Health Care Reform Articles - November 16, 2015

Many Say High Deductibles Make Their Health Law Insurance All but Useless 

By ROBERT PEARNOV. 14, 2015

WASHINGTON — Obama administration officials, urging people to sign up for health insurance under the Affordable Care Act, have trumpeted the low premiums available on the law’s new marketplaces.

But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.

“The deductible, $3,000 a year, makes it impossible to actually go to the doctor,” said David R. Reines, 60, of Jefferson Township, N.J., a former hardware salesman with chronic knee pain. “We have insurance, but can’t afford to use it.”

In many states, more than half the plans offered for sale through HealthCare.gov, the federal online marketplace, have a deductible of $3,000 or more, a New York Times review has found. Those deductibles are causing concern among Democrats — and some Republican detractors of the health law, who once pushed high-deductible health plans in the belief that consumers would be more cost-conscious if they had more of a financial stake or skin in the game.

“We could not afford the deductible,” said Kevin Fanning, 59, who lives in North Texas, near Wichita Falls. “Basically I was paying for insurance I could not afford to use.”

He dropped his policy.

As the health care law enters its third annual open enrollment period, premiums and subsidies have been one of the administration’s main selling points.

“Most Americans will find an option that costs less than $75 a month,” President Obama said.

Sylvia Mathews Burwell, the secretary of health and human services, issued a report analyzing premiums in the 38 states that use HealthCare.gov. “Eight out of 10 returning consumers will be able to buy a plan with premiums less than $100 a month after tax credits,” she said.

But in interviews, a number of consumers made it clear that premiums were only one side of the affordability equation.

“Our deductible is so high, we practically pay for all of our medical expenses out of pocket,” said Wendy Kaplan, 50, of Evanston, Ill. “So our policy is really there for emergencies only, and basic wellness appointments.”

Her family of four pays premiums of $1,200 a month for coverage with an annual deductible of $12,700.

In Miami, the median deductible, according to HealthCare.gov, is $5,000. (Half of the plans are above the median, and half below it.) In Jackson, Miss., the comparable figure is $5,500. In Chicago, the median deductible is $3,400. In Phoenix, it is $4,000; in Houston and Des Moines, $3,000.

http://www.nytimes.com/2015/11/15/us/politics/many-say-high-deductibles-make-their-health-law-insurance-all-but-useless.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0

Americans’ loyalty to employers and insurance plans is costing them billions

By Catherine Rampell Opinion writer November 9

As the Black Friday stampedes will soon attest, Americans are among the most enthusiastic and aggressive shoppers in the world. 

Yet when it comes to two of the most financially significant decisions in our lives — our health insurance and our jobs — we’ve proved exceptionally lazy. The latest data suggest that Americans are leaving billions of dollars on the table due to our reluctance to shop around.

It’s currently “open enrollment” season, the one time of year when most Americans are allowed to change their health insurance. Yet relatively few choose to do so.

It’s little wonder why. Insurance plans are complicated, with more moving parts and narrower doctor networks than in the past. Insurers don’t exactly go out of their way to make price comparisons easy, either. Plus, consumers have to go through the rigmarole of figuring out whether their preferred doctors participate in competing plans (though of course these preferred doctors could always drop out of their current plans, too).

All this results in relatively few people taking the time to learn about their alternatives. They just auto-renew whatever they have. If it ain’t broke, right?

This is exactly the attitude that insurers count on. 

Multiple economic studies have found that insurers jack up rates on those too lazy or inattentive to investigate other options. Plans end up raising premiums, deductibles or co-pays from year to year, harvesting as much additional money from enrollees’ inertia as possible. Insurers take advantage of consumers’ vague recollection that they did their homework last year, or perhaps the year before, so they don’t need to repeat the exercise. But the plan that was the best deal a year ago could well be the worst one now. 

Those with employer-sponsored health insurance theoretically should be shielded from some of this “harvesting,” since employers are supposed to negotiate on behalf of their workers. Consumers getting insurance through Medicare Advantage, Medicare Part D and the Obamacare exchanges are at greater risk. 

