Saturday, May 12, 2018

Health Care Reform Articles - May 12, 2018

Medicine Universal health care, worldwide, is within reach

The case for it is a powerful one—including in poor countries

The Economist - April 26, 2018
The case for it is a powerful one—including in poor countries
BY MANY measures the world has never been in better health. Since 2000 the number of children who die before they are five has fallen by almost half, to 5.6m. Life expectancy has reached 71, a gain of five years. More children than ever are vaccinated. Malaria, TB and HIV/AIDS are in retreat.
Yet the gap between this progress and the still greater potential that medicine offers has perhaps never been wider. At least half the world is without access to what the World Health Organisation deems essential, including antenatal care, insecticide-treated bednets, screening for cervical cancer and vaccinations against diphtheria, tetanus and whooping cough. Safe, basic surgery is out of reach for 5bn people.
Those who can get to see a doctor often pay a crippling price. More than 800m people spend over 10% of their annual household income on medical expenses; nearly 180m spend over 25%. The quality of what they get in return is often woeful. In studies of consultations in rural Indian and Chinese clinics, just 12-26% of patients received a correct diagnosis.
That is a terrible waste. As this week’s special report shows, the goal of universal basic health care is sensible, affordable and practical, even in poor countries. Without it, the potential of modern medicine will be squandered.
How the other half dies
Universal basic health care is sensible in the way that, say, universal basic education is sensible—because it yields benefits to society as well as to individuals. In some quarters the very idea leads to a dangerous elevation of the blood pressure, because it suggests paternalism, coercion or worse. There is no hiding that public health-insurance schemes require the rich to subsidise the poor, the young to subsidise the old and the healthy to underwrite the sick. And universal schemes must have a way of forcing people to pay, through taxes, say, or by mandating that they buy insurance.
But there is a principled, liberal case for universal health care. Good health is something everyone can reasonably be assumed to want in order to realise their full individual potential. Universal care is a way of providing it that is pro-growth. The costs of inaccessible, expensive and abject treatment are enormous. The sick struggle to get an education or to be productive at work. Land cannot be developed if it is full of disease-carrying parasites. According to several studies, confidence about health makes people more likely to set up their own businesses.
Universal basic health care is also affordable. A country need not wait to be rich before it can have comprehensive, if rudimentary, treatment. Health care is a labour-intensive industry, and community health workers, paid relatively little compared with doctors and nurses, can make a big difference in poor countries. There is also already a lot of spending on health in poor countries, but it is often inefficient. In India and Nigeria, for example, more than 60% of health spending is through out-of-pocket payments. More services could be provided if that money—and the risk of falling ill—were pooled.
The evidence for the feasibility of universal health care goes beyond theories jotted on the back of prescription pads. It is supported by several pioneering examples. Chile and Costa Rica spend about an eighth of what America does per person on health and have similar life expectancies. Thailand spends $220 per person a year on health, and yet has outcomes nearly as good as in the OECD. Its rate of deaths related to pregnancy, for example, is just over half that of African-American mothers. Rwanda has introduced ultrabasic health insurance for more than 90% of its people; infant mortality has fallen from 120 per 1,000 live births in 2000 to under 30 last year.
And universal health care is practical. It is a way to prevent free-riders from passing on the costs of not being covered to others, for example by clogging up emergency rooms or by spreading contagious diseases. It does not have to mean big government. Private insurers and providers can still play an important role.
Indeed such a practical approach is just what the low-cost revolution needs. Take, for instance, the design of health-insurance schemes. Many countries start by making a small group of people eligible for a large number of benefits, in the expectation that other groups will be added later. (Civil servants are, mysteriously, common beneficiaries.) This is not only unfair and inefficient, but also risks creating a constituency opposed to extending insurance to others. The better option is to cover as many people as possible, even if the services available are sparse, as under Mexico’s Seguro Popular scheme.
Small amounts of spending can go a long way. Research led by Dean Jamison, a health economist, has identified over 200 effective interventions, including immunisations and neglected procedures such as basic surgery. In total, these would cost poor countries about an extra $1 per week per person and cut the number of premature deaths there by more than a quarter. Around half that funding would go to primary health centres, not city hospitals, which today receive more than their fair share of the money.
The health of nations
Consider, too, the $37bn spent each year on health aid. Since 2000, this has helped save millions from infectious diseases. But international health organisations can distort domestic institutions, for example by setting up parallel programmes or by diverting health workers into pet projects. A better approach, seen in Rwanda, is when programmes targeting a particular disease bring broader benefits. One example is the way that the Global Fund to Fight AIDS, Tuberculosis and Malaria finances community health workers who treat patients with HIV but also those with other diseases.
Europeans have long wondered why the United States shuns the efficiencies and health gains from universal care, but its potential in developing countries is less understood. So long as half the world goes without essential treatment, the fruits of centuries of medical science will be wasted. Universal basic health care can help realise its promise.

This article appeared in the Leaders section of the print edition under the headline"Within reach"

The importance of primary care

Good primary care is an essential precondition for a decent health-care system
The Economist - April 26, 2018
IT IS MONDAY morning at Connaught hospital in Freetown, the capital of Sierra Leone, and the accident and emergency department is abuzz. One of only four specialist hospitals in the country, it should provide the sophisticated care not available elsewhere. Instead, like many urban hospitals in poor countries, it is full of people with simple problems that should have been dealt with through primary care (the generalist branch of medicine), or patients with complex conditions that should have been treated earlier.
For many patients Connaught is a last resort. If they find themselves ill, their first response is to hope that their symptoms will pass; their second is to self-medicate. This may involve a visit to a drugseller, perhaps buying a “shotgun bag” containing a few days-worth of antimalarial medicine, antibiotics and painkillers. If that does not work, they go to Connaught. A board in the entrance of the A&E ward lists prices, from 10,000 leones ($1.30) for catheterisation to 30,000 ($3.90) for a transfer to a bed. Once admitted, patients have to pay extra for food and supplies. About half of the nurses are not on the payroll but come in the hope of picking up work. Consultation can easily turn into negotiation. That can harm patients. And if clinicians do not treat what they have diagnosed, they will be slower to learn.
If you fall ill in Sierra Leone, Connaught is one of the better options. But both its staff and its patients are victims of the sort of dysfunctional health system common in poor countries. In November the IHME and the University of Washington published the latest volume of its Disease Control Priorities report (known as DCP3), one of the most influential documents in global public health. It tries to set out which treatments and policies poor countries should prioritise, based on the most cost-effective ways to improve healthy life expectancy and prevent financial catastrophe. “Unfortunately,” notes the report, “most countries lack health systems that meet this standard.”
In many developing countries people get their health care mostly from informal private providers such as drug shops or unqualified practitioners. In India, informal providers account for three-quarters of all visits. The figures in other countries are similar, if mostly less extreme: 65-77% in Bangladesh, 36-49% in Nigeria and 33% in Kenya. Often these markets exist side by side with public-sector providers who rely on patients paying for drugs and tests, as in China, despite a spate of recent regulations.
It is easy enough to measure how long patients have to wait or whether drugs are available. In rural India, for example, 66% of the population does not have access to preventive medicines, and 33% must travel more than 30km to get treatment. But answering the most important question—whether a problem is diagnosed and treated correctly—has proved harder. That is why recent research by Jishnu Das of the World Bank and colleagues is so welcome. Inspired by “mystery shoppers” who visit supermarkets, they send “standardised patients” to clinics across the world. These patients present with symptoms that are specific to particular diseases. After the consultation they are quizzed on whether the health workers adhered to clinical guidelines.
The findings show widespread woefulness. In one Chinese study the average consultation time was a minute and a half. In India the average length was double that, but one-third of the visits lasted just one minute and featured a single question: “What is wrong with you?” Only 30% of consultations in India and 26% in China resulted in correct diagnoses, and patients were more likely to receive unnecessary or harmful treatment than the correct sort. Studies in Paraguay, Senegal and Tanzania have produced similar results.
Before 1995 just 25% of Costa Ricans had access to primary health care; by 2006 the share was 93%
The consequences of such ineptitude are severe. In India about half a million children die of diarrhoeal diseases every year. In a study in Delhi only 25% of providers asked parents whether there was blood or mucus in the child’s stool, a clear symptom of such disease. Health workers who had undergone more training provided more accurate diagnoses, but that alone is not enough. Curiously, Mr Das and his team also found that, even when clinicians know what treatment should be given, they often do not provide it. In one study 74% of Indian clinicians were able to tell researchers how to deal with patients suffering from angina, asthma or diarrhoea, but when visited by mystery “patients” presenting with exactly these symptoms, just 31% treated them correctly. One explanation for the “know-do gap” is that patients generally know far less about the best course of action than clinicians, who can get away with under- or over-treatment when they are not held accountable for their work.
Other developing countries provide much better care at low cost. An exemplar is Costa Rica, whose model shows the benefit of high-quality primary health care. This is often ignored as countries splurge on big hospitals. “Primary care is not heroic,” explains Asaf Bitton of Ariadne Labs, “but it works well.” Between 1995 and 2002 Costa Rica established more than 800 “Equipos Básicos de Atención Integral de Salud”, or integrated primary-health-care teams, each looking after 4,000-5,000 people. The teams are made up of a technical assistant, who visits patients at home; a clerk who keeps up-to-date records; a nurse; a doctor; and a pharmacist. The doctors have a lot of scope to run the teams the way they think best, but the health ministry holds them accountable for their patients’ outcomes.
Before the programme was in place, just 25% of Costa Ricans had access to primary health care; by 2006 the share had risen to 93%. It was introduced in stages, which enabled researchers to assess its impact. A study in 2004 found that for every five years it was in place, child mortality declined by 13% and adult mortality by 4%, compared with areas not yet covered. Another study estimated that 75% of the gains in health outcomes resulted from the reforms.
Supply-side reforms to health care in other countries have also brought dramatic improvements. Thailand in the 1980s froze capital investment in urban hospitals and reallocated the funding to primary-care centres, which cut mortality rates. Ethiopia since 2004 has trained more than 38,000 “health extension workers”, rural high-school graduates who undergo a year’s training before being sent back to their local area. They have helped cut child and maternal mortality by 32% and 38% respectively. In Rwanda each village has to have three community health workers, elected by their peers, who offer basic services and make referrals. “People who have a minimum education can do a lot,” says Agnes Binagwaho, a former health minister.
One lesson from countries like Rwanda is that closing the gap between knowledge and action requires reforms far beyond the consultation room. Training helps, but so do incentives and accountability. When Rwandan health workers were paid to adhere to clinical guidelines, their performance improved. And when rural Ugandans were given more information about the quality of local health services, clinicians did a better job.
But care needs to be taken to set the right incentives. Doctors who are rewarded for prescribing medicines will overdo it. One study from 2013 found that more than half of all outpatient prescriptions in China contained antibiotics (the WHO suggests the share should be less than 30%). China has also rapidly expanded hospitals over the past 20 years; today it has more hospital beds per person than Britain or America. Yet between 2002 and 2013 the number of primary-care providers actually fell.
Have you taken your medicine?
Aid organisations can make matters worse. If you drive from Freetown to Kono in the east of Sierra Leone, you will pass a graveyard of failed projects. Signs mark clinics built but never staffed. But in Kono, with the help of Partners in Health, an American charity, Dr Barrie is trying to buck the trend. This region of 500,000 people has just two doctors who are paid by the government. That makes the job of Mabel Konoma, a community health worker, even more vital. Every morning she visits patients with tuberculosis or HIV. As she goes from house to house, she asks people whether they have taken their medicines. One woman with HIV says she has struggled since villagers started shunning her rice stall because of the stigma attached to the disease. No custom means no money, no food and no medicine. Mabel takes a note and arranges for the woman to receive food.
When patients need further care they are referred to the Wellbody clinic, a primary health centre. Unlike most in Sierra Leone, it does all of the basics well. On arrival, patients are screened for signs of Ebola as a precaution, and triaged. They receive an electronic record number so their cases can be tracked. This is useful in Sierra Leone where many first-born children are given the same name: Sahr for boys and Sia for girls. Because of the shortage of doctors, Wellbody has trained “associates”, somewhere between a nurse and a doctor.
It also has an obstetrics wing, where pregnant women with potential complications wait to give birth. Sierra Leone has one of the world’s highest rates of maternal mortality, partly because most women would rather give birth at home with the help of traditional birth attendants than go to a clinic far from home that may lack trained midwives or perhaps even electricity. Wellbody is properly equipped, and to encourage women to give birth there it allows the birth attendants to come, too.
DCP3, the value-for-money report, says that for maximum cost-effectiveness, poor countries would spend about 50% of any increase in funding on primary care and 18% on community care. Yet although these are the building blocks of strong health systems, by themselves they are not enough. Hospitals will always be needed to provide emergency and specialist care. This is particularly true in a field that campaigners for universal health care rarely mention: surgery.
This article appeared in the Special report section of the print edition under the headline "First things first"

