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Friday, March 8, 2019

Health Care Reform Articles - March 8, 2019

Medicare For All Can Begin In 2021: Here’s How

by Billy Wynne and Alyssa Llamas - Health Affairs - February 28, 2019

While Democratic presidential candidates and the newspaper headlines hash out the ideological nuances of a Medicare-based single payer coverage scheme, work is underway to consider how coverage can be expanded to those in need within a realistic timeframe at minimal cost or disruption to the existing system.

Even if we stretch to assume that Democrats, much less the broader public and any Republicans, can coalesce around a unified vision of what “true” Medicare for All would look like, history and political demands suggest that other priorities will capture their attention and expenditure of political capital should the party gain control of the White House and Senate in 2021. After all, they spent the first year and a half of President Obama’s first term drafting and passing the Affordable Care Act (ACA), and eight years hence paying the political price for it.
Instead, through use of existing authority under section 1332 of the ACA and the Center for Medicare and Medicaid Innovation (CMMI), states could begin opting in to a Medicare fallback option that will help expand coverage and stabilize existing markets. If deemed necessary and viable, modest statutory changes could be included in a reconciliation package (oh yes, it’s coming…) to strengthen and broaden the long-term horizon for such a plan. More importantly, legislation has already been introduced that points to how the program could be designed and implemented under current law.
Bills introduced by Senators Michael Bennet (D-CO) and Tim Kaine (D-VA) as well as Senator Debbie Stabenow (D-MI) provide a roadmap to how a Medicare fallback plan could be implemented.
In the Medicare-X Choice Act of 2017, Senators Bennet and Kaine propose allowing individuals to purchase a Medicare-like plan through the ACA Exchanges if their county has one or less plan options currently available in that marketplace. A Medicare-X plan would be available in all Exchange markets, including for small businesses, shortly after that.
They recognize that some mechanical changes would be necessary to institute such a program. For example, benefits offered would need to be expanded to cover essential health benefits required by the respective participating states. Premiums would need to be set by CMS using local market factors and ensuring that the actuarial value of the plan and administrative costs are covered. They would also include enrollees in the Medicare-X plan in their respective Exchange risk pools to ensure costs and benefits for existing Medicare beneficiaries are not impacted.
Senators Bennet and Kaine include some policy changes for Medicare-X however that we believe are unnecessary and, because they will create new bureaucratic and political burdens, are probably ill-advised at this point. (Editor's Note 1)
For example, requiring CMS to negotiate drug prices and adopt new payment models (beyond the numerous approaches already being implemented) will likely expand the playing field of opposition and complexity that could jeopardize enactment.
Senator Stabenow’s Medicare at 50 Act also provides some framework for how a Medicare fallback option could be implemented. While her bill limits coverage expansion to those between 50-64 and does not require enrollment via the Exchanges, it specifically applies premium and cost-sharing subsidies available via the Exchanges to Medicare buy-in enrollees and allows for enrollment in Medicare Advantage (MA) plans that include prescription drug coverage.
Here, as elsewhere, to facilitate adoption of this ambitious but limited program, it will be vital to maintain existing policies whenever possible. We undermine ourselves when we get jazzed about designing wholly new coverage systems (and bureaucracies).
So, in sum, we propose the following core components of the plan:
  • Enrollees in Exchange markets with one or no plans currently available would be allowed to purchase a traditional Medicare or MA plan with drug coverage currently available in those areas, with wrap-around coverage included to ensure compliance with state essential health benefit requirements. Additional Exchange markets could be added after initial testing on this more limited basis, a la the Bennet-Kaine bill.
  • Medicare providers participating in Medicare or in applicable MA plan networks would be included and paid at existing Medicare or relevant MA rates.
  • Premiums would be based on a combination of the actuarial value of the plan and the local Exchange market, as other Exchange plans are. Premium and cost-sharing subsidies would be identical to those offered in the Exchanges today.
That’s about it folks. No fancy bells or whistles, just offering the current Medicare program in uncompetitive Exchange markets. Pencils down.
Now the admittedly trickier part: demonstrating that the program can be implemented via a combination of existing ACA section 1332 waiver and CMMI authority.
Under the ACA, section 1332 waivers allow states to test innovative approaches to coverage so long as they insure as many people as the ACA regime would with the same or more generous coverage and at the same or less cost (in a nutshell). One way to leverage this authority could be to suggest that most individuals who elect the Medicare fallback option would have otherwise enrolled in an Exchange plan and that, by leveraging Medicare provider rates and reduced administrative costs, their premiums would be lower, thereby reducing Federal subsidy expenditures. The Congressional Budget Office took this view in its 2013 analysis of a potential public plan in the Exchange markets.