A recent report from the Department of Health and Human Services found that only about a quarter of people who enrolled in plans on the Obamacare exchanges in 2014 switched plans in 2015. Those who did, and who moved to a plan with about the same level of coverage (from one “silver plan” to another, for example), saved on average nearly $400 annually on premiums relative to what they would have paid had they remained in the same plan. 

https://www.washingtonpost.com/opinions/americans-loyalty-to-employers-and-insurance-plans-is-costing-them-billions/2015/11/09/8e04a9de-8726-11e5-be39-0034bb576eee_story.html?hpid=hp_no-name_opinion-card-d%3Ahomepage%2Fstory

Data on Benefits of Lower Blood Pressure Brings Clarity for Doctors and Patients

By GINA KOLATANOV. 9, 2015

When the federal government announced in September that it had abruptly halted a large blood pressure study because its results were so compelling, doctors were left in frustrating limbo.

The announcement said researchers had found that driving systolic blood pressure to levels far below what current guidelines recommend — less than 120 instead of 140 or 150 millimeters of mercury — can save lives and prevent heart disease and strokes. But they declined to release any data on the number of lives saved, the number of heart attacks prevented or other critical measures.

“How can anyone do anything different tomorrow with regard to blood pressure control without knowing more about what they found?” asked Dr. Harlan Krumholz, a cardiologist at Yale, echoing the concerns of other specialists.

On Monday, reporting at an American Heart Association meeting in Orlando, Fla., and in a paper published simultaneously in The New England Journal of Medicine, study investigators lifted the veil. Among the 9,361 hypertension patients followed for an average of 3.2 years, there were 26 percent fewer deaths (155 compared with 210) and 38 percent fewer cases of heart failure (62 compared with 100) among patients who achieved the systolic pressure target of 120 than among those who achieved the current 140 target.

Systolic pressure is the higher of the two blood pressure numbers and represents pressure on blood vessels when the heart contracts.

Over all, there was a 24 percent reduction — 243 compared with 319 — in people who had a heart attack, heart failure or stroke or died from heart disease, Dr. Paul K. Whelton, a principal investigator for the study, said.

The older participants did just as well as younger ones.

http://www.nytimes.com/2015/11/10/health/data-on-benefits-of-lower-blood-pressure-brings-clarity-for-doctors-and-patients.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0

Kentucky’s newly insured worry about their health under next governor

By Amy Goldstein November 9

PIKEVILLE, Ky. — Amid the coal fields of eastern Kentucky, a small clinic that is part of the Big Sandy Health Care network furnishes daily proof of this state’s full embrace of the Affordable Care Act.

It was here that Mindy Fleming handed a wad of tissues to Tiffany Coleman when she arrived, sleepless and frantic, with no health insurance and a daughter suffering a 103-degree fever and mysterious pain. “It will be all right,” Fleming assured her, and it was. An hour later, Coleman had a WellCare card that paid for hospital tests, which found that 4-year-old Alexsis had an unusual bladder problem.

Such one-by-one life changes are the ground-level stakes ushered in by the election last week of businessman Matt Bevin as Kentucky’s next governor. The second Republican elected to the office in 48 years, he wrapped his campaign around a pledge to dismantle Kynect, the state’s response to the federal health-care law. If he follows through, the Bluegrass State would go from being perhaps the nation’s premier ACA success story to the first to undo the law’s results, razing a state insurance exchange and reversing its considerable expansion of Medicaid.

https://www.washingtonpost.com/national/health-science/next-kentucky-governors-aca-animus-raises-concerns-in-coal-country/2015/11/09/5143a0ea-8492-11e5-8ba6-cec48b74b2a7_story.html?hpid=hp_hp-more-top-stories_kentucky-250pm%3Ahomepage%2Fstory

Another View: Kentucky won’t save money by dumping Medicaid expansion

Matt Bevin, the newly elected Republican governor of Kentucky, says his state can’t afford to keep covering the people who have gained health insurance through Medicaid expansion. If money really is the issue, Bevin may find that Kentucky can’t afford not to.

The Affordable Care Act lets states extend Medicaid coverage to anyone earning up to 138 percent of the poverty level (this year, $33,465 for a family of four), with 90 percent of the cost paid by the federal government. So far, 30 states and Washington, D.C., have done so, providing health coverage to some 12 million more people.