Sensible, single payer

by Jim Cook - Sacramento News and Review - May 2 2018

The numbers speak volumes.
Five years ago, 40 million Americans were without health insurance. Today, that number is 45 million and growing, with 18,000 dying each year from a lack of health care. 
In response, many politicians have produced “reforms” that side with drug manufacturers, insurance companies and large corporations like Wal-Mart, instead of the hardworking people they were elected to represent. They have tried to silence working families and seniors with complex schemes like “health savings accounts,” “association health plans,” “discount cards” and inefficient programs that require a Ph.D. in bureaucracy to be understood. 
The people have been promised change, but all we’ve gotten is lip service, confusion and miles of red tape. We’ve been promised increased affordability and access, but we’ve gotten double-digit increases in insurance premiums, co-payments, deductibles and prescription-drug costs. 
So, who benefits from a broken health-care system? Who else? Special interests and the politicians who protect them. It comes as no surprise that insurance companies, drug manufacturers and irresponsible employers that shift their employees’ health-care costs onto the shoulders of taxpayers are making record profits—or that they have spent hundreds of millions of dollars waging a war of misinformation against every meaningful health-care reform proposed in the past 10 years. 
Meanwhile, nearly 7 million Californians now lack health insurance, 10 million lack drug coverage, and more than 80 percent of the uninsured are members of the same working families that drive our state’s economy. Worst of all, 20 percent of our children have no health insurance at all.
It’s time for elected officials who will stand up for a real health-care solution. Single-payer health care (Senate Bill 840 by Sheila Kuehl) would insure every Californian; eliminate the uncertainty of losing coverage during life transitions; improve health-information systems; and provide both consumers and taxpayers with fewer costs, greater choices, better care and improved efficiency. 
Because a single-payer system corrects the abuses of those who benefit from the current system, we must stand united against another campaign of deception designed to undermine sensible health-care reform.

Hold off on single-payer

by Jeff Vonkaenel - Sacramento News and Revies - June 29, 2017

I support the idea of a single-payer health insurance system. But I have to agree with California Assembly Speaker Anthony Rendon’s shelving of the single-payer legislation, Senate Bill 562, the Healthy California Act, which was recently passed by the California Senate.
In a press release, Rendon explained “… there are potentially fatal flaws in the bill, including the fact it does not address many serious issues, such as financing, delivery of care, cost controls, or the realities of needed action by the Trump Administration and voters.”
A single-payer health care system—sometimes called “Medicare for all”—would use tax funds to pay the health care costs of all residents, regardless of income, occupation or health status. It would replace the current system, in which select individuals or employers purchase health insurance from private companies that offer varying levels of coverage and cost.
In other words, goodbye insurance companies, hello government. Advocates for the single-payer system believe that a major reason why health care is so expensive in America, even though we don’t provide universal coverage, is because of our for-profit health insurance system. Annual health care costs per capita in the United States are $9,024 on average, compared to $3,620 in other developed countries, according to a June 2016 report from the Organisation for Economic Co-operation and Development.
After comparing American health care costs and those of our sister countries, any rational person would want to adopt the Canadian or European health care model, with the obvious exception of the beneficiaries of our current bloated system—insurance companies, doctors, pharmaceutical companies and politicians receiving campaign donations.
A recent Morning Consult-slash-POLITICO poll showed that 44 percent of Americans support single-payer health care, where “all Americans would get their health insurance from one government plan.” Only 36 percent of those surveyed were opposed.
We should move to a single-payer system. But we can make things worse if we don’t plan carefully. SB 562 is not a carefully worked-out plan. It does not include cost controls, address funding sources or map out the logistics of a transition. And the fact that it is being used as a political football by the California Nurses Association and others is not helping the situation. Besides, the plan would work only with federal cooperation, which seems unlikely.
I would love to see the California Legislature sort this all out and come up with a workable plan. However, a more attainable approach to reforming health care and moving toward a single-payer system might be for California to set up a government-run public-option plan. That is what Nevada’s Democratic legislators recently passed, only to have it vetoed by their Republican governor.
The Nevada Care Plan, while separate from the state Medicaid plan, would have offered benefits similar to those provided by Medicaid. Anyone, regardless of income, could choose to participate in the plan. It would compete with the other plans in the marketplace. I believe, and the insurance companies fear, that the government-run public-option program would be more efficient than our current for-profit insurance system, just as our government-run Social Security system has lower administrative costs than for-profit retirement plans.
This would not be single-payer, but it would be a move in the right direction. We’d be able to determine whether the government could run the public-option system more effectively than the for-profit insurance companies. If the government can do that, then over time we could move toward a much saner health-care system.

The Royal Baby Is Lucky He Wasn’t Born in America

by Laurie Garrett - Foreign Policy - April 24, 2018

On April 23, the Duchess of Cambridge gave birth to her third child in a posh London maternity center called the Lindo Wing inside St. Mary’s Hospital, where a small army of attendants looked after her and Prince William for 24 hours in a secluded, luxurious room at a cost of $8,900, according to the Economist. Mother Kate and her 8-pound, 7-ounce baby boy are hale and hearty by all accounts.
Most Western Europeans and Canadians, of course, don’t deliver babies in the Lindo Wing. Otherwise, however, their treatment and outcomes are pretty much consistent with the royal couple’s. Parents pay nothing for their maternity care and delivery, with low risks of maternal and infant mortality.
Americans, by contrast, are saddled with the worst maternal health care in the West. If they do not realize their system is in scandalous disrepair, it is only because they have become inured to it.
The average American woman gives birth in a noisy hospital with few frills or amenities and for an average cost of $12,290. Everything is quite average, in terms of quality and aesthetics in the birthing environment, except, on a worldwide scale, the costs. Should she require a cesarean section (an average of $16,907) or any emergency services, her bill could swiftly soar above $30,000. Have premature triplets and costs top $870,000. Young parents, at the beginnings of their careers and earnings, are on the hook for thousands of dollars, regardless of what health plan they may have.
Meanwhile, the U.S. infant mortality rate in 2017 was 6.1 deaths for every 1,000 births, which is about three times higher than Japan’s and is one of the worst death rates in the entire Organization for Economic Cooperation and Development (OECD). America leads the wealthy world in maternal death rates by far. According to the Institute for Health Metrics and Evaluation at the University of Washington, 26.4 mothers died of pregnancy-associated causes in 2015 out of every 100,000 births, which is three times the rate of the next worst, the United Kingdom, and more than six times the maternal mortality rates of Finland, Denmark, and Italy.
According to the National Academy of Medicine, the United States lags far behind the rest of the OECD for a long list of health problems, including maternal and infant mortality. In the OECD, only Turkey and Mexico had higher infant mortality rates than Mississippi, and the state with the best infant mortality in the United States — New Hampshire — would still rank way down at 28 in OECD stature. From 2001 to 2010, compared with the rest of the OECD, “the risk of death in the US was 76 percent greater for infants and 57 percent greater for children ages 1-19.” For the last two years, average life expectancy in the United States has fallen backward, now at a male/female combined 78.7 years. The average for the rest of the OECD? 80.3 years.
Americans also pay for the privilege of these terrible results. In 2016, Americans spent $3.3 trillion on health care, almost 18 percent of GDP. One study found that Americans used health care services at about the same rate as Europeans — perhaps even less — yet paid nearly twice as much for just about everything. As health economics analyst Martin Gaynor put it to NBC News, the whole health system is on an upward spiral, ultimately hurting patients the most: “When health care costs more, that means health insurance premiums are higher and when premiums are higher, employers pay more. Employees indirectly pay for most of that,” with higher deductibles, copays, and premiums.
Thanks to the Affordable Care Act (ACA), also known as Obamacare, fewer Americans are uninsured in 2018, though the Congressional Budget Office estimates that changes made by Republicans to the ACA will lead to loss of insurance for 9 million Americans by the end of 2019. But even the so-called fully insured quickly discover the U.S. system’s inadequacies as soon as they suffer a serious illness. A teacher in Andover, Massachusetts, says she was firedwhen the school board discovered her son’s cancer care cost $1 million. A woman recovering from back surgery was slapped with a $17,850 bill for lab tests that her insurer, Blue Cross and Blue Shield of Texas, refused to cover. Even Medicare recipients are suffering, with a third of them in 2013 spending at least 20 percent of their total annual income on out-of-pocket health costs.
Today, tens of thousands of Americans are crowdfunding their health care, searching for help to offset the costs that their insurance companies refuse to cover. The crowdfunding website YouCaring has a special section for medical fundraisers, through which strangers are asked to help pay for, for example, a teenager named Edoardo’s stage 3 cancer care or the treatment and physical therapy for teens Angel and John — he, shot by an unknown assailant and left paralyzed, while she is in a coma after having been run over by a vehicle fleeing the scene. Another popular crowdfunding website, GoFundMe, also has a special medical section, where Orla raised $80,000 for a lung transplant; Janie, $19,000 for Lyme disease care; Dave, $43,000 to deal with his brain tumor; and Tara, $30,000 for post-stroke rehabilitation.
It has come to this. America is a nation of beggars, forced to seek the pity of strangers who may, in turn, choose who shall live based on charity and who shall die for lack of financial support. A blonde 2-year-old girl in a ballerina tutu may garner more such kindness than a black 10-year-old boy in a Black Panther suit, who in turn gleans greater compassion from the online masses than a 50-year-old gunshot victim or an elderly Latina dying from diabetes. It’s like a macabre version of the 1950s TV show Queen for a Day, in which needy women pleaded for a fridge, dishwasher, new flatware, or a smart set of work clothes and an “applause-o-meter” was used to measure studio audience choices.

