To the Editor:
Part of the cause of the long waiting times in the V.A. system is surely a combination of the V.A.’s difficulties in recruiting doctors (especially primary care doctors) and the surge in demand in recent years due to our military interventions in Iraq and Afghanistan. Neither of these causes of the current backlog will be fixed quickly.
If Congress is serious about helping to alleviate the problem and showing our gratitude to and support for our veterans, it will expand Medicare coverage to include all veterans. If that is done, our veterans could choose between the V.A. system and any doctor who participates in Medicare.
Medicare is approaching its 50th anniversary as one of the most durable, successful and popular federal programs ever created. Do our veterans deserve any less?
PHILIP R. LEE
PHILIP CAPER
Brooklin, Me., June 2, 2014
PHILIP CAPER
Brooklin, Me., June 2, 2014
Dr. Lee, a Korea veteran, was an assistant secretary for health in the Johnson and Clinton administrations. Dr. Caper was a senior health care adviser to Senator Edward M. Kennedy.
Hospital Charges Surge for Common Ailments, Data Shows
Wyden’s Waiver: State Innovation on Steroids
John E. McDonough
Harvard University
Section 1332 of Title I of the Affordable Care Act offers to state govern-
ments the ability to waive significant portions of the ACA, including requirements
related to qualified health plans, health benefit exchanges, cost sharing, and refundable
tax credits. It permits state governments to obtain funding that otherwise would have
gone to residents and businesses through the ACA and to use those funds to establish,
beginning in 2017, an alternative health reform framework within statutory limitations.
Section 1332 also permits states to apply in a coordinated fashion for waivers from
Medicare, Medicaid, the Children’s Health Insurance Program, and ‘‘any other federal
law relating to the provision of health care items or services.’’ This article reviews the
statutory provisions and related regulations of this new and unprecedented state waiver
authority, as well as the legislative history of section 1332. Finally, it reviews the limited
activities thus far by states contemplating use of this provision and considers ways this
authority may be considered for use by states in the future. Section 1332 has the
potential to instigate a new, varied, and unprecedented array of state health sector
innovations from both sides of the political divide over health care reform.
Over time, the Affordable Care Act (ACA) will be known for many things. The law includes a treasure chest of policy innovations, most of them unknown and uncelebrated beyond small circles that pay close attention to their respective arenas. Thus far, the ACA has not been known as a stimulus for state health policy innovation. That reputation is undeserved as we see, for example, the federal Centers for Medicare and Medicaid Services (CMS) approve new and unorthodox waivers to states such as Arkansas, Iowa, and Michigan to draw these otherwise recalcitrant states into the ACA’s Medicaid expansion orbit. Arguably, the law’s biggest impact on state innovation will be section 1332 in Title I, the ‘‘Waiver for State Journal of Health Politics, Policy and Law, Vol. 39, No. 4, August 2014
DOI 10.1215/03616878-2744824 Ó 2014 by Duke University Press
Over time, the Affordable Care Act (ACA) will be known for many things. The law includes a treasure chest of policy innovations, most of them unknown and uncelebrated beyond small circles that pay close attention to their respective arenas. Thus far, the ACA has not been known as a stimulus for state health policy innovation. That reputation is undeserved as we see, for example, the federal Centers for Medicare and Medicaid Services (CMS) approve new and unorthodox waivers to states such as Arkansas, Iowa, and Michigan to draw these otherwise recalcitrant states into the ACA’s Medicaid expansion orbit. Arguably, the law’s biggest impact on state innovation will be section 1332 in Title I, the ‘‘Waiver for State Journal of Health Politics, Policy and Law, Vol. 39, No. 4, August 2014
DOI 10.1215/03616878-2744824 Ó 2014 by Duke University Press
Abstract
Heralded medical treatments often fail to live up to their promise
Posted June 02, 2014, at 10:24 a.m.
KANSAS CITY, Missouri — For the millions of people who couldn’t get their high blood pressure under control, even with handfuls of pills, a simple procedure was supposed to be the breakthrough.
Burn away hypersensitive nerves in the kidneys. Watch blood pressure readings go down.
The American Heart Association hinted the procedure — renal denervation — might become a drug-free cure, even for mild cases of high blood pressure. Media reports, including one in The Kansas City Star, highlighted great results of preliminary research.
Patients eager to get off their meds started calling hospitals.
“The potential benefit was huge,” Kamal Gupta, a cardiologist at University of Kansas Hospital, said.
If only it worked.
In March, doctors reported data from the first truly rigorous study. Patients’ blood pressure did drop, but it fell just as much among those who had a fake version. Device manufacturers canceled additional studies.
“This could be considered the biggest disappointment in cardiology of this century,” Gupta said. But, he added, “the medical community went about it right.”
If only that were always the case.
A combination of industry marketing, overly eager doctors, demanding patients and news media ready to cheer on anything that sounds like a breakthrough is popularizing many drugs, surgeries and other treatments long before they’re adequately tested. Far too often, they’re ultimately proved ineffective — no better than older, cheaper therapies, or even hazardous.