They’ve done this at rock-bottom cost, because Medicaid is one of the least expensive ways to provide insurance. For every newly enrolled adult last year, the Medicaid coverage cost $5,517, almost 10 percent less than the average premium for employer-sponsored health insurance.

Opponents of expansion contend that, even so, the states’ 10 percent share is too much to bear. Without question, that cost is significant. But Bevin and like-minded Republican officials in other states are wrong to conclude that cutting it will save them money.

That’s because looking at the state expense in isolation ignores the economic impact of the other 90 percent. Every dollar the federal government spends on health care in Kentucky is a dollar of revenue for hospitals, doctors and other health care providers. In the past year, Alaska, Montana and Indiana have overcome their reluctance to sign up. Before taking his state in the opposite direction, Bevin should look closer at the problem he’s trying to solve.

http://www.pressherald.com/2015/11/10/another-view-kentucky-wont-save-money-by-dumping-medicaid-expansion/

White House Seeks to Ease Veterans’ Access to Care

By JULIE HIRSCHFELD DAVISNOV. 11, 2015

WASHINGTON — The Obama administration on Wednesday will call on Congress to enact measures to help military veterans gain easier access to health care, disability and educational benefits, part of a push to spotlight its efforts to improve the way the government treats veterans after a scandal at the Department of Veterans Affairs.

President Obama will urge Congress to improve a program that allows veterans to receive private medical care, speed the appeal process for disability claims and pass legislation aiming to improve the quality of schools that serve veterans. Timed to coincide with Veterans Day, Mr. Obama’s proposals also come as the administration is promoting the first fruits of its efforts to reduce homelessness among veterans, with Gov. Terry McAuliffe of Virginia set to announce that his state has become the first to end veteran homelessness.

The cities of Las Vegas; Syracuse; and Schenectady, N.Y., will also announce that they have ended veteran homelessness, the White House said.

The administration laid out a plan in 2010 to end chronic homelessness among veterans by the end of this year, saying that goal would be reached when there were no veterans sleeping on streets and no more than 12,500 veterans in shelters or transitional housing. In August, Connecticut became the first state to be designated by the administration as having achieved the milestone.

The Obama administration is also set to unveil a new tool to allow veterans to compare college and university options, modeled after a college scorecard website it started in September to provide information to prospective students and their parents about annual costs, graduation rates and salaries after graduation.

It will also announce that all 50 states, the District of Columbia and Puerto Rico will provide “recently transitioning veterans” and their dependents with in-state tuition at public colleges and universities, in line with a provision in the $16 billion overhaul of the Department of Veterans Affairs passed by Congress last year after the scandal.

The moves reflect the degree to which Mr. Obama is still fine-tuning that law, including provisions that allow veterans to use private doctors at the government’s expense if they cannot get an appointment with a Department of Veterans Affairs physician within 30 days. The White House said that 7 percent more veterans have been able to use that option over the past year, but that the program needs improvements. The agency sent Congress a plan to do so earlier this month.

http://www.nytimes.com/2015/11/11/us/politics/white-house-seeks-to-ease-veterans-access-to-care.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region&region=top-news&WT.nav=top-news

Regulators Urge Broader Health Networks

By ROBERT PEARNOV. 8, 2015

WASHINGTON — The nation’s insurance commissioners are recommending sweeping new standards to address complaints from consumers about limited access to doctors and hospitals in health plans sold under the Affordable Care Act.

Limited networks of health care providers are a feature of many insurance policies offered in the public marketplaces, or exchanges, where people with low incomes can often obtain subsidies that reduce their monthly premiums to $100 or less. Such “narrow networks,” consumers say, often do not include the doctors they need for specialized care for themselves or their children.

The National Association of Insurance Commissioners, which represents state officials, would require that insurers have enough doctors and hospitals in their networks to provide all covered services to consumers “without unreasonable travel or delay.” States remain the primary regulators of insurance, despite a huge increase in federal insurance standards since adoption of the health law in 2010.

The thrust of the recommendations is to help consumers get care from providers affiliated with their health plan and to protect them against exorbitant costs if, for some reason, they receive care from doctors or hospitals that are not in the insurer’s network. Patients are typically required to pay more of the bill if they receive care outside their network.