Luckily, however, Mr. Trump and his Administration have set such a strong precedent for “creative” reinterpretation of these waivers that such economic gymnastics won’t be necessary. In this age of tit-for-tat politics, we are happy to take their ball and run with it to expand quality coverage at relatively low cost.
Naturally, the Trump Administration’s interpretation of section 1332 waivers flexes them in the opposite direction of what we’re suggesting here, i.e., they are allowing states to reduce coverage and limit benefits. For example, under their guidelines, states need only make available coverage options that are as comprehensive as those under the ACA and need not demonstrate that those comparable plans will actually be purchased.
The essential health benefits requirements for such waivers don’t even have to be the actual requirements already elected by that state. They just need to be any benefit package the state could theoretically design. States are then free to offer alongside that token coverage other options that do not meet ACA standards for benefits, preexisting condition protections, etc. Swell deal.
In assessing cost, the new 1332 wavier standard looks at the “aggregate effects of the waiver” and that deficit neutrality take into account “all changes in income, payroll, or excise tax revenue” as a result of the plan. Waivers that include access to noncompliant ACA plans like association health plans and short-term limited duration plans will be viewed “favorably.”
We think you get the point. Section 1332 waivers today are a long way from home. By applying a lesser degree of deviation from the underlying law than the current Administration, new Medicare fallback option waivers could comfortably be approved in 2021.
While less pivotal, ACA authority afforded to CMMI would permit CMS staff to expend the time and energy necessary to facilitate modification of existing Medicare and MA plan options to meet the new fallback plan requirements. Federal regulation of these plan options would be loosely comparable to those applied to employer group waiver plans (EGWPs), which are essentially MA plans with modest modifications to meet the needs of that market.
CMMI authority allows for pilot programs that maintain or reduce expenditures under the applicable program while maintaining or enhancing the quality of care delivered. It is focused primarily on Medicare, though participation by other payors is encouraged. The Medicare fallback option is consistent with this goal by improving the quality of care delivered to the un- and underinsured, and progress toward that end would be assessed via the same metrics currently deployed for Medicare and MA plans. Deficit neutrality requirements would be met by accurately embedding administrative costs into the fallback plan premiums. No other Medicare-related costs would be incurred because the fallback option would be funded by a combination of premiums and Exchange subsidies.
CMMI also has the authority to extend permanently and expand the geographic area encompassed by such pilot programs if they prove effective in meeting their quality and cost goals. Section 1332 waivers assume the programs would be permanent.
To demonstrate how this plan could work immediately, we suggest examining the market in Colorado, which happens to be home to one of us as well as one of the Medicare-X plan’s lead sponsors, Senator Michael Bennet. It also has a newly elected governor, former Congressman Jared Polis, who won handily on a platform that included implementing Medicare for All in the state. Both chambers of the legislature are controlled, with some room to spare, by Democrats.
According to the Colorado Department of Regulatory Agencies, for 2019, consumers in 14 of the state’s 64 counties only have access to a single insurer. Essential health benefits the state has adopted that are not currently covered by Medicare include routine eye exams, vision care, maternity care, well baby visits, dental care, and a few other services. It is not hard to see how this program could be implemented in Colorado with relatively streamlined administrative burden, so long as the state and federal government stay disciplined in adhering to the core, necessary components.
In addition to the traditional Medicare benefit being offered statewide, 51 MA plans are available from ten insurers in Colorado, with 95 percent of Medicare beneficiaries in the state having access to MA. On average, a beneficiary can choose from 19 plans offered by five insurers. In other words, there is ample competition in the vast majority of areas. In 2018, 36 percent of Medicare beneficiaries in Colorado were enrolled in an MA plan, a portion and trend that reflects the programs rising popularity nationwide.
Consistent with Billy Wynne’s five-part series, we believe it is a serious mistake, from coverage expansion, consumer satisfaction, and political viability perspectives, for Democrats to deny the full range of Medicare coverage options to any new program claiming the Medicare for All mantle, as the single payer bill recently introduced by Congresswoman Pramila Jayapal (D-WA) and over 100 other House Democrats would do. We want to actually get this done, right?
While it’s imperative to be honest about legal and regulatory requirements, not to mention political and other practical barriers, it’s also necessary to be aggressive and perhaps a bit shameless in utilizing all existing pathways to expanding coverage and bringing down health care costs. Enough is enough and, in this case, it starts with Democrats.
Let’s not cannibalize each other over relatively minor ideological differences that won’t actually have much impact on coverage, quality, or cost. Let’s look at the policy and political reality before us, such as it is in this relatively conservative of developed nations, and initiate a Medicare fallback option that will bring coverage and cost relief to millions immediately without sabotaging equally important efforts to address the manifold challenges we face.
https://www.healthaffairs.org/do/10.1377/hblog20190228.968246/full/?