In a sensible health care system, there are no applause-o-meters; insurance actually covers patients’ costs; drugs and medicines are purchased in volume to bring down those prices; and life expectancy is independent of personal income. But America never had anything approaching such health care, and many on Capitol Hill would like to see the role of government as both a financer and regulator of health further diminished.
Prince William is estimated to be worth $40 million, and he stands to inherit some of his grandmother’s estate valued at well over $1 billion just in real estate. He can afford to spend the $8,900 for the best maternity care available in the U.K. Sadly, that is a burden few American couples aged 20-24, earning on average $27,300 per year, or 25- to 34-year-olds, with an average household income of $40,352 per year, could manage. But, of course, none of them can hope to find a hospital that will provide such a princely birthing bargain in the first place, as costs in the United States, for everything from basic to high-end care, are far higher. Even if they are fortunate enough to be well-insured through an employer plan, young Americans are likely to face deductibles of $3,000 to $5,000.
The results is that the royal couple paid about 0.000025 percent of their wealth to have their third child. For the less grandly wealthy young couples in the U.K., the National Health Service bears most of the costs of vaginal childbirth. Costs for a typical young couple having their first child in the United States are 13 times more than those shouldered by their U.K. counterparts. A typical set of U.S. parents puts out about 10 percent of their wealth to pay the uncovered portion of maternity costs.
It may be an overstatement to say that every American baby deserves to be born in the equivalent of the Lindo Wing, costing just $8,900. But it damned well ought to be true that every mother goes through labor in a safe, clean, comfortable setting, her baby caught by a competent caregiver, without parents fretting over how in the world they will pay their newborn’s medical bills.

Letter to the editor: Canada’s single-payer system works

If you want everyone to have access to good medical care, move away from the current profit-based system.
Portland Press Herald - May 7, 2018
In his letter to the editor May 2, Don Vose of Naples argued that a single-payer health care system would not serve us well, referring in part to Canadians “forgoing” their single-payer system.
This may be a commonly held view, but it is not accurate. A poll by Nanos Research found that 86.2 percent of Canadians support the single-payer system and want to strengthen it, rather than move toward a private insurance-based model. This is because on the whole, regular people are well served by this system. Under a single-payer system you will not find yourself in a “coverage gap,” you are not charged a dime if you get hit by a car and you will never go bankrupt if you get cancer, no matter what.
I have experienced both health care systems after marrying a U.S. citizen and moving to Maine. In Canada I had a great doctor, could stop in any walk-in clinic in town if I needed and was always able to access the specialist care I required. Here, I know many people without health care coverage, and I fear that with one wrong move or unlucky break I could be forced to join their ranks.
Altogether, Canada’s single-payer system is not as radically different as some think. A mix of private businesses (including doctors, the majority of whom are self-employed) bill the government for the services they provide; as a rule, the government doesn’t own facilities or employ health care professionals.
Bottom line: If you want everyone to have access to good medical care, move toward single-payer and away from the current profit-based system.
Hillary Barter

Love the 'Smart' Functions in EHRs? I Don't

Shortcuts aim to make entries easier, but the reality is more complicated

by Fred Pelzman - Medpage Today - May 4, 2018

How smart do we want our electronic health record to be?
Somewhere between as dumb as a piece of paper and a pen, and too smart for our own good.
Many, many years ago, before we spent the majority of our office visit staring at a flatscreen LED and typing away, our charts were simple manila folders with those bendy metal bars that allowed you to insert new pages, separated into multiple sections with cool little colored divider tabs.
You'd open up the chart, find the most recent progress note, go to the end of that one, and just start writing.
Sure, there were red pages that listed allergies, little flags that said whether the patient was a smoker, yellow pages where a patient's medical problem list were supposed to be kept updated, a separate page for medications, then a lot of laboratory and imaging and miscellaneous sections.
Paper and pen.
Not much room for natural language processing, population health management, data analysis, or artificial intelligence.
If you wanted to find out something, you had to go back and flip through the pages. Trying to remember when an event took place, whether this had happened before, trying to spot trends in their blood pressure or their renal function, all took place manually.
And remember all the chart reviews we had to do manually if you were interested in doing a research project?
Stacks of charts piled on your desk, incredibly labor-intensive work digging through all those pages trying to find what you're looking for.
Today, we have something more, something smarter, and yet we are still going through growing pains trying to figure out how to have the electronic health record work for us instead of the other way around.
Those who designed it are convinced that it fills our needs, that it gives us everything we want.
Now, it's certainly better than what we had before.
Remember the countless hours we spent tracking down lab reports, radiology reports, or consultant notes, and then manually having to put them into the chart?
Refilling medications has become a breeze, and despite all our complaints about the button clicking it takes, it's clearly worlds better than in those earlier days, that exasperated feeling we used to have at the end of an appointment when a patient would say "Oh yes, and I need all my medicines".
Handwriting out a dozen or more prescriptions on a paper prescription pad, or even worse a triplicate form for controlled substances, would leave us with cramps at the end of a long day of refilling meds.
And I can trend someone's complete blood count to spot a gradual developing problem.
And I can reconcile medications from outside sources.
And for our patients who see specialists and subspecialists within our own institution, their consultation notes are instantly available for us to view, to know what happened at those appointments.
But some of the bells and whistles that have been built really don't add much to care, and they were often created by people who think they are making our lives easier.
As part of our institution's plan to do a huge conversion to bring every provider within the organization under the same electronic health record, we've been going through the functionality piece by piece, line by line, to see what's there, to try and figure out what to put in for everyone to use, to try and standardize, minimize, streamline.
Each area of clinical care, Emergency Medicine, Critical Care Units, Surgery, ENT, Ob/Gyn, Pediatrics, Adult Internal Medicine, and so on, each has their core team of clinical advisors who are going through all of the tools and widgets that providers have available to document the care of our patients within the electronic health record.
The goal set for the team is to figure out what is useful, and what is not, to make a limited number of suggestions for things to add or change, and hopefully find a lot of things we can get rid of.
Just recently we started going through all of these in a weekly conference call, and all of the providers on the phone have been amazed at what's there.
Most users of electronic health record barely scratch the surface of the functionality that hides within.
But are these worth it?
Do the macros, templates, forms, and smart sets, really make our lives and the lives of our patients better?
Take for instance those Smart Sets.
They were created to help streamline an episode of care around a single clinical situation that providers within that specific specialty frequently encounter.
They are an attempt to make it easier to collect the history, a review of systems, physical exam, and place any orders specific to the management of that particular problem.
There's a Smart Set for just about everything.
Sinusitis. Routine well woman exam. Chest pain. Upper respiratory tract infection. Urinary tract infection. School health form.
The list just within outpatient adult primary care goes on for several pages, and each different specialty has their own list of shortcuts, macros, and templated texts.
Often these take the form of sections where you can move from question to question, toggling between yes or no, present or absent.
Take for instance gastroenteritis.
Here's a little bit of the Smart Set that is built into the electronic health record for patients presenting to the office with symptoms suggestive of gastroenteritis:
Subjective: This <AGE> year old <GENDER> presents with these symptoms:
Abdominal pain:{YES/NO:***}
Nausea: {YES/NO:***}
Fever: {YES/NO:***}
Duration: ***
Relevant dietary history: ***
Similar illness in contacts: {YES/NO:***}
Recent antibiotic use: {YES/NO:***}
Past Medical History/Diagnosis Date:
Objective: BP ***/*** | Pulse *** | Resp ** | SpO2 **% | Breastfeeding? No
Gen: well-nourished, well-developed ***male, NAD, healthy-appearing
Head: normocephalic, atraumatic
Eyes: EOMI, anicteric sclerae, pink conjunctivae
CV: RRR, no murmurs/rubs/gallops appreciated, PMI- 5ICS-MCL
Lungs: clear to auscultation b/l, good air exchange, no respiratory distress
Abdominal exam:
Bowel sounds: {ABDOMEN AUSCULTATION:***}
Rebound: {YES/NO:***}
Masses: {YES/NO:***}
Ext: no edema
Assessment: Gastroenteritis
Plan: Current Outpatient Prescriptions on File Prior to Visit: <PULLED FROM ACTIVE MEDICATION LIST>
Patient Education:
Pt counseled to drink frequent small amounts of clear fluids (especially Gatorade), then advance diet as tolerated. May try BRAT diet if desired, use meticulous hand washing, avoid dairy products for now, and rest as much as possible. Pt to call or return if high fever, worse abdominal pain, severe weakness or fainting, or bloody stools occur or if sx not fully resolved in 2-3 days.
These things are designed so that if there's something I see frequently, using this Smart Set will make my life easier, as I can quickly flow through these fields to fill in the information to give me a fully fleshed out history, physical exam, and plan for care of the problem.
The problem is, for most of the things we do, there's nuance in how patients present, how we interpret it, and how we proceed down the clinical pathway that helps us get to a decision.
Rarely is one presentation enough like all the others that these templates are really going to end up saving us much time.
True, there certainly are things that we do exactly the same way every time, and if we can find ways to save on keystrokes, clicks, and typing, then more power to those who provide them.
But for those of us who live and breathe in the words of the history, the subtleties of the physical examination findings, and a carefully crafted assessment and plan, this often feels like we're trying to squeeze our patients into a rigid set of yes/no questions that they rarely comfortably fit into.
Just the other day, I saw an elderly patient with gastroenteritis, and it was only after I'd finished typing my history, documenting relevant findings on her physical examination, and clearly stating my plan for what we were going to try next, did it even occur to me to try typing the commands that brought up the gastroenteritis Smart Set.
In some ways, it looked a lot like my note, but it felt cold, sterile, and clinical -- and not in a good way.
Maybe we should get better at using these, and maybe we should try to figure out ways to make them feel more natural, more like the way we really take a history and document what we find.
Our hope is that the electronic health record can evolve in the future, become more than just a glorified word processing system, and that together we can learn to harness its computational power and the new tools of natural language processing and artificial intelligence to help us identify gaps in care, recognize trends, start to become proactive and predictive in the care we provide rather than reactive.
I'm sure lots of folks out there using this functionality of the electronic health record really love using shortcuts, and I'm not saying we should get rid of them all.
But as we build a 21st-century tool to help us take care of our patients, we need to insist that it's not just templates and macros we need, but a smart electronic system that stands by our side and augments the care we provide.