Many consumers have been infuriated after using a hospital in their network and then receiving large medical bills from doctors who work at the hospital but are not in the network.

Under the commissioners’ proposals, in the form of a model state law, insurers and hospitals would be required to inform patients of any possibility that they may be charged extra by “a health care professional, such as an anesthesiologist, pathologist or radiologist,” who does not participate in the insurer’s network.

In such situations, the proposals say, patients should not be forced to pay more than their usual share of the bill for services provided by doctors affiliated with their health plan. Doctors who object to the amount of the payment could haggle with the insurer in a mediation process, but the patient would be “held harmless.”

Stephanie Mohl, the manager of government relations at the American Heart Association, said the proposals were “a huge step forward” for patients.

In determining whether a network of providers is sufficient, state insurance commissioners would consider factors like the ratio of people enrolled in a health plan to the number of doctors in each specialty, the “geographic accessibility of providers,” waiting times for appointments, and the ability of health plans to meet the needs of low-income people and “children and adults with serious, chronic or complex health conditions or physical or mental disabilities.”

The commissioners developed the proposals in an exhaustive 18-month drafting process that was open at every stage to consumers, insurers, health care providers and other experts.

The Obama administration said this year that it was waiting to see the “model act” devised by the commissioners’ association before deciding whether to adopt detailed federal standards for provider networks.

Insurers defend smaller networks as a way to hold down costs and improve care by steering patients to selected high-performing doctors and hospitals. Moreover, they say, most consumers seeking insurance on the exchanges focus on price more than any other factor and are willing to accept limits on their choice of doctors and hospitals in return for lower premiums.

But William J. Psolka, a 50-year-old photographer in Somerset, N.J., is one of many patients aggrieved by such narrow networks. He visits doctors in Boston and New York for a complex heart defect he has had since birth. For decades, his insurance policy covered those visits.

“But in 2014,” Mr. Psolka said, “the insurer got rid of out-of-network coverage, as did many carriers in New Jersey, and I don’t know if I will be able to continue seeing the specialized cardiologists at the clinics in Boston and New York.” For months, he said, he has been seeking permission from his insurer.

http://www.nytimes.com/2015/11/09/us/regulators-urge-broader-health-networks.html?mabReward=CTM&action=click&pgtype=Homepage&region=CColumn&module=Recommendation&src=rechp&WT.nav=RecEngine

Yellow Canaries and Middle-Aged White Men

NOVEMBER 12, 2015 

Sam Pizzigati

Americans live longer today than we used to live, sometimes a lot longer. Just over 32,000 centenarians called the United States home in 1980. In 2010, we had morethan 53,000 Americans in triple digits.

This trend line — longer and longer lives for more and more people — has embedded itself into our popular culture. Sixty, we quip, has become the new 40. We are living longer than our parents, our kids will live longer than us. We celebrate this march of progress. We take it for granted.

Amid the celebrating, to be sure, we have had some voices urging caution. Yes, these voices note, Americans are living longer. But people elsewhere in the developed nations are living significantly longer than Americans.

Epidemiologists — scientists who study the health of populations — have been tracking these differing national longevity patterns for several decades now. And they’ve been linking the differences, in study after study, to economic inequality. People who live in more equal countries, their research shows, tend to live longer than people who live in societies that have become more unequal.

This insight hasn’t yet worked its way into our public consciousness, for an understandable reason. We don’t, after all, typically compare the length of our lifespans to the length of lifespans in other countries. We compare ourselves to our parents and grandparents. They didn’t live as long as we’re living. So why worry about such complexities as inequality and longevity when everybody around us is living longer?

Why worry? Newly released research from Angus Deaton, the latest Nobel Prize winner in economics, and his Princeton colleague Anne Case suggests a reason why some serious worry may now be in order. In the United States, everybody around us is no longer living longer.

To be more specific, white men at midlife — 45-to-54-year-olds — are now dying at an earlier age. Their death rates, Case and Deaton show in their new National Academy of Sciences study, have been rising since 1999.

How much of a difference has this rising death rate made? If these white men had spent the last dozen years dying at the 1998 death rate, nearly 100,000 more of them would still be alive today. And if the white midlife death rate had kept declining after 1999 at the same pace this rate declined between 1978 and 1998, almost 500,000 more white Americans would still be alive and kicking.

