineCare, the state’s version of the Medicaid program.
With “dual eligible” patients, Medicare pays its share of the claim first, reimbursing hospitals for services that were provided. Then the claim typically “crosses over” to MaineCare, which helps low-income patients to afford their Medicare coverage by footing the bill for Medicare co-insurance and deductible expenses.
But in July 1999, MaineCare decided to stop paying such “crossover claims,” according to the suit. MaineCare sent health providers documentation showing zero payment for the claims, which providers could then furnish to the federal government to get paid through Medicare.
In MMC’s case, an “anomaly of unknown origin” prevented MaineCare from processing those crossover claims between November 2001 and August 2003, according to the suit. Because the claims were never processed, MMC wasn’t issued the zero payment documentation and couldn’t get reimbursed by Medicare.
A Medicare payment contractor rejected the hospital’s request for payment, according to the suit. The unpaid claims amounted to $1.1 million in fiscal year 2002 and $1.7 million in fiscal year 2003.
MaineCare still hasn’t been able to retrieve or process the claims, according to the suit.
MMC appealed the payment denial to an independent Medicare review board, which unanimously favored the hospital in a Nov. 29, 2012 decision.
The head of the Centers for Medicare and Medicaid Services, acting for Sebelius, then reversed the review board’s decision in early February, citing MMC’s lack of documentation. In the suit, MMC described the decision to reverse the review board’s ruling as “arbitrary” and “capricious.” The hospital asked the court to instruct CMS to uphold the review board’s decision.
An MMC spokesman did not immediately provide comment on the suit.

Price Shopping in Consumer-Directed Health Plans

1 / Zachary Wagner2 / Peter Huckfeldt3 / Amelia M. Haviland3
1University of Southern California
2Leonard D. Schaeffer Center for Health Policy and Economics
3RAND Corporation
Corresponding author: Neeraj Sood, University of Southern California
Citation Information: Forum for Health Economics and Policy. Volume 0, Issue 0, Pages 1–19, ISSN (Online) 1558-9544, ISSN (Print) 2194-6191, DOI: 10.1515/fhep-2012-0028, March 2013
Publication History:
Published Online:
2013-03-20

Abstract

We use health insurance claims data from 63 large employers to estimate the extent of price shopping for nine common outpatient services in consumer-directed health plans (CDHPs) compared to traditional health plans. The main measures of price shopping include (1) the total price paid on the claim, (2) the share of claims from low- and high-cost providers, and (3) the savings from price shopping relative to choosing prices randomly. All analyses control for individual and zip code level demographics and plan characteristics. We also estimate differences in price shopping within CDHPs depending on expected health care costs and whether the service was bought before or after reaching the deductible. For eight out of nine services analyzed, prices paid by CDHP and traditional plan enrollees did not differ significantly; CDHP enrollees paid 2.3% less for office visits. Similarly, office visits was the only service where CDHP enrollment resulted in a significantly larger share of claims from low-cost providers and greater savings from price shopping relative to traditional plans. There was also no evidence that, within CDHP plans, consumers with lower expected medical expenses exhibited more price shopping or that consumers exhibited more price shopping before reaching the deductible.
Local doctor fighting cancer taken aback by drug bill: Each treatment costs $44,000 at Dover hospital

ROCHESTER — A year ago, city physician Dr. Terry Bennett was diagnosed with cancer.

Since the diagnosis, his cancer has been controlled by various medications that attacked his cancer cells and healthy cells alike. As a result, he has been struggling with fatigue, loss of hair, and swelling of his leg.

But a promising new drug recently approved by the Food and Drug Administration appears to be the solution for treating Bennett's cancer without the debilitating symptoms that makes him feel “sick as a dog,” he said.

The problem is, the new drug that's now open for public use, Kadcyla, also known as TDM-1, comes with a high cost, Bennett said.

Bennett, 74, recently received his first IV of the medication, and Wentworth-Douglass Hospital in Dover charged him close to $44,000 for the treatment. The medication is supposed to be administered every three weeks, and for each treatment, Bennett is expecting a similar bill.

At the same time, Genentech, the company that developed the drug, only charges $9,800 a month for Kadcyla, according to Genentech spokeswoman Susan Wilson. That means Wentworth-Douglass charged approximately $34,200 more for the treatment than Genentech charges.
Noreen Biehl, vice president of community relations at Wentworth-Douglas Hospital, said there are several factors that go into the mark-up for the medication.

Some of the extra cost goes to cover the patient assistance program the hospital offers for uninsured and underinsured patients, said Biehl. The mark-up also makes up for patients who just don't pay their bills — a problem at many hospitals, said Biehl — as well as other operational costs to keep the hospital running.

Biehl emphasized Wentworth-Douglas is a nonprofit hospital, which treats all patients regardless of their ability to pay. 

“We treat all patients who come,” she said.

All treated patients get billed for treatment, unless they qualify for the assistance program, which typically requires patients to be at 200 percent of the poverty level, said Biehl.

Tax Lobby Builds Ties to Chairman of Finance Panel


By 

WASHINGTON — Restaurant chains like McDonald’s want to keep their lucrative tax credit for hiring veterans. Altria, the tobacco giant, wants to cut the corporate tax rate. And Sapphire Energy, a small alternative energy company, is determined to protect a tax incentive it believes could turn algae into a popular motor fuel.
To make their case as Congress prepares to debate a rewrite of the nation’s tax code, this diverse set of businesses has at least one strategy in common: they have retained firms that employ lobbyists who are former aides to Max Baucus, the chairman of the Senate Finance Committee, which will have a crucial role in shaping any legislation.
No other lawmaker on Capitol Hill has such a sizable constellation of former aides working as tax lobbyists, representing blue-chip clients that include telecommunications businesses, oil companies, retailers and financial firms, according to an analysis by LegiStorm, an online database that tracks Congressional staff members and lobbying. At least 28 aides who have worked for Mr. Baucus, Democrat of Montana, since he became the committee chairman in 2001 have lobbied on tax issues during the Obama administration — more than any other current member of Congress, according to the analysis of lobbying filings performed for The New York Times.
“K Street is literally littered with former Baucus staffers,” said Jade West, an executive at a wholesalers’ trade association that relies on a former finance panel aide,Mary Burke Baker. “It opens doors that allow you to make the case.”
Like Ms. Baker, many of those lobbyists have already saved their clients millions — in some cases, billions — of dollars after Mr. Baucus backed their requests to extend certain corporate tax perks, provisions that were adopted as part of the so-called fiscal cliff legislation in January. Baucus aides who later became lobbyists helped financial firms save $11.2 billion in tax deferments and helped secure a $222 million tax benefit that is shared with the liquor industry.
Sean Neary, a spokesman for Mr. Baucus, said the senator had regularly rejected requests from those lobbyists for provisions benefiting their clients, like an appeal from one former aide, Pat Bousliman, now working as a wind industry lobbyist, to extend an alternative grant in lieu of tax credit program that expired in 2011.
Mr. Baucus’s decisions are based on the merits of the policies, Mr. Neary said, not on who is advocating for them. “The fact is, oftentimes good policy can indirectly benefit someone,” he said. “That doesn’t mean it shouldn’t be done.”







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