Surge in 'Deaths of Despair' Hits the US

by Megan Brooks - Medpage Today - May 3, 2018Gaps in mental health care services are pervasive in the United States, at a time when deaths from suicide, alcohol, and drugs have surged, according to a new report released today by the Commonwealth Fund.
The combined rate of deaths from suicide, alcohol, opioids, and other drugs — sometimes called "deaths of despair" — increased 50% from 2005 to 2016. Rates rose in all states, doubling or more than doubling in Delaware, New Hampshire, New York, Ohio, and West Virginia, the report notes.
What's more, the pace seems to have picked up. Average annual growth in deaths of despair was 3% per year from 2005 to 2014 but tripled to 9% from 2015 to 2016.
"This is one of the most troubling mortality trends we see in this year's report," David Radley, PhD, senior scientist at the Commonwealth Fund, noted in a media briefing outlining key findings from the Commonwealth Fund's 2018 Scorecard on State Health System Performance.
The report assesses all 50 states and the District of Columbia on 43 measures dealing with access to healthcare, quality of care, efficiency in care delivery, health outcomes, and income-based healthcare disparities.
"The Scorecard reports, published since 2006, are a comprehensive overview of how well the healthcare system is working for the American people," said David Blumenthal, MD, president of the Commonwealth Fund.
Although the 2018 Scorecard report provides some "good news about the direction we are heading, we do continue to see wide disparities between states," said Blumenthal.
"Also of concern are some areas where we see no progress or even reversal of positive trends. For example, life expectancy has fallen, in large part due to the opioid epidemic; premature deaths from preventable or treatable causes are increasing in many states; and obesity rates continue to rise representing a public health crisis of grave concern," Blumenthal said.

Unmet Mental Health Care Needs
The report confirms that accessing mental health care is tough in the United States. Up to one quarter of adults with a mental illness reported a need for care that was not met during the 2013-2015 period, and up to one third of children needing mental health treatment in 2016 did not receive it. Across states, 41% to 66% of adults with symptoms of a mental illness received no treatment in 2013-2015.
Deaths from treatable conditions are also moving in the wrong direction. After trending downward for most of the past decade, there has been an uptick nationally in premature deaths from preventable or treatable causes — a measure called "mortality amenable to health care."
Two thirds of states saw an increase in 2014-2015 in this measure. In six states — Colorado, Maine, Nebraska, Oklahoma, Vermont, and Wyoming — the increase was greater than 5%.
"Premature deaths are on the rise in states across the country. Some of this is driven by deaths from substance abuse, but increases in deaths from treatable conditions is a sign that healthcare systems are also falling short," said Radley.
Obesity remains an ongoing public health threat as well, the report notes. In Mississippi and West Virginia, the proportion of adults who are obese reached 39% in 2016. Even in states with the lowest rates, a quarter of all adults are obese.
Best, Worst Performers
Still, on balance, the 2018 report shows that across all dimensions of performance of state healthcare systems, there was more improvement than worsening from 2013 to 2016 — a reversal of what happened during the 2000s, when progress stalled or perfomance worsened.
By region, New England, the Upper Midwest, and several states in the West are at the top of the overall rankings. Southern states generally rank at the bottom.
By individual state performance, Hawaii, Massachusetts, Minnesota, Vermont, and Utah are the top-ranked, and Louisiana, Oklahoma, and Mississippi are the bottom-ranked.
California and Oregon made the greatest gains, jumping 9 and 10 spots, respectively. Both states expanded eligibility for Medicaid.
New York improved on 18 of the 37 indicators tracked over time, the most of any state. Arkansas, Louisiana, Oklahoma, and West Virginia each improved on 17 indicators.
The report also shows that the expansion of Medicaid has led to gains in access to care. In 47 states, the rate for adults aged 19 to 64 who are uninsured was at least five percentage points lower in 2016 than it had been in 2013. Eleven of the 13 states in which there was at least a 10-point drop had expanded Medicaid overage by January 2016. During this time, there was also a drop in the percentage of people reporting that they had not gone to the doctor when needed, owing to cost. States that expanded Medicaid coverage saw greater improvement, on average, than states that did not.
"Scaling back or even repealing pieces of the Affordable Care Act could put many of those improvements that we see in the Scorecard in jeopardy across states," Radley warned.
The report concludes that if every state achieved the performance of the top-ranked state on each indicator, the gains in healthcare access, quality, efficiency, and outcomes would be "dramatic." With the current rates of improvement, however, it may take many years or decades for states and the nation to see such progress.

Physicians, Patients Frustrated by Unexplained Care Costs
by Marcia Frellick - Medpage Today - April 26, 2018
NEW ORLEANS — Physician frustration was evident during a session on how to talk with patients about the costs of care on the closing day of the American College of Physicians (ACP) Internal Medicine Meeting 2018.
Patients don't know what costs are coming. And physicians often don't know what care costs because insurance status, type of insurance, negotiated rates, deductible status, and other factors affect specific charges.
When recommending options, doctors must find a balance between optimal care and the financial stress that can prompt a patient to discontinue treatment.
Experts offered resources for estimating costs and provided examples of how patients and physicians can lower healthcare bills.
In a recent HealthFirst Financial Patient Survey, 77% of patients said it is important or very important that they know the cost before treatment. And 53% want to talk about financing options before care.
Patients Want to Know Prices
Unfortunately, few of these discussions are happening.
Of the 1011 adults surveyed in 2017, only 18% reported that any healthcare provider had spoken to them about financing options in the previous 2 years. And 35% of respondents expressed concern about paying a bill of less than $500.
In a 2017 report by Accenture, 46% of patients surveyed reported including out-of-pocket healthcare costs in personal budgets, but only 11% shopped around for competitive prices.
In 2016, out-of-pocket healthcare costs borne directly by consumers rose 3.9%, which is the fastest increase since 2007, according one recent report (Health Aff [Millwood]. 2018;37:150-160). Much of the increase can be attributed to higher deductibles.
Out-of-Pocket Costs on the Rise
In a 2017 analysis by the Kaiser Family Foundation, 24% of people covered by large employer plans reported spending more than $1000 out of pocket on healthcare in 2015, up from 17% in 2005.
Time off work, parking, transportation, cafeteria meals, and childcare must be factored into the overall cost of care, as must the indirect costs of anxiety and depression.
Desiree Bradley, a patient advocate and family adviser at Texas Children's Hospital in Houston, described her own experience seeking care for her daughter who has medically complex issues.
In the previous 2 weeks, her daughter had 11 appointments. "That's 11 copays and 11 days of parking," she pointed out. The ancillary cost for those 11 visits was $1300.
Patients Are Paying for More Than Just Care
"I go to sleep dreaming about the healthcare costs that we may have coming up," Bradley said.
The average deductible for people with employer coverage rose from $303 in 2006 to $1505 in 2017, according to a 2017 survey from the Kaiser Family Foundation.
The timing of services matters when a patient has a high-deductible plan, said Wendy Nickel, MPH, director of the Center for Patient Partnership in Healthcare at the ACP.
"Last year, in January, my son was diagnosed with scoliosis," she reported. "We were following his curve over time and I probably saw the doctor four times. The doctor never talked with me about what the cost of care might be if we had to brace my son. I never brought it up either. It didn't occur to me."
Higher Deductibles Mean Tough Choices
In December 2017, Nickel's son had to be fitted for a brace. "We went to get fitted and it wasn't going to arrive until the beginning of January — when the deductible started again and I would be out of pocket $3000, she said.
"Had I known the mechanisms and talked about costs throughout the year, I might have pushed to have his brace provided in December," Nickel explained. "It ended up that I did push and was able to get his brace on December 29. I take responsibility in this. I was not as engaged as I should have been around the mechanisms of my healthcare plan."
Where to Find Cost Estimates
Five online resources that provide information on costs were recommended by Jessica Dine, MD, a pulmonologist from the University of Pennsylvania in Philadelphia, who collaborates with the ACP on issues related to high-value care.
Healthcare Bluebook gives average cost information, by ZIP code or hospital, on everything from hearing aids to hospital procedures to dental work.
guroo — created by the Health Care Cost Institute, an independent nonprofit research organization, and powered by claims data contributed by insurers — provides national, state, and local prices for healthcare products and services.
GoodRx provides costs at more than 70,000 pharmacies for every prescription drug approved by the US Food and Drug Administration, and also supplies links to coupons. provides information useful even to those not on Medicare.
NH HealthCost was developed by the New Hampshire Insurance Department to improve the transparency of healthcare prices across New Hampshire. "I think we'll see more and more of those," Dine said.
Barriers to Cost Discussions
Physicians in the audience shared why conversations about cost don't always happen:
It is hard to talk with patients when expenses can be way beyond a patient's reach, said Kathleen Volkman, MD, an internist from a neighborhood outpatient clinic in Seattle affiliated with the University of Washington.
Some patients — even those with diabetes who need insulin and those with asthma who need an inhaler — stop coming in rather than racking up bills, she told Medscape Medical News.
"The preferred alternatives are sometimes $200 to $300 a month," she explained.
Bias Can Hurt Cost-of-Care Discussions
Unconscious preconceptions can also affect cost-of-care discussions. Dine recommends that physicians take the implicit associations test on the Project Implicit website.
Project Implicit is a nonprofit organization and international collaboration between researchers who are interested in implicit social cognition — the thoughts and feelings outside of conscious awareness and control.
"We are going to assume some patients can pay and some can't, whether because of race, gender, obesity, age, whatever," Dine explained.
Possible Cost-Reduction Options
Patient advocate Bradley told the audience she was able to cut costs by asking a few questions when her daughter had 11 medical visits in 2 weeks for unexplained seizures.
One day, her daughter underwent head-to-toe imaging. The next day, another provider ordered almost the same complete imaging to look for something else. Bradley asked whether the first set of images could be used for the second request and, after referrals to two more providers in the hospital, the answer was yes.
Eliminating the duplication saved her a few hundred dollars. "At the end of the day, we have to make some hard choices," Bradley said. "Some days, I'm faced with deciding whether I'm going to pay my mortgage or provide the care she needs."
Cost-saving options to keep in mind:
Talking About Costs Can Improve Outcomes
"What are patients going to do if they can't afford your $5000 test?" Dine asked. "They're not going to do it, and then they're going to get labelled nonadherent," she pointed out.
"Conversations are going to improve outcomes because you're going to figure out how to get it done or what to do instead," she said