No other developed nation, the new Princeton research makes clear, shows this same startling about-face in midlife longevity. Forty- and fifty-somethings elsewhere are continuing to live at least a little longer every year.

So what’s going on here? Why are middle-aged white men in the United States now living shorter lives?

Plenty of pundits are currently contemplating that question, and their interest should come as no surprise. The new stats of American midlife mortality challenge a hefty chunk of what we Americans hold dear. How could we be “exceptional” if we’re dying sooner?

Something must have gone terribly wrong. But what? Why do we now see in America so much “midlife distress,” the tag that researchers Case and Deaton place on the rising incidence among middle-aged whites of “drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis”?

Case and Deaton themselves offer no grand explanation. The white midlife increase in disease and death, they write, remains “only partly understood.”

https://ourfuture.org/20151112/yellow-canaries-and-middle-aged-white-men

Senate Rules Entangle Bid to Repeal Health Care Law

By ROBERT PEARNOV. 12, 2015

WASHINGTON — Efforts to repeal the Affordable Care Act have become snarled in the complex rules of the Senate, raising questions about whether the Republican-controlled Congress can fulfill its pledge to send a repeal measure to President Obama.

Repealing the law, passed five and a half years ago, is a goal cherished by Republican politicians, including those running for president, and by elements of the party’s base. Mr. Obama has repeatedly vowed to use his veto power if necessary to preserve the health care law, the biggest change in domestic social policy in a generation.

The House on Oct. 23 adopted a budget-reconciliation package that would repeal core elements of the Affordable Care Act. The bill would eliminate the requirement that Americans have health insurance, and that larger employers offer coverage to full-time employees. It would also repeal taxes on medical devices and high-cost employer-sponsored insurance.

In the Senate, Republicans are determined to dismantle or defund the law using a fast-track procedure that requires a simple majority vote, rather than the 60 votes needed for most hotly contested measures.

But the Senate parliamentarian, Elizabeth MacDonough, ruled this week that some provisions of the House-passed bill were not eligible for expedited procedures, aides to Senate leaders of both parties said Thursday. Democrats said the ruling meant that Republicans would need a supermajority of 60 votes, which they do not have, to repeal the individual and employer mandates.

The office of the Democratic leader, Senator Harry Reid of Nevada, issued a statement on Thursday saying, “The parliamentarian has ruled that Obamacare cannot be repealed through reconciliation.”

“Any fix that repeals the individual or employer mandates will require 60 votes and therefore will not pass,” the statement added.

However, Republicans said that Mr. Reid had misrepresented the parliamentarian’s ruling, the text of which has not been made public. They said that if some provisions of the bill were changed, the Senate could still take up the bill by a simple majority vote and consider it using fast-track procedures.

http://www.nytimes.com/2015/11/13/us/senate-rules-entangle-bid-to-repeal-health-care-law.html?mabReward=CTM&action=click&pgtype=Homepage&region=CColumn&module=Recommendation&src=rechp&WT.nav=RecEngine

How to Decrease Prices for an Expensive Class of Drugs

NOV. 16, 2015

by Austin Frat

Competition among generic drug makers pushes drug prices downward. But such competition is weak for a growing and expensive class of drugs called biologics. A big reason has to do with the science that underlies them.

Biologics — large-molecule, protein-based drugs — are made by living organisms, not by chemical processes, which are the source of non-biologic, or small-molecule, drugs. Their complexity makes them harder to reverse engineer than small-molecule drugs, making generic versions of them — called biosimilars — more costly to bring to market.

Comparing insulin (perhaps the most familiar biologic drug) with aspirin (perhaps the quintessential small-molecule drug) offers a sense of how the two classes differ, and why one is so much more expensive to produce. Aspirin is relatively simple, consisting of four ingredients, two of which are cornstarch and water. The composition of small-molecule drugs like aspirin is no mystery; it’s published in their patents. From aspirin’s ingredients it’s relatively easy for engineers to intuit how it could be produced. In fact, you can find a video on the Internet showing how to make aspirin. (But at pennies a dose, you really needn’t bother, unless you are lost in the woods.)

