Health Care Reform Articles - March 19, 2015

How American health care turned patients into consumers

By Dr. Philip Caper, Special to the BDN

A clash of cultures is rapidly developing among those of us who see the mission of the health care system to be primarily the diagnosis and healing of illness and those who see it primarily as an opportunity to create personal wealth.

The concept of health care primarily as a business is uniquely American, and it has gained ascendancy during the last few decades. While there have always been a few greedy doctors, businessmen-wealth-seekers — not doctors — now dominate the medical-industrial complex. They include for-profit insurance, medical device and pharmaceutical companies as well as for-profit and nonprofit corporate providers of health care services, such as the three large hospital systems in Maine.

Partly because of the Affordable Care Act, they also include a rapidly growing army of lawyers, consultants and policy wonks who are creating lucrative businesses helping hapless “consumers” — formerly “patients” — “navigate” their way through the grotesquely byzantine maze our health care system has become.

This shift in emphasis from patient care to money profoundly has affected the practice of medicine and resulted in the clash of cultures within health care. As increasing numbers of “providers” — formerly “doctors” — become employees of large health care corporations — formerly community hospitals — we have come under increasing pressure to diagnose profitable diseases and order profitable tests and procedures without enough regard to the benefits or harm accruing to patients. Hospital “CEOs” — formerly “administrators” — trained in the ethics and practices of business rather than health care are incentivized to configure their “product lines” — formerly “services” — to produce the largest “profits” — formerly “margins.”

Those of us in the health care “business” — formerly “profession” — have been slow to react to this hijacking of our health care calling. Patients, despite sensing something is deeply wrong, feel helpless to push back. That now seems to be changing.

For the past three years The Lown Institute, founded by Dr. Bernard Lown, renowned cardiologist and advocate for universal health care, has held conferences designed to point out the growing problem of overtreatment in medicine. Recently they also have turned their attention to the equally disturbing problem of impaired access to health care and undertreatment. They now advocate for RightCare — not too much treatment and not too little.

Arguably some of the most important effects of Obamacare have been the destabilization of our deeply dysfunctional health care system and an order-of-magnitude increase in the amount of attention given to its dysfunction by the media and the public. Elisabeth Rosenthal’s excellent New York Times series “Pay Till It Hurts” and Steven Brill’s Time magazine cover story and book titled “America’s Bitter Pill” are two of the most recent examples. These two factors have created an opportunity for real structural and cultural change.

There are many advocacy groups — Physicians for a National Health Program, HealthCare-NOW, Maine AllCare — trying to highlight these issues and to propose ways to turn this runaway train around.

While they are necessary, attempts at education and persuasion are not sufficient. Unlike past human rights movements, such as women’s suffrage and marriage equality, the fight for the right to health care for all Americans will require redirecting huge sums of money away from deeply entrenched, profit-oriented private corporations to not-for-profit programs that directly promote the public’s health and wellbeing.

The Institute of Medicine estimates that the convoluted American health care system wastes $750 billion per year in inefficiency and fraud, unnecessary administrative complexity and medical services, unjustifiably high prices and missed prevention opportunities. That waste creates a lot of jobs but does not pay for one Band-Aid or aspirin.

I attended the latest Lown conference, held last week in San Diego, to talk about the “Heal-In” held at Boston City Hospital in 1967 as an example of direct action taken by doctors, nurses and other healers to achieve a political goal without compromising patient care. The capstone of the conference was to announce the expansion of Lown’s mission, previously focused on education and discussion, to include creation of a national grassroots movement that will include direct action. Their first foray will be called RightCare Action week and is scheduled for the fall. Stay tuned.

Changing our health care system is as much about persuasion through power as it is about the power of persuasion. We as patients have power through the ballot box, and we as health care workers have power through our key roles in the “business” of health care to return and redirect its mission toward healing and away from its increasingly singular obsession with profitability.

All we have to do is summon the will and the courage to exercise that power.

http://bangordailynews.com/2015/03/19/health/blogs-and-columns/how-american-health-care-turned-patients-into-consumers/print/

Poll on Health Care Law Shows Increased Support

By ABBY GOODNOUGHMARCH 19, 2015

WASHINGTON — The gap between Americans who view the Affordable Care Act favorably and those who do not is smaller now than at any time since the fall of 2012, a year before the law’s disastrous rollout, according to a monthly poll that has tracked attitudes about the polarizing law since President Obama signed it five years ago.

The latest Kaiser Health Tracking Poll, conducted in early March by the Kaiser Family Foundation, a nonpartisan health policy research group, found that 43 percent of respondents had an unfavorable opinion of the law, while 41 percent viewed it favorably. Though more Americans continue to reject the law than embrace it, the margin has narrowed considerably even since last July, when 53 percent viewed it unfavorably in the Kaiser poll and 37 percent viewed it favorably.