On Anniversary of House Obamacare Repeal, Democrats Look to Extract a Price

by Thomas Kaplan - NYT - May 2, 2018

WASHINGTON — A year ago Friday, Representative Claudia Tenney of New York stood among dozens of enthusiastic colleagues in the Rose Garden to celebrate passage of a bill to repeal and replace the Affordable Care Act. When President Trump made his way onstage, Ms. Tenney clapped and smiled.
On this not-so-happy anniversary, a Democratic “super PAC” is on the air with a television commercial reminding her constituents of a repeal vote that Republicans were once convinced would be a political winner. Ms. Tenney’s Democratic challenger, Anthony Brindisi, a state assemblyman, said health care is consistently one of the top issues in a vast district that runs from Lake Ontario through Utica and Rome to the Pennsylvania border.
“I think her vote is wildly unpopular among constituents in the district,” Mr. Brindisi said. “And what adds insult to injury is that she celebrated her vote by snapping selfies of herself at the White House, gleefully cheering a vote that would take health insurance away from thousands of her constituents.”
House passage of the Obamacare repeal bill left that chamber’s Republicans in a no-win situation. They took the hard vote, but because the Senate failed to follow suit, no one can claim a victory. Now Democrats hope to extract a price. Far from the liability that the Affordable Care Act has been in past elections, Democrats believe health care will be a key advantage heading into this fall’s midterm elections.

Though President Barack Obama’s signature domestic achievement has endured, Democrats accuse the Trump administration and congressional Republicans of sabotaging the health law’s insurance marketplaces through actions such as ending the requirement that most people have coverage or pay a penalty. And in the weeks before this fall’s elections, consumers are expected to learn of another wave of premium increases.
Mr. Brindisi said the repeal bill, the American Health Care Act, would have had devastating effects on the district that Ms. Tenney represents in upstate New York, harming hospitals that are important to the local economy and diminishing access to opioid treatment.
But in an interview last week, Ms. Tenney, a former state assemblywoman who is in her first term, showed no sign of regret.

“The real issue is, how are we going to make health care affordable again?” she said. “We polled ‘repeal and replace’ twice,” she added. “People want Obamacare repealed in the majority in my district.”
On one level, the passage of the House repeal bill was a political achievement for Republican lawmakers; after years of campaign promises, they could tell their political base that they had done what they had pledged to do, even if the Senate stumbled once the baton was handed over to that chamber.
But viewed another way, the House repeal bill amounted to a political gift to Democrats. Opponents said its enactment would have left people with pre-existing medical conditions unable to afford health coverage and would have resulted in health plans that omit benefits that are currently required, like maternity care and mental health services. Republicans said Democrats’ claims were exaggerated, if not false. But the bill never became law, and supporters have no way of getting real-world evidence to rebut them.
All told, the House bill would have increased the number of people without health insurance by 14 million this year and by 23 million in 2026, the Congressional Budget Office estimated.
A year ago, Democrats warned that Republicans were practically begging voters to unseat them. When the repeal bill narrowly passed the House, Democratic lawmakers serenaded their Republican colleagues with, “Na na na na, na na na na, hey hey hey, goodbye!”
Beyond the House repeal bill, Democrats have also developed a broader argument that Republicans have inflicted damage on health insurance markets, partly because of actions taken by the Trump administration to undermine the Affordable Care Act.
Just this week, they gained an assist from an unlikely figure: Tom Price, Mr. Trump’s former secretary of health and human services, who said that ending the requirement that most people have coverage, known as the individual mandate, would increase costs for people buying insurance.
Helping the Democrats, polls have shown that the Affordable Care Act has gained in popularity since the 2016 elections. In an NBC News/Wall Street Journal poll conducted last month, Democrats had an 18 percentage point edge when people were asked which party they thought would do a better job dealing with health care.
To mark the anniversary of House passage, health care advocates are holding events around the country this week. On Friday, a coalition called Save My Care plans to air a television commercial that reminds viewers about the House bill and concludes with the narrator saying, “We won’t forget.”
Representative Tom Cole of Oklahoma, a former chairman of the House Republicans’ campaign arm, cast doubt on how much of an effect the repeal bill would have in midterm races.
“I don’t think talking about a bill that didn’t happen is particularly effective,” he said. “People punish you for things that you do successfully, not for things that never happen just because you cast a vote.”
Mr. Cole suggested that a more significant risk stemmed from Republican voters who are disappointed that their party’s lawmakers ultimately failed to repeal the health law despite years of promises. “It’s more a matter of deflating our base than enraging the other side because they’re already pretty enraged and energetic, anyway,” he said.
Then there is the question of how much health care will remain a prominent issue when last year’s repeal effort is an increasingly distant memory.
“My fear is that there’s all this salacious stuff — there’s all this focus on Russia and Stormy Daniels and Michael Cohen,” said Laurel Smith, 57, a health care activist in New Jersey whose congressman, Tom MacArthur, played a pivotal role in passing the House repeal bill. “It’s easy to get distracted.”
Ms. Smith said she had previously voted for Mr. MacArthur, a Republican, but now backs his Democratic challenger, Andy Kim. Ms. Smith’s 27-year-old son, who has a chronic and incurable disease, has been volunteering for Mr. Kim’s campaign.
Mr. Kim, a former National Security Council staff member in the Obama White House, said he wants every voter to know about Mr. MacArthur’s role, which landed him a speaking slot at the Rose Garden ceremony.
“He wasn’t just a yes vote,” Mr. Kim said. “He’s got his name on it.”
Mr. MacArthur said he was not worried.
“The reality is I didn’t come here to be a potted plant,” he said. “I came here to work on problems facing the American people, and health care costs are hurting my constituents.”
But that Rose Garden ceremony remains a touchstone.
Elissa Slotkin said she was contemplating a run for Congress when she saw her Republican congressman, Mike Bishop of Michigan, at that Rose Garden celebration.
“He was smiling and beaming and proud and thrilled,” she recalled. “I turned to my husband and said, ‘You do not get to do this. You don’t get to ignore the public and vote against their interests and keep your job.’”
Ms. Slotkin, a former senior official in the Defense Department, jumped in. She is seen by the House Democrats’ campaign arm as a formidable challenger.
Mr. Bishop bristled at his critics.
“In order to win this, the Democrats have infused fear and panic, and they have done so by misrepresenting the truth,” he said. “If you need to do that to win, then count me out, because I would never do that.”

Trump to Drop Call for Medicare to Negotiate Lower Drug Prices

by Robert Pear - NYT - May 10, 2018

WASHINGTON — President Trump will lay out on Friday a broad strategy to reduce prescription drug prices, but in a break from one of his most popular campaign promises, he will not call for Medicare to negotiate lower prices with drug manufacturers, senior administration officials said.
The White House will issue a blueprint that represents “the most comprehensive plan to tackle prescription drug affordability of any president,” a senior official told journalists on Thursday night.
Asked if the plan would include direct negotiations by Medicare, the official said, “No, we are talking about something different.”
“We are not calling for Medicare negotiation in the way that Democrats have called for,” the official said later. “We clearly want to make important changes that will dramatically improve the way negotiation takes place inside the Medicare program.”