Insulin, by contrast, consists of larger, more complex molecules originally extracted from the pancreatic tissue of dogs, then pigs and cows. Today, like other biologic drugs, it can be made by manipulating the genetics of certain micro-organisms. It’s this complexity — and the fact that the precise means of production is not included in their patents — that makes biologics’ composition and source far harder to discern than for small-molecule drugs like aspirin. Search online all you want — you won’t find a simple recipe to make PCSK9 inhibitors, the new cholesterol-lowering drugs (with high prices), in your kitchen. (Unlike original insulin, discovered in 1901, modern biologics are not naturally occurring, but made only through genetic manipulation.)

As the law professors W. Nicholson Price and Arti Rai put it, “If an aspirin were a bicycle, a small biologic would be a Toyota Prius, and a large biologic would be an F-16 fighter jet.” It is 100 times more expensive to reverse engineer a modern biologic than a small-molecule drug.

In a paper to appear in the Iowa Law Review, they argue that because biologics cost more to make, relatively higher prices are required to encourage manufacturers to do so. They suggest that if the science of biologic production were more open, the barriers to entry for biosimilars would fall, and with it their prices.

http://www.nytimes.com/2015/11/17/upshot/how-to-decrease-prices-for-an-expensive-class-of-drugs.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well

How Many Deaths from Mistakes in US Health Care?

By Timothy Taylor

Back in the 1999, the Institute of Medicine (part of the National Academies of Science) estimated in its report To Err is Human that in 1997 at least 44,000 and as many as 98,000 patients died in hospitals as the result of medical errors that could have been prevented. Current estimates are higher, as Thomas R. Krause points out in "Department of Measurement: Scorecard Needed" in the Milken Institute Review(Fourth Quarter 2015, pp. 91-94). Krause writes:

"You've seen the astounding numbers: hundreds of thousands of Americans die each year due to medical treatment errors. Indeed, the median credible estimate is 350,000, more than U.S. combat deaths in all of World War II. If you measure the “value of life” the way economists and federal agencies do it – that is, by observing how much individuals voluntarily pay in daily life to reduce the risk of accidental death – those 350,000 lives represent a loss exceeding $3 trillion, or one-sixth of GDP. But when decades pass and little seems to change, even these figures lose their power to shock, and the public is inclined to focus its outrage on apparently more tractable problems."

In case you're one of the vast majority who actually haven't seen those estimates, or at least haven't mentally registered that they exist, here are a couple of the more recent underlying sources.

The Agency for Healthcare Research and Quality (part of the US Department of Health and Human Services) published in May 2015 the 2014 National Healthcare Quality and Disparities Report. Here are some good news/bad news statistics from the report:

From 2010 to 2013, the overall rate of hospital-acquired conditions declined from 145 to 121 per 1,000 hospital discharges. This decline is estimated to correspond to 1.3 million fewer hospital-acquired conditions, 50,000 fewer inpatient deaths, and $12 billion savings in health care costs. Large declines were observed in rates of adverse drug events, healthcare-associated infections, and pressure ulcers.

The good news is 50,000 fewer deaths, along with health improvements and saving money. The bad new is that the rate of hospital-acquired conditions basically fell from one patient in every seven patients to one out of every eight. Sure, hospital-acquired conditions will never fall to zero. But it certainly looks to me as if at least tens thousands of lives were being lost each year because that rate had not been reduced, and that tens of thousands of additional could be saved be reducing the rate further. For another analysis in a different setting, here's a 2014 US government study about adverse and preventable effects of care in nursing care facilities.

John T. James published "A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care" in the Journal of Patient Safety (September 2013, pp. 122-128). James reviews four studies of quality of care that focus on relatively small numbers of patients (three of the studies are less than 1000 patient records, the other is 2,300). He uses a software package called the Global Trigger Tool to flag cases where preventable errors might have occurred, and then those cases are examined by physicians. James describes the process this way:

http://conversableeconomist.blogspot.com/2015/11/how-many-deaths-from-mistakes-in-us.html

Irmat, a Mail-Order Pharmacy, Sues OptumRx in Latest Drug-Price Skirmish

By ANDREW POLLACKNOV. 13, 2015

Irmat Pharmacy on Park Avenue in Manhattan still looks like the neighborhood drugstore it has been since the 1970s.