Editor's Note:

Here is a link to an "interview" of PNHP President Adam Gaffney by a gang of five Fox Business "News" talking heads. Apparently they thought it would take five of them to take on Dr. Gaffney.

Very informative:

US should transition to single-payer health care system: Dr. Adam Gaffney

by Fox Business News - March 1, 2019

http://video.foxbusiness.com/v/6009079277001/

-SPC

The following clipping from Don McCanne's "Quote of the Day" is a worthwhile and thought provoking essay. The authors, from the Hasting Center (a bioethics research center) points out the differences between "patients" and "consumers", and the misguided efforts to conflate the two, part of the concerted effort to portray a professionally managed public service as a business.

Well worth the time it will take to read it.

 -SPC  

Patient-Centered Care, Yes; Patients As Consumers, No 

1Michael K. Gusmano, Karen J. Maschke and Mildred Z. Soloman - Health Affairs - March, 2019

Abstract

There are numerous calls for building health care delivery systems that are more patient centered. The focus on patient-centered care has increasingly begun to rely upon, and even merge with, the concept of patients as consumers. Early references to patients as consumers were made by patient advocates who were attempting to challenge professional and corporate dominance in health care. Today, “consumer-driven” health care has become associated with neoliberal efforts to emphasize market factors in health reform and deemphasize government regulation and financing. In our view, a narrow focus on consumerism is conceptually confused and potentially harmful. The consumer metaphor wrongly assumes that health care is a market in the usual understanding of that term, that the high cost of US health care is a function of excessive consumer demand, and that price transparency and competition can deliver on the promise of reducing costs or ensuring quality. Furthermore, a consumer metaphor places disproportionate burdens on patients to reduce health care costs, and it could erode professional obligations to provide appropriate and effective care.

Introduction

Building a health care delivery system that is more patient centered has a lengthy history, including powerful grassroots efforts beginning in the 1960s. These initiatives see patient-centered care as an important means of improving health outcomes and a morally worthy good in itself. As a means to an end, patient-centered care includes efforts to make the care delivery system more efficient and easier for patients to navigate. Patient engagement—a particular form of patient-centered care—yields better, well-documented outcomes by stimulating patients to take on more active roles in promoting and maintaining their health. As a moral end in itself, patient-centered care emphasizes the importance of honoring patients’ values and preferences, and it is less paternalistic and more respectful. Although there are concerns about how the concept might be misapplied, there is broad support for it, evidenced by federal investment in studying how best to ensure patient-centered outcomes and patient-centered outcomes research.