As he campaigned for the presidency, Mr. Trump boldly broke with his party and embraced a longstanding Democratic proposal when he called for the federal government to use its buying power to negotiate lower drug prices for Medicare recipients. The proposal was popular with voters but not with other Republican politicians, who had been battling it for years.
Under Part D of Medicare, millions of older Americans receive insurance coverage for prescription drugs. The benefit is delivered entirely by private entities under contract with Medicare. These private entities — insurance companies and the middlemen known as pharmacy benefit managers — negotiate prices with drugmakers. But under a 2003 law, the federal government “may not interfere” in those negotiations.
The president’s plan will make it easier for private plans to negotiate “better deals for our seniors, especially for high-cost medications,” said the senior administration official, who spoke on the condition that he would not be named. The official refused to provide details, which he said would be disclosed on Friday.
Congressional Democrats said they would like to work with Mr. Trump on plans to rein in drug costs, but they predicted that his proposals would be inadequate.
“On the campaign trail, he spoke like a populist,” the Senate Democratic leader, Chuck Schumer of New York, said on Thursday. “He talked the talk, but he has failed — at least so far — to walk the walk.”
Mr. Trump plans to speak in the Rose Garden of the White House to an audience that includes members of Congress and patients who have suffered because of high drug costs.
The theme of the president’s initiative is “American patients first,” and his plan takes aim at what the White House calls “foreign freeloading.” The administration will, as expected, put pressure on foreign countries to relax drug price controls, in the belief that pharmaceutical companies can then lower prices in the United States.
“Other countries use socialized health care to command unfairly low prices from U.S. drugmakers,” said a summary provided by the White House on Thursday. “This places the burden of financing drug development largely on American patients and taxpayers, subsidizes foreign consumers, and reduces innovation and the development of new treatments.”
The United States spends well over $300 billion a year on prescription drugs sold at pharmacies and other retail outlets, and Medicare and Medicaid account for nearly 40 percent of that spending, according to the Department of Health and Human Services.
Mr. Trump plans to criticize brand-name drug manufacturers for setting high list prices and for trying to stifle competition by delaying the marketing of lower-cost generic drugs. He is also expected to criticize pharmacy benefit managers, saying they profit from rebates paid by drug companies but do not pass on much of the savings to patients.
Mr. Trump has repeatedly said that drug companies are “getting away with murder.”
In his State of the Union address in January, he said that “fixing the injustice of high drug prices” was one of his top priorities for 2018. “And prices will come down substantially,” he said. “Watch.”
As a presidential candidate, Mr. Trump supported two ideas that are anathema to the pharmaceutical industry: allowing Medicare officials to negotiate prices and allowing consumers to import prescription drugs from Canada and certain other countries where brand-name drug prices are generally lower than in the United States.
But top administration officials, like Alex M. Azar II, the secretary of health and human services, and Dr. Scott Gottlieb, the commissioner of the Food and Drug Administration, strenuously oppose those ideas. Republicans argue that the federal government has such overwhelming power as a buyer that it could basically set a price that manufacturers would have to comply with.
And since taking office, Mr. Trump has not endorsed such proposals.
Many ideas in the president’s “blueprint to lower drug prices” can be carried out unilaterally by the secretary of health and human services. But the blueprint also includes several legislative proposals from the president’s 2019 budget request.
One legislative proposal would allow low-income people on Medicare to obtain free generic drugs, without co-payments. Another would, for the first time, establish an overall limit on Medicare beneficiaries’ out-of-pocket costs for prescription drugs. Mr. Trump also wants to lower costs for consumers at the pharmacy counter by requiring Medicare drug plans to pass on at least one-third of the rebates they receive from drug manufacturers.
Mr. Azar, testifying on Capitol Hill on Thursday, described the problem this way: “Prescription drug costs in our country are too high. List prices are too high. Seniors and government programs are overpaying due to lack of negotiating tools. Out-of-pocket costs are too high. And foreign governments are freeloading off of our investments in innovation.”
Democrats are driving for a more aggressive approach. Representative Peter Welch, Democrat of Vermont, said: “We acknowledge that drug companies make life-extending and pain-relieving drugs, and that’s a good thing. But the price gouging is killing patients.” Consumers, he said, are being “held hostage to the pricing power of Big Pharma.”
The Food and Drug Administration approved 1,027 generic drugs last year, a record, and nearly 90 percent of prescriptions are filled with generic medicines, for which consumers often pay less than $25.
But increasing numbers of costly new brand-name drugs are also entering the market. Some provide highly effective treatments for some forms of cancer and other diseases. But the prices sometimes exceed $100,000 a year, and even patients with health insurance may be responsible for tens of thousands of dollars in co-payments.

The Health 202: Here's why it's a nightmare to lower U.S. drug prices
by Paige Winfield Cunningham - The Washington Post - May 3, 2018

Whatever President Trump suggests next week to lower U.S. drug costs, don’t forget this cold, hard fact: It’s extremely difficult to make sweeping reforms to a health-care system as piecemeal as ours.
If you’re employed, you might have coverage through your job. If you’re a senior, you have some version of Medicare. If you’re a low-income American, you may qualify for Medicaid. If no insurance is available to you through those avenues, you’ve probably bought subsidized, private coverage through the state-based Obamacare marketplaces. Or, maybe you’re simply uninsured.
Health insurance typically isn’t such a patchwork system in other countries with wealth comparable to the United States. In Canada, Australia and many European nations, the government plays a far greater role in delivering coverage, keeping people's out-of-pocket costs low — and putting a damper along the supply chain on how much private industry can pocket from medications.
It’s true that spending on pharmaceutical products has been rising just about everywhere in the past three decades, as specialty medicines for complex or rare, chronic conditions such as cancer, rheumatoid arthritis and H.I.V. have become more widely available. But in the United States, average spending on prescription drugs exceeds $1,000 per person per year — a hefty figure compared to, say, the United Kingdom, where it’s $497, or even Switzerland, where it’s $783.
It’s a situation garnering increasing attention from liberals and conservatives alike. Policymakers from Sen. Bernie Sanders (I-Vt.) to Trump to his top health chief Alex Azar have been sounding the alarm that the government and individuals are paying far too much for prescription medicines.
Speaking yesterday at the World Health Care Congress, Azar said action on drug costs is “desperately needed.” He listed several problems he said “plague drug markets” — including high list prices, the government’s lack of negotiating tools, rising out-of-pocket costs for consumers and other countries “free-riding” off the investments of U.S. companies in developing high-cost specialty drugs.
Trump proposed a smorgasbord of policies in his 2019 budget aimed at tweaking prices downward. But Azar hinted the president may suggest bolder reforms in his speech next week, although he didn’t provide specifics.
“HHS is currently working with the president on a comprehensive strategy to solve these problems,” Azar said. “We’ll be building on the proposals in the president’s budget, but he wants to go further.”
Books could be — and have been — written on why drug costs are so high in the United States. The prescription drug industry is perhaps the most complicated ecosystem I’ve tried to understand, driven by all sorts of pricing pressures along the supply pipeline. But it’s possible to boil down a few key differences between the United States and other developed countries who are able to offer cheaper medicines to their citizens.
Here they are:
1. The U.S. government has less leverage over how much drugmakers are paid.
The most significant avenue available for the government to influence drug prices is through Medicare’s prescription drug program, which covers about 42 million elderly and disabled Americans. Prices for medicines offered in these Medicare "Part D"  plans are negotiated between pharmaceutical companies and the private insurers who bid for the right to sell the program's plans.
In the past, Trump has joined in calls from Democrats to allow the government to directly negotiate prices with the drugmakers, thereby pushing down prices. It’s unlikely — although possible — the president will call for Congress to make such a change in his address planned for next Tuesday.
But there’s a plethora of ways other countries attempt to rein in drug prices — such as by capping how much government plans will pay for them, regulating how much the industry can charge private insurers or limiting markups along the supply chain.
England’s National Health Service, which is the country’s main buyer of drugs, sets payments based on a government evaluation of the drugs’ cost-effectiveness. Germany’s sickness funds, which are its version of a public-health insurance system, also apply a value assessment to medications to determine reimbursement levels.
These price levers are harder for the U.S. government to come by because of the point outlined earlier: Our health insurance system is a lot more fragmented. Only about one-third of Americans are on some form of government-sponsored insurance. And the U.S. government has traditionally played a much smaller role in regulating private industry overall.
“[Other countries] have policies in place that are more centralized in the pricing of their drugs,” said Shawn Bishop, a vice president at the Commonwealth Fund. “They have policies in place that directly link the price of the drug to the value of the drug — we don’t have anything like that.”
2. There’s less regulation along the supply chain.
Paying for drugs isn’t a simple matter of what the manufacturer charges. As companies sell their medicines to pharmacies, which in turn bill private or government insurance plans, pharmacy benefit managers (known as PBMs) act as middlemen to negotiate which drugs are covered and how generously.
The system is further convoluted by increasingly common rebates that drug companies pay to PBMs. Critics charge these rebates incentivize PBMs to favor higher-cost drugs or charge insurers more than they’re charging the pharmacy — and pocketing the difference.
Translated, it’s a lot harder to find the list price of drugs, there is a huge imbalance in what different payers are charged and plenty of room for all the involved parties to try to get a bigger piece of the pie via markups and transaction costs.
In most other wealthy countries, the government puts a lot more limits on prices along the supply chain, said Anna Kaltenboeck, program director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center.
“I don’t see Express Scripts operating in Germany, for example,” said Kaltenboeck, referring to the country’s largest PBM.
3. Drug companies use coupons to lower prices for consumers while they raise their medications’ list prices.
There’s another practice growing increasingly popular in the United States. Drug companies are offering coupons to customers to incentivize them to buy brand-name drugs rather than generics. While these coupons lower consumers’ out-of-pocket costs, they ensure their insurance plans pays for more expensive drugs. By 2016, one in five brand-name drugs in commercial insurance plans used a co-pay assistance coupon.
This practice isn’t found in other developed countries, where patients’ out-of-pocket costs tend to be more fixed and much lower, Kaltenboeck told me.
“It allows manufacturers to increase prices and maintain very high prices,” she said.