But two years ago it added a new business as a nationwide mail-order dispenser of expensive drugs for acne and other skin conditions. That business has prospered, and Irmat has grown to 208 employees today from 20 in 2012.

Now, however, Irmat’s very existence is threatened, it says, because a large pharmacy benefit manager plans to stop doing business with it at the end of this month. Irmat is suing that company, OptumRx, which is owned by UnitedHealth Group, the insurance giant, in an effort to stop that from happening.

It appears to be the latest skirmish in a budding war between pharmacy benefit managers, which seek to rein in spending on drugs, and mail-order pharmacies, which have been increasingly enlisted by drug manufacturers to help protect their products from being swapped for cheaper generic alternatives.

In the most notable example, Optum, Express Scripts and CVS Caremark abruptly stopped doing business last month with Philidor Rx Services, which was reported to have used questionable tactics to increase the sales of dermatology drugs made by Valeant Pharmaceuticals International. Once those practices drew public criticism, Valeant said that it would sever its ties to Philidor and that Philidor would be closed.

This week Express Scripts, the nation’s largest pharmacy benefit manager, terminated its relationship with Linden Care, a Long Island pharmacy that participates in a program called Prescriptions Made Easy aimed at increasing the sales of pain relievers sold by Horizon Pharma. Linden Care filed suit seeking to revoke that action.

“Disclosures about Valeant and Philidor opened a lot of payers’ eyes as to what might be going on out there,” said Adam J. Fein, president of Pembroke Consulting, which tracks the pharmacy business. “Unfortunately, all pharmacies should now expect much greater oversight.”

http://www.nytimes.com/2015/11/14/business/irmat-a-mail-order-pharmacy-sues-optumrx-in-latest-drug-price-skirmish.html?mabReward=CTM&action=click&pgtype=Homepage&region=CColumn&module=Recommendation&src=rechp&WT.nav=RecEngine

A Baby Dies at Day Care, and a Mother Asks Why She Had to Leave Him So Soon

By AMBER SCORAH

 NOVEMBER 15, 2015 

As he did most mornings of the 117 days of his life, the first thing Karl did that Monday morning in July was to give me a smile like sunlight. He lay in the bed for a while, between his dad and me, looking from one of us to the other, working himself up with gurgles of delight. That morning, which started the same as all his others, would be a little different, however: it was his mommy’s first day back at work. 

In comparison with the other new mothers I knew, I felt lucky to have three months’ paid maternity leave after Karl was born. Most of the parents in my community had only weeks before they had to leave their babies to go back to work. But nonetheless, even with three months under our belts and Karl’s neck strong enough to hold himself up, I was uncomfortable with the idea of leaving him. I wanted to be his caregiver longer, until he was a bit bigger. I could see how our time together in this early infancy was of so much value, how being with me every day made him more and more comfortable navigating his new environment. I noticed how he looked to me to learn things and make sense of his world. I could tell how safe and secure he felt. Though it was a hard and tiring time, every minute with Karl felt like an investment in his current and future well-being. Not to mention I was hopelessly tickled with him.

As the end of my leave drew near, I asked my company for more time off, without pay. I was told by the HR department that there was no system in place that allowed for extending maternity leaves. I went higher up the chain. Just two more months? There was nothing that could be done. The only option would be to quit. 

I contemplated it. By the time I paid for child care in New York City, I was barely making much take-home pay anyway. But what compounded the financial concern was that if I quit, I would lose our health insurance. Lee, my partner, works freelance and Karl was covered under my work insurance. 

We are luckier than many: We sat down and did the math and maybe Lee’s wages could cover rent and food for a few months, but certainly not that as well as the cost of health insurance for a family of three, not to mention the portion we would be on the hook for in the case of a medical emergency. On top of that, I was very concerned about losing my job. I don’t have a degree, and though I’ve managed to carve out a position at a publishing company, the memory of the year I spent unemployed, trying unsuccessfully to get my résumé past the algorithms of online applications, loomed large. If I did it again, it would be with a little child in tow. 

Lee’s quitting was out of the question. There was no way we could pay all our bills on my salary, which is lower than his.