Billions of dollars are wasted and tens of millions of patients are put at risk.
Remember Vioxx, the pain pill for arthritis? It was prescribed to 80 million people worldwide from the time the Food and Drug Administration approved it in 1999 until 2004, when its manufacturer, Merck, withdrew it from the market as evidence emerged that it raised the risk of heart attack and stroke. The FDA said Vioxx caused an additional 88,000 to 138,000 heart attacks and sudden cardiac deaths in the U.S. alone.
Or consider arthroscopic knee surgery. Doctors were doing about 650,000 of these procedures per year at a cost of about $5,000 each. It seemed to relieve pain in about half the arthritis patients who had it done. Then in 2002, researchers compared results of the surgery to a sham version of the operation. Patients had just as much relief when the surgery was fake. It’s the same case with renal denervation; it turned out to be a costly placebo.
“There’s a tendency by doctors and patients to believe that newer is better and more expensive is better and higher tech is better,” said Richard Deyo, a physician on the faculty of Oregon Health and Science University and co-author of “Hope or Hype: The Obsession With Medical Advances and the High Cost of False Promises.”
“The truth is, it really is very difficult — even within the medical profession — to distinguish the really important advances from things that aren’t,” he said.
Right now, hospitals are investing millions to buy surgical robots and hundreds of millions to build proton beam cancer radiation facilities performing so-called bloodless surgery. Both are technological marvels. But even as the money is spent, the medical evidence remains unclear whether they’re better than conventional methods.
What is clear, with serious money at stake, the advertising and marketing of these technologies is unrelenting.
“Marketing drives much more of medicine than most people like to admit. When it comes to high-paying procedures, particularly when they’re reimbursed by Medicare and private insurance in our fee-for-service health care system, doctors and hospitals compete for patients,” Ivan Oransky, a physician and investigative journalist who is global editorial director of MedPage Today, said.
“We’ve all seen the billboards for robotic surgery and bloodless operations. We’ve fetishized ‘cutting-edge.’ When it sounds shiny and new, doctors can be very persuasive and take advantage of patients’ natural tendency to think they have their best interests in mind.”
Journalists charged with “feeding the beast of the daily news cycle” also whip up enthusiasm for the latest medical treatments, said Gary Schwitzer, a former CNN medical reporter turned academic.
Schwitzer has been critiquing the work of his former colleagues for nearly a decade. Earlier this month, he published a study that reviewed the quality of 1,889 medical news stories. It wasn’t flattering.
“Drugs, medical devices and other interventions were usually portrayed positively; potential harms were minimized, and costs were ignored,” his study said.
Reporters often “don’t have the time or don’t have the expertise to scrutinize claims or to evaluate evidence,” Schwitzer said.
This will only get worse, he predicted, as major news organizations demand briefer stories.
“I fear what lies ahead,” he said.
Calling an Ordinary Health Problem a Disease Leads to Bigger Problems
Infants vomit more often because they have an all-liquid diet. They have an immature esophageal sphincter, which doesn’t quite close off the stomach from the esophagus. They eat every few hours, and they have small stomachs. Countless infants will have symptoms of gastroesophageal reflux.
Gastroesophageal reflux disease (GERD) is different. Children with GERD have symptoms so severe that it degrades their life. It’s rare. But over time, more and more babies with reflux were labeled as having a “disease.” The incidence of a diagnosis of GERD in infants tripled from 2000 to 2005.
We often treat diseases with drugs. Today, we commonly treat infants with a group of drugs called proton pump inhibitors (P.P.I.s). Between 1999 and 2004, the use of one child-friendly liquid form of P.P.I. increased more than 16-fold. This was in spite of the fact that P.P.I.s have never been approved by the Food and Drug Administration for the treatment of GERD in infants.
http://www.nytimes.com/2014/06/03/upshot/calling-an-ordinary-health-problem-a-disease-leads-to-bigger-problems.html?hpw&rref=
| For Some, Affordable Care Act Provides Key to 'Job Lock' | |||||||||
| 06/02/2014 Reported By: Patty B. Wight | |||||||||
For decades, the best way to get good health insurance in the U.S. has been through the workplace. But with the Affordable Care Act's online marketplace, health insurance doesn't have to be tied to a job anymore. It's allowing some people to escape so-called "job lock" - saying with a job purely for the health benefits. And while critics of the ACA worry that the law will encourage companies to cut staff and hours to avoid insurance mandates, some Maine workers say new insurance options have freed them to pursue their career ambitions. Patty Wight reports.
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http://www.mpbn.net/Home/tabid/36/ctl/ViewItem/mid/5347/ItemId/34000/Default.aspx
Maine co-op to offer Affordable Care insurance in New Hampshire
Maine Community Health will hire more workers and give residents in the neighboring state another insurance option next year.
By Joe Lawlor jlawlor@pressherald.com
Staff Writer
Staff Writer
Maine Community Health Options will no longer operate exclusively in Maine, as the health insurance co-op will begin offering plans on the New Hampshire health insurance marketplace starting in 2015.