Increasingly, however, the focus on patient-centered care has begun to rely upon, and even merge with, the concept of patients as consumers. In this article we call for greater vigilance in distinguishing patient-centered care from the concept of consumer-driven health care. Too often consumer-driven health care is used as if it were a synonym for patient-centered care. We argue that consumer-driven care is based on critical myths about what creates, and what can rein in, high-cost care. Moreover, the consumer-driven concept can easily place the burden for systemwide cost containment on the shoulders of individual patients. In this article we offer a brief history of the patient-centered care movement, demonstrate how the language of patient-centeredness is becoming appropriated by those advocating market reforms, and then articulate why the consumer metaphor is misguided and potentially harmful.

Origins of the Patient-Centered Care Movement

In contrast to the early use of these terms to connote ways of empowering patients, consumer driven and consumerism are now associated with market-oriented health reforms that place a burden on patients to solve cost and quality problems. These consumer terms function as metaphors that represent conceptual confusion and are potentially harmful. The terms wrongly assume that health care is a competitive market and that the high cost of US health care is a function of excessive consumer demand. Because these requisite assumptions are not met, the metaphor’s remedy—price transparency and competition—cannot deliver on the promise of reducing costs or ensuring quality. Moreover, it is misleading to use consumer driven, defined in this narrow sense, as a synonym for patient centered. A consumer metaphor could also erode obligations by policy makers and health care systems to build a truly patient-centered care system.

Health Care Is Not a Market

Patients can be construed as consumers only if they are operating within a market. But health care is not a market in the usual way that markets are defined, and thus patients do not have the power that consumers have to shape that market. Patients are not as well informed as physicians are about medical care. Often patients do not have well-formed preferences, and they seek care under circumstances in which they do not have the time or emotional stamina to shop around on the basis of quality and price. And if policy makers treat health care like any other market, there will likely be very limited cost savings, if any, and huge inequities will continue and likely increase. As Nancy Tomes puts it, “this linguistic transformation has come to represent the worst consequences of American medicine’s growing market orientation.

The High Cost of US Health Care Is Not Due To Excessive Consumer Demand

Policy makers in the US frequently act as if the main problem is excess volume, which in turn arises from excess patient demand. Because most patients in the US have some form of health insurance, they are insulated from the full cost of health care. Some commentators are concerned that there is a potential moral hazard, because insurance provides patients with an incentive to consume health care beyond the point at which marginal benefit equals marginal cost.

More than just a technical term, moral hazard is a concept that is normatively loaded. It suggests that health care spending is the result of policies that offer an incentive for bad behavior.

Moral hazard concerns suggest that the use of expensive hospitalizations, surgeries, and other interventions are shaped primarily by ability to pay. This perspective fails to recognize that most people consume such services only reluctantly. The use of these services is often driven by providers, not by patients. Indeed, academics and policy makers have expressed concern for decades about the reliance of the health insurance system on fee-for-service payments to physicians, hospitals, and other health care providers. Fee-for-service provides an incentive for physicians to deliver additional and more complex services than patients need (or more care than economists would view as efficient) because health care providers receive an additional payment for every additional service—and services that are viewed as more technically complex generate higher fees. In most countries outside the US, however, “provider-driven” demand is not countered by shifting costs to individual patients and asking them to control costs by acting as informed consumers in a marketplace. Instead, most countries rely on a combination of overall budget targets for health care services and systems of all-payer rate regulation in which national health insurance funds negotiate rates for hospital, physician, and other services with representatives from those professions. Because the US does not use the negotiating power of government to confront the power of providers, it pays higher prices for all medical goods and services than other countries do.