So we did the best, most responsible-seeming thing we could think of. After a long search, many waiting lists, interviews and a great deal of angst, we settled on a day care near my workplace. With this day care, I could still go over at lunch and breastfeed Karl, and have a visit with him, so we would never be apart more than a few hours. And the day care was recommended by many moms I knew who had similar circumstances to mine. It felt like a loving, safe space for Karl. 

HTTP://PARENTING.BLOGS.NYTIMES.COM/2015/11/15/A-BABY-DIES-AT-DAY-CARE-AND-A-MOTHER-ASKS-WHY-SHE-HAD-TO-LEAVE-HIM-SO-SOON/?ACTION=CLICK&PGTYPE=HOMEPAGE&REGION=CCOLUMN&MODULE=MOSTVIEWED&VERSION=FULL&SRC=MV&WT.NAV=MOSTVIEWED

Group bolsters efforts to enroll former inmates in Medi-Cal

Soumya Karlamangla

When Hilda Sims earned her release from prison last year after serving 22 years for murder, she got something that could dramatically reduce the odds that she'd ever have to return: health insurance.

For years, many who left California lockups on parole or probation would do so without easy access to medical care. For someone like Sims, who survived breast cancer behind bars, that meant health problems might go untreated or result in big medical bills just as they were struggling to return to society.

Studies have shown that lacking access to healthcare can make former inmates return to crime, eventually falling back into the prison system, says Elizabeth Siggins and her colleagues at the nonprofit advocacy group Californians for Safety and Justice.

It was a "population with a lot of need, a largely uninsured population, who was not getting access," Siggins said.

In 2013, however, the California Legislature passed a bill allowing county workers to help released prisoners enroll in the state's low-income health program Medi-Cal. Once limited to the disabled and mothers, Medi-Cal was greatly expanded under the Affordable Care Act last year — to anyone who makes less than $16,105 annually — and now the $91-billion program covers more than a third of state residents.

Sims — who testified against her husband and was convicted of first-degree murder in the kidnapping and shooting death of a Van Nuys woman in 1990, according to media reports — had an emergency mastectomy in 2011 while in state prison. When she moved to live with relatives in L.A. last year, she was worried she couldn't afford the follow-up care she needed.

HTTP://WWW.LATIMES.COM/LOCAL/CALIFORNIA/LA-ME-PRISON-HEALTH-20151116-STORY.HTML

Susan Collins leads Senate push against medication ‘price gouging’

By Russ Van Arsdale, executive director Northeast CONTACT

Posted Nov. 16, 2015, at 9:20 a.m.

Recent news reports about sharply rising drug prices — some of which have followed mergers — have raised a lot of questions. Now the leaders of the U.S. Senate Special Committee on Aging say they want answers.

Last week, Sens. Susan Collins, R-Maine, and Claire McCaskill, D-Missouri, announced a bipartisan investigation into the pricing of pharmaceuticals. They said in a statement that sudden, steep price increases — often on drugs that have been around for years — could inflate the cost of health care by hundreds of millions of dollars annually.

“Given the potential harm to patients across the country who rely on these drugs for critical care and treatment, the Senate Special Committee on Aging considers these massive price increases worthy of a serious, bipartisan investigation into the causes, impacts and potential solutions,” Collins said.

McCaskill said some of the pharmaceutical industry’s hikes “have looked like little more than price gouging.” She said consumers deserve to know the reasons for the big increases “that seemingly have no relationship to research and development costs.”

To get answers, the committee has asked Valeant Pharmaceuticals, Turing Pharmaceuticals, Retrophin Inc. and Rodelis Therapeutics for information about price hikes.

The committee is especially keen on finding out why certain drugs, which until recently had been under patent protection, suddenly cost a lot more when another company acquired the rights to manufacture them.

For example, in their letter to Turing the senators asked about the price of a drug used to treat malaria and toxoplasmosis, a cost that rose from $13.50 per pill to $750 per pill. In their letter to the chairman and CEO of Valeant, they asked about three drugs. The senators wrote that the cost of those three drugs rose between 312 percent and 2,949 percent.

http://bangordailynews.com/2015/11/16/business/susan-collins-leads-senate-push-against-medication-price-gouging/print/