The Lewiston-based co-op – a nonprofit owned by its members – will hire an additional 30 employees over two years, some in Lewiston, others in Concord and other locations in New Hampshire, said Kevin Lewis, its executive director.
The marketplace is where the previously uninsured – often self-employed or part-time workers – can purchase subsidized insurance through the Affordable Care Act. New Hampshire’s marketplace will jump from one insurer, Anthem Blue Cross Blue Shield, to five next year, with the Maine co-op in the mix.
Meanwhile, Maine’s marketplace in 2015 will include Anthem, Maine Community Health Options and new entrant Harvard Pilgrim Health Care.
With more insurance companies offering plans, New Hampshire residents will likely see lower rates. A 2014 study by the National Bureau of Economic Research found that residents who lived in states with one or few insurance companies operating generally paid higher rates.
Initially, the Maine co-op will offer plans in the four New Hampshire counties that border Maine – Rockingham, Strafford, Carroll and Coos – with plans in 2016 to expand into other New Hampshire counties.
Pre-Existing Condition Bans – Are They Really Gone?
Maine hospitals tout Medicare cost data, but health care quality watchdog says ‘we could be a lot better’
Posted June 03, 2014, at 8:03 a.m.
Maine hospitals are touting new data released by the federal government showing the state delivers health care to seniors more cost effectively than most of its counterparts.
A Maine health care cost and quality organization, however, urged examining the numbers from a global perspective.
On Monday, Medicare released a trove of data aimed at making health care costs and outcomes more available and understandable to the public. Among the warehouse of information was data showing geographic variation in costs under Medicare, the government health insurance program for seniors.
Maine’s total Medicare expenditures per capita were 17 percent lower than the national average. The figures account for the portion of the population covered under Medicare, excluding other forms of health insurance, and reflect Medicare reimbursement rates and beneficiaries’ use of health care services across all types of providers.
The Maine Hospital Association highlighted expenditures for inpatient hospital care, which were even lower, falling 20 percent below the national average. From 2009 to 2012, those costs rose less than a half of 1 percent, the association said in a Tuesday news release.
“On a cost basis in Medicare, we’re a good provider,” said Jeff Austin, vice president of government affairs and communications for the Maine Hospital Association. “That’s a message we continually try to deliver to Washington, that they need to become smarter purchasers.”
As for the quality of that health care, the association pointed to a separate set of data previously published by a division of the federal Centers for Medicare and Medicaid Services showing Maine hospitals delivered the best quality care in the nation.
While Maine hospitals compare well against other states, the U.S. sets a discouragingly low bar for health care, said Nancy Morris, a spokeswoman for the Maine Health Management Coalition.
“We’re better than the national average, and that’s good,” she said. “But the reality is we could be a lot better.”
Gary Alexander brings trouble with a capital “T”
LePage delays on refund for fundamentally dishonest report
Medicare Could Save Billions By Scrapping Random Drug Plan Assignment
In 2013, an estimated 10 million people who participate in the Medicare prescription drug program, known as Part D, received government subsidies to help pay for that coverage. They account for an estimated three-quarters of the program’s cost. Most of those low-income enrollees are randomly placed in a plan that costs less than the average for the region where the person lives.
But even though these are lower-cost plans, they often end up costing the government and the beneficiary more. If Medicare instead assigned those people to a drug plan based on the actual drugs they took, it could save those patients hassle and money, and potentially save the government billions of dollars, according to the study by researchers from the University of Pittsburgh. The study appears in the June issue of the policy journal Health Affairs.
Using a 5 percent sample of Medicare drug claims data from 2008 and 2009, the researchers calculated that if Medicare had matched beneficiaries to drug plans using “intelligent reassignment,” rather than random chance, the government would have saved $5 billion in 2009. That’s because the government is responsible for picking up the copayments for many low-income beneficiaries.
Meanwhile, beneficiaries who are assigned to plans that don’t cover the drugs they take are on the hook for out-of pocket expenses, or have to go back to their doctors to get authorization for specific drugs or specific quantities of medications.
“We found that most people are not in the least-expensive plans that satisfy their medical needs,” said Yuting Zhang, the lead author of the study and an associate professor of health economics at the University of Pittsburgh.
Zhang and her colleagues created an algorithm that used patients’ previous drug claims to match them to a more appropriate plan. It resulted in not just a mean total saving of $743 per individual to the government, but also far fewer prescriptions subject to utilization review (19 percent rather than 29 percent) or quantity limits (19 percent rather than 27 percent).
In an interview, Zhang said it should be relatively simple for the federal government to change the way it assigns low-income beneficiaries to Part D plans. “They have much better data than we do,” she said. “And they’re already doing the assignment.”
But sometimes even simple things aren’t so simple. The random assignment of beneficiaries to plans (if beneficiaries don’t choose a plan) was a decision made specifically at the outset of the law to ensure that no one plan got a disproportionate number of very sick beneficiaries, according to a study from Georgetown University and the University of Chicago.
And changing the way Medicare assigns low-income beneficiaries to Part D plans would actually require a change in the law, according to Medicare officials. That means it would be up to Congress to make the savings happen.
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