Not only is the use of market competition limited when it comes to asking patients to make efficient decisions about health care services and providers, but it also does not work well when it comes to making decisions about health insurance plans. Competition among health plans in the Medicare program was promoted as a method for reducing the costs of the program, but Medicare Advantage has not produced the intended savings. In fact, there has been some examination of choices made in Medicare Part D, suggesting that consumers do not necessarily make choices in their own best interests: Beneficiaries fail to select plans that provide better risk protection at lower cost. These findings are consistent with earlier work on choice overload and Medicare beneficiaries’ selection of health plans. The findings led economist Paul Krugman to exclaim that “‘consumer-based’ medicine has been a bust everywhere it has been tried.

While it is wise to help patients make more informed decisions about the costs of care and to grow in their ability to make quality comparisons across health systems, the main driver of health care costs is not consumer demand, but rather the introduction of new technologies and unwillingness on the part of US political leaders to regulate prices—or at least use government bargaining power as leverage to negotiate lower prices. The US relies on a system of uncoordinated payment by thousands of payers, many of which do not have the bargaining power necessary to drive down prices. This has resulted in high prices for medical services. Technological improvements in health care have driven increases in cost all over the world, but extraordinarily high prices and a refusal by government to regulate them or bargain them lower differentiate the US from other countries.

The Consumer Metaphor Could Erode Health Care Professionalism

Medical professionalism requires independent, discretionary judgment. Professionals do not simply do as they are told or requested but must act on the basis of knowledge, skill, and fiduciary obligations to patients’ well-being.

Hospitals must judge each case to find the right balance between patient and family preference and physician integrity. It seems reasonable to anticipate that as the consumer metaphor grows, physicians’ authority in these kinds of cases could erode to the point where they may become technicians doing what they are asked to do, but doing so against their own consciences.

Professionalism may also erode if physicians are more inclined to offer unproven treatments simply because patients demand them. If the customer is always right, self-restraint on the part of providers could erode. 

Conclusion

After four decades of organized patient advocacy, US patients are still struggling to influence the health care decisions and policies that shape their lives. Conflating consumer approaches with authentically patient-centered approaches will exacerbate this gap. In health care delivery and health policy, a patient-centered approach affirms the ethical principles of respect for persons and justice while striving to make the health system more responsive to patients’ values and preferences. There are some patient-centered approaches, such as patient engagement and activation, that yield substantial improvements in health outcomes. Pursuing the sensible goal of creating a patient-centered health system will be undermined if consumer metaphors prevail. It is important for policy makers and health system leaders to be vigilant in distinguishing between these seemingly similar, but different, approaches. Patient-centered approaches aim to ensure clinical care that can meet patients’ preferences and needs. That is different from a consumer orientation calling on patients to be prudent purchasers of medical care services. The former approach empowers patients. The latter expects patients to solve society’s cost-containment challenges.
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05019

At least 25% of diabetes patients rationing insulin as drug costs continue to skyrocket

by Walter Einenkel - Daily Kos - February 28, 2019

One of the many hopes of a Medicare-for-all program is that in giving our government a larger share of the medical “market” (for lack of a better term), Americans—collectively—will be able to negotiate down the skyrocketing costs of medicine. Every day brings tragic stories of Americans young and old, of all racial backgrounds, dying after rationing their insulin—the result of explosive increases in the costs of the drug. While some people’s diabetes treatments have risen from $24 to $80 per vial over the past decade, others face much more prohibitive prices. As diabetes patient Alec Raeshawn Smith’s mother told NPR in September, her son’s monthly bill for insulin and related supplies was around $1,300 without insurance—something he and his family could not afford. He died, having most likely been rationing a lifesaving medication he could not afford.
These aren’t outliers. According to a study by Yale University researchers, 1 in 4 people with diabetes are rationing their prescriptions. This is not a new phenomenon, but one that is getting worse with the continuing rise in drug costs.
The most severe cost of insulin deprivation is death, but people who survive with diabetes have to deal with the stresses brought about by rising and falling blood sugar levels. These can include passing out, losing one’s ability to control their temper, nausea, and dizziness. A woman recounted to the New Yorker’s Amanda Schaffer how she and her sister, who both have Type 1 diabetes, have shared and rationed their insulin due to its rising costs. It’s something that has driven her life, leading to her dropping out of college her first year: “I lost a lot of weight that year, about twenty pounds. When you don’t have insulin, you can’t eat much because you can’t correct your blood sugar. So I was barely eating. I was supposed to take four to five shots of insulin a day, and I was only taking two to three. I was lethargic all the time. I was rationing just so I could live. I knew if I ran out I wouldn’t survive more than a few days. That took a mental toll.”
The solution is cheaper insulin. The problem, as Audrey Farley writes in the Washington Post, is that many people are hoping that older types of cheaper insulin are the solution—they just need to go to Walmart! The problem with using older forms of insulin is that the level of planning for adults and children can be unrealistic, as the older, slower-acting forms must be taken well in advance of eating meals. The costs of older, slow-acting insulins may be less, but the possibility of error on the part of patients is much higher. When Trump breaks his campaign promises about lowering drug prices, he’s not simply being a corrupt liar—he’s complicit in our growing public health crises.
https://www.dailykos.com/stories/2019/2/26/1837835/-t-least-25-of-diabetes-patients-rationing-insulin-as-drug-costs-continue-to-skyrocket