Trump’s Plan to Lower Drug Prices Diverges From Campaign Promise

by Robert Pear - NYT - May 11, 2018

WASHINGTON — President Trump vowed on Friday to “bring soaring drug prices back down to earth” by promoting competition among pharmaceutical companies, and he suggested that the government could require drugmakers to disclose prices in their ubiquitous television advertising.
But he dropped the popular and populist proposals of his presidential campaign, opting not to have the federal government directly negotiate lower drug prices for Medicare. And he chose not to allow American consumers to import low-cost medicines from abroad.
He would instead give private entities more tools to negotiate better deals on behalf of consumers, insurers and employers.
Speaking in the sun-splashed Rose Garden of the White House, Mr. Trump said that a “tangled web of special interests” had conspired to keep drug prices high at the expense of American consumers.
“Everyone involved in the broken system — the drugmakers, insurance companies, distributors, pharmacy benefit managers and many others — contribute to the problem,” Mr. Trump said. “Government has also been part of the problem because previous leaders turned a blind eye to this incredible abuse. But under this administration we are putting American patients first.”
His proposals hardly put a scare into the system he criticized.
Ronny Gal, a securities analyst at Sanford C. Bernstein & Company, said the president’s speech was “very, very positive to pharma,” and he added, “We have not seen anything about that speech which should concern investors” in the pharmaceutical industry.
Shares of several major drug and biotech companies rose immediately after the speech, as did the stocks of pharmacy benefit managers, the “middlemen” who Mr. Trump said had gotten “very, very rich.” The Nasdaq Biotechnology Index rose 2.7 percent on Friday. CVS Health, which manages pharmacy benefits for many insurers and employers, finished up 3.2 percent.
Mr. Trump and other Republicans are eager to show an achievement on health care this year to counter arguments by Democrats who say that Americans are losing coverage because of Mr. Trump’s efforts to sabotage the Affordable Care Act. Soaring pharmaceutical prices are directly hitting consumer wallets, and high-profile cases — like the sudden jump in the price of EpiPens or the jailing of the hedge fund manager Martin Shkreli, who greatly increased the price of a drug under his control — have turned pharmaceuticals into a hot political topic.
Many of Mr. Trump’s ideas can be put into effect through regulations or guidance documents. Some will require legislation.
Republicans in Congress welcomed the president’s attention to high drug prices and promised to review his proposals, which Mr. Trump said would “derail the gravy train for special interests.”
Democrats embraced the opportunity to push health care back to the center of the political debate.
“President Trump offered little more than window dressing to combat the rising cost of drugs — a problem that is pinching the pocketbook of far too many Americans,” Senator Chuck Schumer of New York, the Democratic leader, said after the speech. “We Democrats have offered a better deal on prescription drugs through true transparency, Medicare Part D negotiation, and a cop on the beat to police and stop exorbitant price hikes.”
After supporting some of those same proposals on the campaign trail, Mr. Trump pivoted to a different approach. He said his administration would provide new powers for Medicare’s private prescription drug plans, known as Part D, to negotiate lower prices but he would not use the purchasing power of the federal government to conduct direct negotiations. He said he would make it easier for pharmacists to inform patients of cheaper alternatives and would speed the approval of over-the-counter drugs “so that patients can get more medicines without prescription.”
Mr. Trump also denounced foreign countries that he said “extort unreasonably low prices from U.S. drugmakers” so that their citizens often pay much less than American consumers for the same drugs.
“America will not be cheated any longer, and especially will not be cheated by foreign countries,” Mr. Trump said. He directed his trade representative to “make fixing this injustice a top priority” in negotiations with every trading partner.
“It’s time to end the global freeloading once and for all,” Mr. Trump said.
It is not clear why higher profits in other countries would be passed on to American consumers in the form of lower prices, and officials in those countries pushed back hard.
“With our price regulations, drug companies are still making profits — just lower profits than in the United States,” said Dr. Mitchell Levine, the chairman of Canada’s Patented Medicine Prices Review Board, which reviews prices to ensure they are not excessive.
The administration floated several ideas that could radically change the marketing of prescription drugs.
Alex M. Azar II, the secretary of health and human services, said the Food and Drug Administration would explore requiring drug companies to disclose list prices in their television advertisements.
The government, he said, will consider whether to “outlaw rebates” — the discounts and price concessions that are a key link in the drug supply chain. Pharmacy benefit managers are hired by insurers and large employers to negotiate lower drug prices, but they also receive rebate payments from drugmakers, creating a potential conflict of interest, the administration said.
Mr. Trump said he would end “the dishonest double-dealing that allows the middleman to pocket rebates and discounts that should be passed on to consumers and patients.”
Mark Merritt, the president and chief executive of the Pharmaceutical Care Management Association, which represents drug benefit managers, said the real problem was the high prices set by drugmakers.
“Getting rid of rebates and other price concessions would leave patients and payers, including Medicaid and Medicare, at the mercy of drug manufacturers’ pricing strategies,” Mr. Merritt said.
Thomas M. Moriarty, an executive vice president of CVS Health, said his company already offers clients the option to share rebates and discounts with consumers when they fill prescriptions.
Experts said some of the president’s ideas could help lower drug prices.
“It’s framed as a pro-competitive agenda, and touches on a range of government programs that the administration can change through regulation — so that the president can take unilateral action,” said Daniel N. Mendelson, the president of Avalere Health, a research and consulting company. “The trick here for the administration is to do something visible before the midterm elections, so they can take credit for an action that reduces drug prices for consumers.”
Mr. Trump’s “blueprint to lower drug prices” has four main themes: increasing competition in drug markets; giving private plans more tools to negotiate discounts for Medicare beneficiaries; providing new incentives for drug manufacturers to reduce list prices; and cutting consumers’ out-of-pocket costs.
The administration would lower out-of-pocket costs for Medicare patients by requiring prescription drug plans to pass on some of the discounts and rebates they receive from drug manufacturers. Patients could see those savings at the pharmacy counter. At the same time, Medicare officials say, there could be a modest increase in premiums for Medicare drug coverage.
Health policy experts like this idea because it reduces the burden on patients with serious chronic illnesses and spreads the expense of needed medications across the entire insured population.
But Democrats said Mr. Trump’s policy prescriptions fell far short of what was needed, especially next to the populist promises he made during the 2016 campaign.
“I think very expensive champagne will be popping in drug company boardrooms across the country tonight,” said Representative Elijah E. Cummings, Democrat of Maryland, who has been investigating drug prices for the last year. “The president is apparently abandoning his campaign promise to authorize Medicare to negotiate directly with drug companies to lower prices.”
Administration officials were somewhat defensive about the president’s plan, saying it was bold and significant even though it was not what Democrats wanted — or what candidate Trump favored.
In a round of television interviews on Friday, Mr. Azar said the president’s plan included “over 50 different initiatives — very sophisticated, the kind of thing you’d expect from a C.E.O. like Donald Trump, getting at the real heart of the business problem.”
Mr. Azar said the president’s plan would “unleash those who negotiate for us with the greater powers of the private sector” to obtain good deals.
In trade negotiations, the White House wants to put pressure on other countries to increase the prices of brand-name drugs, with the expectation that pharmaceutical companies would then lower prices here at home.
America’s trading partners “need to pay more because they’re using socialist price controls, market access controls, to get unfair pricing,” said Mr. Azar, a former top executive at the drugmaker Eli Lilly and Company. “And they’re doing it on the backs of their patients. God help you if you get cancer in some of these countries.”
Other nations, also struggling with high drug prices, scorned Mr. Trump’s advice on this issue.
“Drug manufacturers in the United States set their own prices, and that is not the norm elsewhere in the world,” a spokesman for the 28-member European Union said on Friday. “E.U. member states have government entities that either negotiate drug prices or decide not to cover drugs whose prices they deem excessive. No similar negotiating happens in the U.S.”
Katie Thomas contributed reporting from Chicago, and Peter Baker from Washington.

6 Takeaways From Trump’s Plans to Try to Lower Drug Prices

by Katie Thomas - NYT - May 11, 2018

President Trump has the power to sink pharmaceutical stocks with a single jab about high drug prices.
But in a much-anticipated speech on the topic on Friday, Mr. Trump largely avoided the issues the industry fears the most, such as allowing Medicare to directly negotiate drug prices, or allowing Americans to import drugs. Investors noticed: Stocks of major drug companies rose after his speech, as did those of pharmacy benefit managers, or the “middlemen” that Mr. Trump said were getting “very, very rich.”
As the health care world parsed the president’s newly released “blueprint” to lower drug prices, the overarching insight seemed to be this: The drug industry’s formidable lobbyists had won some key victories, even if they did not escape entirely unscathed. Many proposals were light on detail and will need action by Congress to become real.
Yet Mr. Trump won some praise for having taken a stab at tackling such a complex and vitally important issue to many Americans.
Here is a rundown of the key proposals unveiled on Friday.

Lower drug prices for older people

On the campaign trail, Mr. Trump embraced allowing Medicare to negotiate the price of the drugs it buys for older people, an issue traditionally supported by Democrats but long opposed by Republicans — and the powerful drug industry.
Friday’s proposal falls far short of that goal. But it does include some ideas for giving the government better leverage in negotiating with drug companies. It calls for exploring whether to allow Medicare drug plans to pay different amounts for the same drug, depending on the illness involved. And it would experiment with “value-based purchasing” in federal programs, essentially a money-back guarantee in which a drugmaker promises to refund money if a medication does not work as expected. Drug companies and insurers are increasingly entering into these kind of arrangements, although the evidence is far from clear that they lower costs.
The administration also reiterated earlier proposals: making generic drugs free for some low-income older people on Medicare and allowing people to keep a portion of the rebates that are normally pocketed by the insurers that manage the Medicare drug program.

Persuade other countries to pay more

One key proposal would involve pressuring other countries to raise their prices for prescription medicines. Drug prices in the United States are the highest in the world; many countries with centralized health care systems have successfully negotiated lower prices from pharmaceutical companies.
Mr. Trump, echoing the longstanding position of the drug industry, has said these companies are “free-riding” off the ingenuity of American corporations, and that high drug prices in the United States are subsidizing innovation that benefits the whole world.
“We have great power over the trading partners; you’re seeing that already,” Mr. Trump said on Friday. “America will not be cheated any longer, and especially will not be cheated by foreign countries.”
The Trump administration plans to work with several federal agencies to address what it described as this “unfair disparity.”
But it is unclear whether other countries would be willing to raise their prices, or whether doing so would lead drug companies — which are beholden to shareholders hungry for profit — to lower prices in the United States.

Require drug ads to include the price

Prescription drug commercials are ubiquitous. But what if those ads had to disclose the drug’s price? That is something the Trump administration says it wants to explore.
The idea would certainly grab attention, and fear of a consumer backlash could pressure some drugmakers into dropping their prices.
But the notion poses a lot of issues For one: which price? The list price, which is about what a pharmacy would charge if someone paid for the drug in cash? Or the discounted price that insurers and employers pay? Most consumers have health insurance and pay a much smaller out-of-pocket cost, although that can still add up to thousands of dollars a month.
Other questions include whether such a requirement would survive a First Amendment challenge, and whether posting a high sticker price — which few ultimately pay — could dissuade patients seeking out a necessary drug.
Finally, drug companies are masterful at distracting viewers from the lengthy list of risks and side effects that is already required by the Food and Drug Administration. Some have been known to employ noisy brass sections or buzzing bees to de-emphasize the required information. Would the drug’s price similarly fade into the background?

Ban ‘gag clauses’ for pharmacists

Some contracts between pharmacies and pharmacy benefit managers prohibit pharmacists from telling patients when a drug they need would be cheaper if they paid in cash, rather than using their insurance.
“This is a total rip-off, and we are ending it,” Mr. Trump said in his speech on Friday. The administration’s written proposal is more vague, saying that it “may” prohibit these gag clauses in plans for Part D, the Medicare drug program.

End the patent games

Patent protection for new drugs is vital, the industry insists, to allow drugmakers to recoup the millions of dollars invested in researching and developing lifesaving products.
But over the years, the industry has become known for finding new ways to hold on to that patent protection, and with it the power to charge whatever it wants without generic competition.
One recent flashpoint has been the refusal of some brand-name companies to turn over samples of their drugs to generic drugmakers, effectively preventing competing products from being developed. Republican and Democratic lawmakers have proposed changes that would end this practice but have been unsuccessful.
Trump said on Friday he would rein in this game-playing, saying “our patent system will reward innovation, but it will not be used as a shield to protect unfair monopolies.”

On the horizon

Some of the most theoretical ideas also have the potential to be the most disruptive.
One is to upend the existing rebate system, in which drug companies pay rebates, or discounts, off the list price to insurers and employers. But those rebates are often considered trade secrets, and pharmacy-benefit managers pocket a portion of the rebate for themselves, creating what many have described as perverse incentives that keep drug prices rising.
The Trump administration has said it is examining whether it should consider rebates to be a form of illegal kickback, a change that would likely require congressional action.