Drew Altman, the foundation’s president, noted that the near closing of the gap had happened after a three-month open enrollment period that involved few technological problems, and at a time when the law is not being as bitterly debated in Washington and in the states as it has been in the past.

“It reflects the fact that the last several months have not been a time when, compared to the past, the Affordable Care Act has been under sharp political attack,” Mr. Altman said.

Forty percent of respondents said they would like to see Congress repeal or scale back the law, while 46 percent said they would prefer that Congress move forward with carrying out the law or expand what it does. Still, Mr. Altman noted, most Republicans continue to oppose the law, and most Democrats continue to favor it. “Opinion on the A.C.A. is still stuck in an intractable partisan divide,” he said.

http://www.nytimes.com/2015/03/20/us/poll-on-health-care-law-shows-increased-support.html?hp&action=click&pgtype=Homepage&module=second-column-region&region=top-news&WT.nav=top-news

Manufactured Medicare outrage

By Charles Lane Opinion writer

Today’s lesson in How Washington Really Works begins with a look at one of the red-white-and-blue Metro buses rolling around downtown.

Ignore the commuters inside, at least the ones going to work on Capitol Hill or the White House, where, supposedly, policy is made. They, and their bosses, are barely relevant to this story.

Focus instead on the lumbering vehicle’s exterior, where a full-color ad implores: “Support better health care for 17 million seniors. STOP THE NEW CUTS TO MEDICARE ADVANTAGE.”

Oh, no! Who’s out to get the elderly this time? It turns out that this scary but information-poor message is the outdoor advertising component of a health-insurance-industry campaign whose goal is to influence the spending of taxpayer dollars — but the ultimate audience for which is not our elected representatives, who ostensibly have the power of the purse. This is all about pressuring the bureaucracy. You might call it Mediscare 2.0. 

Medicare Advantage (MA) is a $150-billion-plus-a-year program that pays insurance companies to enroll elderly and disabled clients in managed-care plans — unlike traditional Medicare, which reimburses health-care providers directly on a fee-for-service basis. About 16 million people participate in MA, roughly a third of the Medicare-eligible population. MA plans absorb a similar share of Medicare’s $450 billion annual outlays. 

Intended as a more efficient alternative, MA has never quite lived up to this promise — at least not in any generally agreed-upon sense.

MA plans are often more user-friendly than traditional Medicare’s multiple hospital, physician and drug “parts.” Hence, MA enrollment has continued to grow despite the 2010 Affordable Care Act’s attempts to squeeze the programs in favor of expanding coverage for others.

Alas, since its origins in the early ’80s, MA has proven no more immune to perverse incentives and system-gaming than any of the government’s other health programs.

First, insurers cherry-picked healthier customers, who are less costly, and hence more profitable, to treat. Congress responded with new payment formulas to reward companies for accepting relatively sick customers. But this led to rampant “upcoding,” whereby MA plans find and report as many illnesses per enrollee as they can plausibly document. 

Last fall, the Department of Health and Human Services released a comprehensive analysis showing that MA costs grew faster than they would have under fee-for-service between 2004 and 2013 — and that only upcoding, not patient demographics or other neutral factors, could explain this.

A complete market-oriented overhaul of the entire Medicare program is a political nonstarter, of course, so the bureaucrats in charge of MA yank on the policy levers that Congress gave them. HHS has repeatedly tweaked the MA payment formula since 2010, trying to claw back money that would otherwise be lost to upcoding. 

The announcement of each tweak triggers a “comment period” during which industry and the public can weigh in, as required by the federal Administrative Procedure Act. HHS rolled out its latest adjustment on Feb. 20 — which brings us back to our buses.

http://www.washingtonpost.com/opinions/manufactured-medicare-outrage/2015/03/18/4fcbc0e4-cd90-11e4-8c54-ffb5ba6f2f69_story.html?hpid=z4

Why did it take 7 months to learn Blue Shield lost tax-exempt status?

By CHAD TERHUNE

Health insurance giant Blue Shield of California and state tax authorities both came under fire for not disclosing seven months ago a landmark decision taking away the insurer's tax-exempt status, which had been in place since 1939.

The Times first reported Wednesday that the California Franchise Tax Board had quietly revoked Blue Shield's tax-exempt status in August after a lengthy audit of the nonprofit health plan.

At that time, the state agency merely added the company's legal name, California Physicians Service, to a 1,363-page document on its website listing hundreds of organizations that lost their exemption.

Blue Shield is protesting the tax board decision, and a company spokesman said the change wasn't announced in August because "it's not something we felt had to be discussed in public. We are working with the tax board to resolve what we consider a disagreement over their decision."