Drugmaker will offer half-price insulin in wake of debate over rising drug costs

by Thomas Mulier - Bloomberg - March 4, 2019

Eli Lilly's move is one of the first by a major drugmaker to offer a cut-price version of a major product, and could put pressure on other pharmaceutical companies to do the same.
Drugmaker Eli Lilly & Co. will offer a half-priced version of its blockbuster insulin, becoming one of the first companies to effectively cut the price of a top-selling drug amid the ongoing U.S. debate over pharmaceutical costs.
While it will continue selling its brand-name version at the existing price, Indianapolis-based Lilly will also sell a half-cost “authorized generic” for $137.35 a vial, or $265.20 for a five-pack of injectable pens. That will give a better deal to customers who pay cash, or who are in insurance plans that make them pay a percentage of a drug’s list price.
Insurers and PBMs don’t typically pay the listed prices for drugs, and instead negotiate discounts and rebates that can help lower premiums as a whole, but that can result in large out-of-pocket costs for some patients on costly medicine or who have chronic conditions that force them to take treatments year-round.
“The significant rebates we pay on insulins do not directly benefit all patients. This needs to change,” Lilly Chief Executive Officer David Ricks said in a statement announcing the move. “We hope our announcement is a catalyst for positive change across the U.S. health-care system.”
Lilly’s move is one of the first by a major drugmaker to offer a cut-price version of a major product, and could put pressure on other pharmaceutical companies to do the same. Mylan faced a similar outcry over the price of its EpiPen allergy shot, and in 2016 announced a lower-cost authorized generic. But such moves have been rare, even as drug CEOs have been called before Congress and faced frequent criticism from both political parties.
There are millions of people with diabetes in the U.S., and insulin has become a particular flashpoint for the debate over the cost of drugs. Lilly, Novo Nordisk A/S and Sanofi last month were sent letters by a Senate committee asking how they set insulin prices, and Sanofi CEO Olivier Brandicourt was among the pharma bosses who headed to Washington last month to testify on drug costs.
Shares of Novo Nordisk, the world’s biggest maker of insulin, fell as much as 2.8 percent after Lilly’s announcement.
Lilly, Novo and Sanofi all heavily discount the price of many of their diabetes medications, and there is typically a wide difference in the list and net prices.
Sanofi’s CEO said in his testimony that the average net price of Lantus, the company’s most prescribed insulin, has fallen by more than 30 percent since 2012, yet out-of-pocket costs for patients with commercial insurance and Medicare have increased about 60 percent. In an emailed statement, Sanofi said it has a competing version of Humalog, called a biosimilar, that it sells under the name Admelog. The company said it also offers a variety of discount programs for patients.
https://www.pressherald.com/2019/03/04/drugmaker-will-offer-half-price-insulin-in-wake-of-debate-over-rising-drug-costs/?rel=related


Sorry, ER patients. People with elective procedures get the hospital beds first.

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