After Drug Plan Shows Trump 'Will Do Nothing About Their Greed,' Big Pharma Stocks Soar

by Jake Johnson - Common Dreams - May 11, 2018

"Don't be fooled: President Trump and his administration are bought and paid for by Big Pharma," Brad Woodhouse, campaign director of Protect Our Care, said in a statement. (Photo: Jeannie Baumann/Twitter)
In a strong indication that investors and major pharmaceutical companies know President Donald Trump's newly unveiled drug plan "will do nothing to rein in their greed," Big Pharma stocks soared on Friday as Trump delivered a brief and extremely vague speech promising to lower drug costs that critics called a "cover-up for the sweetheart deal" he's offering America's price-gouging drugmakers.
"When big pharmaceutical companies' stocks spike during your big reveal on lowering prices, you're doing something wrong," Brad Woodhouse, campaign director of Protect Our Care, said in a statement following Trump's speech on Friday. "Don't be fooled: President Trump and his administration are bought and paid for by Big Pharma."
Topher Spiro, a senior fellow at the Center for American Progress, argued that a major reason pharma stocks rose as Trump formally announced his plan is because the president placed blame for high U.S. drug prices on the low prices in nations with "socialized healthcare"—exonerating American drug giants from any blame for soaring costs.
Instead of tackling high U.S. prices, Trump effectively promised to work to "boost prices abroad," which is the drug industry's "number one priority," Spiro notes.

The Simple, Obvious, Time Tested Way to Reduce Drug Costs

by Bob Laszewski - Health Care Policy and Marketplace Review - May 11, 2018

I give the President great credit for shining his spotlight on the ridiculous place the U.S. finds itself over drug prices. They are way too high, the private market has proven incapable of dealing with it––PBMs have only made the drug market more opaque, and the biggest drug purchaser in the world, the U.S. government, has been politically unwilling to deal with it.

All while other industrialized countries have nowhere near the problem.

What is even more frustrating is to see an easy solution that has worked for years in these other industrialized countries that, rather than being a single-payer government-run solution, is as American-style free market as it could be.

Would any major U.S. corporation spend loads of money on procurement without first going out to bid on both price and performance? Would the Pentagon buy a new ship or aircraft system without going out to bid on both price and capability? Would the U.S. General Services Administration put up a new government office building without first bidding it out to determine which contractor would construct the best facility for the price?

So, if we are looking for market-based solutions to the high cost of prescription drugs, we need look no further than the government-run health care systems in France, Canada, Germany, the U.K., and others.

Rather than pointing the finger at these other nations that "pay too little" for their drugs and then condemn them for it, we might first recognize that they are out marketeering the United States. 

These foreign bureaucrats are making American capitalists look like little leaguers when it comes to keeping drug prices under control!

What these other countries have in common is that they use a system called reference-based pricing. While there are differences among them, they generally use the market to set a reference price for each prescription drug that also takes clinical results into consideration––it could be the lowest price from a range of alternative drugs in a class (Italy), an average of all of the drugs in a class (Germany), or an average of a group of the lowest priced players (Spain). The health care system then pays no more than the reference price for a drug in the class no matter which pharmaceutical company the consumer and their physician decide to use.

In the end, the market sets the price and innovation is still rewarded by paying the price the most competitive player wants to charge.

In such a competitive bidding process prices and drug outcome results are completely competitive and fully transparent. If a patient and their doctor want to pay more for an alternative drug, because they think it will do a better job for a particular patient, they know all of the prices and the comparative clinical outcomes upfront. If a drug company is truly able to innovate for an existing class of drug, that drug could be placed in a new class––innovation is still rewarded.

The value of reference-based pricing is limited until there is more than one competitor in a class––drug companies are still rewarded for blockbuster breakthroughs.

But when more than one player comes to market in the same drug class, they compete based both on price and clinical outcomes.

How much more American could that be? 

Why does this have to be so hard?

California Doctors Aim to Educate 100,000 Patients & Their Physicians to Support Single Payer

Common Dreams - May 11, 2018

Doctors’ state strategy meeting to follow on Sunday, May 20 at the Hyatt LAX.
Sacramento, CA - A group of California doctors have placed a first-of-its-kind 8-page publication in today’s Sacramento News and Review with the aim of educating patients – and their physicians - about why a single payer plan, also known as “Improved Medicare for All,” is needed in California and nationally. The California chapter of Physicians for a National Health Program (PNHP) fundraised over $20,000 from local members to print 100,000 copies of the pull-out ad, which they are urging patients to use to “talk to their doctors about single payer.” 
“We don’t have the deep pockets of the insurance industry or the pharmaceutical industry, which Californians may recall spent $109 million two years ago to defeat a ballot measure to reduce drug prices, but we are determined to get the facts about single payer out in Sacramento and across the country,” said Dr. Paul Song, a radiation oncologist, President of the California Chapter of PNHP and a co-author of the publication. Dr. Song frequently volunteers his time to speak on health reform to physician and other groups.
“Drug companies spent $280 million last year to stop Congress from regulating drug prices like other nations, and $6.1 billion annually advertising their products directly to consumers, frequently ending with the tag line ”talk to your doctor,” continued Dr. Song.  “We want patients to talk to their doctors about how single payer could dramatically reduce drug costs and allow patients to choose their physicians without co-pays, deductibles, and outrageous out-of-network bills,” Dr. Song said.
The ad includes articles by four California physicians describing how single payer would put doctors back in charge of patient care, reduce bureaucracy, and provide comprehensive care with no out-of-pocket costs.  A recent study by economist Robert Pollin found that single payer legislation in California (SB 562) would cover everyone and cost $37 billion less than what Californians are already spending on health care. The Public Policy Director of National Nurses United, Michael Lighty, also contributed an article.
“There’s a lack of informative, accurate coverage of single payer in the mainstream media,” said Dr. Bill Bronston, chair of the Sacramento Chapter of PNHP.   “This 8-page publication was drafted by doctors to arm patients and physicians with the tools they need to be effective advocates for a system that provides high quality care but doesn’t bankrupt the sick or the U.S. economy. “
Keith McCallin, an activist in the Sacramento chapter of PNHP, and Dr. Bronston distributed copies of the pull-out to every member of the Californian legislature yesterday in advance of today’s publication. Republican legislators and staffers were particularly interested in the benefits to business of a single payer program. “As a matter of fact, Berkshire Hathaway investors Warren Buffett and Charlie Munger have endorsed single payer for its ability to control runaway health care costs, describing health care as a “tapeworm” on the economy,” McCallin said. 
California PNHP members will be gathering for an all-day meeting on Sunday, May 20 at the Hyatt Regency LAX to discuss the path forward. Rep. Keith Ellison, chief sponsor of single payer legislation in the House, HR 676, will be speaking via Skype. All interested physicians are invited.

A true feel-good experience - Ellsworth American

A true feel-good experience 
Dear Editor: A small businessman, a retired physician, a legislator and a former nurse walked into a bar … well, not a bar, but a recent meeting at the Deer Isle Town Hall. Much as I don’t care for meetings, this one recently made me feel good about my fellow citizens.
The subject was the strategy for dealing with the out-of-control relationship between health care costs and health insurance costs. Joe Lendvai, small businessman, founding member of Maine AllCare, and Lynn Cheney of Blue Hill, Maine AllCare Downeast Chapter leader, joined Dr. Jeff Milliken and our own Walter Kumiega for a most informative panel discussion. They described the efforts of Maine AllCare, a committee of conservatives and liberals working together to craft a response for Maine. See the website www.maineallcare. org to learn about how we might get publicly funded universal coverage under a more efficient system the way all other industrialized countries are doing these days.
Just as we pay as a group for the costs of our roads, police, fire protection and education, so we could rearrange things with a simpler system so that health insurance costs — even before mentioning healthdisasters — don’t threaten our families, small businesses and independent contractors with financial ruin. Our small rural hospitals need not be threatened with bankruptcy due to unreimbursed emergency room visits from the uninsured. Our family physicians could spend their time on their patients, not the costly paperwork and a hassle of negotiating with insurance companies.
What do we do right now, at the moment while details are being worked out? We can all inform ourselves at the website, question closely the candidates in the forthcoming mid-term elections, and immediately support lowering the age for Medicare to 50. These are potential steps before we even get to the thorny question of how to deal with the private insurance companies and Big Pharma lobbies. Apparently California and New York states are poised to adopt a single-payer plan and it’s up to us to make sure New England is not far behind.
Do you want these generous good citizen volunteers to come make a presentation to your group? Contact them at info@maineallcare. org and feel good about yourself.
Marnie Reed Crowell Sunset

Thousands of elderly, disabled face eviction from Louisiana nursing homes over Medicaid cuts

by David Begnaud - CBS News - May 9, 2018

BATON ROUGE, La. -- In Louisiana, tens of thousands of elderly and disabled people could soon lose their Medicaid benefits because the state faces a budget shortfall of more than $500 million.
Eviction notices are going out Thursday to thousands in nursing homes and group homes. 
Betty Waller, 89, is a polio survivor and lives in a nursing home in Baton Rouge. Her life savings pays for part of her care, but Medicaid is needed for the rest. 
"I won't be living under a bridge somewhere, but still it's a really scary thing," she said.
On July 1, she could be one of about 37,000 people in the state who will lose their Medicaid eligibility if the state doesn't balance its budget.
Jim Tucker runs 12 nursing homes in the capitol and 800 of his patients could be told to leave.
"It has the potential to kill people," Tucker said.
"I'm not scaring anybody by design," said Gov. John Bel Edwards. "The cuts are so catastrophic we shouldn't contemplate them but as we sit here the legislature has failed to act in a fiscal session last year and a special session this year."
Republican Rep. Cameron Henry is head of the Appropriations Committee in the Louisiana House, and he says they want a budget that is sustainable over the long term. He says Republicans may be willing to pass a tax the governor wants.
We asked Waller, the Baton Rouge resident, what she would tell lawmakers contemplating the cuts. 
"It was something I never thought would be ever taken away," she replied. "I thought it was here forever."

1 comment:

  1. Why does Jim Cook's piece cite a bill which was submitted years ago rather than the one currently before the California legislature?

    Incidentally, SB 562 does have cost controls written into it, and the financing language (proposals for which have alrady been drafted) was supposed to be added by the Assembly Health Committee--until Speaker Rendon short-circuited the process by placing the bill "in suspension." He doubtless would have done this no matter what the bill said, as his purpose was to spare Gov. Brown the political fallow from vetoing it.