All that came about as the San Francisco insurer was already facing criticism for $4 billion in financial reserves, ever-rising premiums and multimillion-dollar executive salaries.

California Insurance Commissioner Dave Jones on Wednesday applauded the tax board's move as further proof that "Blue Shield charges excessive rates and acts like a for-profit insurer."

Now consumer groups are asking for legislative hearings into the tax board's handling of the Blue Shield matter, and the chairman of the Senate Health Committee said he wants to examine the state tax audit in detail.

Jamie Court, president of Santa Monica-based Consumer Watchdog, said, "There should be legislative oversight hearings on why this was kept secret.

"One of the biggest health insurers loses its tax exemption while it's marketing itself aggressively as a not-for-profit. The public deserved to know this before open enrollment" in the state's Obamacare exchange and when employees were choosing coverage at work, Court said.

He also questioned why tax authorities have only required Blue Shield to file tax returns back to 2013. His group suggested that the state should go back eight years for back taxes.

http://www.latimes.com/business/la-fi-blue-shield-react-20150319-story.html

Playing The Odds With Statins: Heart Disease Or Diabetes?

MARCH 10, 2015

WENDY WOLFSON

Last year my cholesterol shot up despite living nowhere near a decent barbeque joint. I was totally stressed. I wasn't overweight. But I was pretty sedentary. My doctor prescribed a high dose of Lipitor, a powerful statin.

For women of a certain age, statins are supposedly the best thing since Lycra for keeping wayward bodies in check. Statins interfere with the synthesis of low-density lipoprotein, the "bad" cholesterol. LDL is a prime suspect in heart disease, the top killer of women.

The statin cut my cholesterol like buttah.

But statins can also increase the risk of developing Type 2 diabetes, muscle and/or liver damage. Heart trouble and diabetes run in my family. Was I trading a heart attack for diabetes?

"We give statins to people with diabetes," was all my doc said.

That didn't answer my question. I knew from an unrelated test that I did not currently have coronary artery disease, so I decided to investigate the statin situation.

In 2012 the Food and Drug Administration slapped a black box warning on statins, saying that they could raise blood glucose levels in people at high risk of Type 2 diabetes. That meant an increase of anywhere from 9 to 27 percent in relative risk – in absolute terms about 0.3 excess cases of diabetes for every 100 people who are treated for a year with high-intensity statins (which lower cholesterol by 50 percent or more) and 0.1 excess cases of diabetes for every 100 people treated with moderate-intensity statins (which lower cholesterol by 30 to 50 percent.)

Because doctors disagree on who should get statins, in 2013 the American College of Cardiology and the American Heart Association issued guidelines advising doctors not to treat to a cholesterol target, but to prescribe statins if patients fit into one of four risk categories and had an estimated 10-year heart disease risk greater than 7.5 percent.

I didn't fit any category, and based on their calculator my 10-year risk of a heart attack was only 2.9 percent. But my father had a heart attack before age 55. That meant medicating was up to my doctor.

That dumped me right back into the slush pile of uncertainty. Comparing clinical studies was frustrating because populations and measures varied, error margins were squishy and effects were small and murky over large populations.

I hit pay dirt with the Statin Diabetes Safety Task Force 2014 Update, which stated that statins lower the relative risk of heart attack, stroke and death by 25 to 30 percent. They increase diabetes by a relative risk of 10 to 12 percent compared to placebo or usual treatment. So if you are at high risk for diabetes, a statin will get you there faster. Boiled down: one excess case of diabetes in 255 people who took a statin, balanced against 5.4 heart events avoided over an average of 4 years.

Lipitor, a blockbuster drug used by millions, went generic in 2011 but is still big business. It had $631 million in U.S. sales in 2013, down from a peak of $7 billion in 2006. That meant Lipitor must have a track record.

http://www.npr.org/blogs/health/2015/03/10/390944811/playing-the-odds-with-statins-heart-disease-or-diabetes

Why Is Insulin So Expensive In The U.S.?

MARCH 19, 2015

By Anders Kelto

Dr. Jeremy Greene sees a lot of patients with diabetes that's out of control.

In fact, he says, sometimes their blood sugar is "so high that you can't even record the number on their glucometer."

Greene, a professor of medicine and history of medicine at Johns Hopkins University, started asking patients at his clinic in Baltimore why they had so much trouble keeping their blood sugar stable. He was shocked by their answer: the high cost of insulin.

Greene decided to call some local pharmacies, to ask about low-cost options. He was told no such options existed.

"Only then did I realize there is no such thing as generic insulin in the United States in the year 2015," he says.

Greene wondered why that was the case. Why was a medicine more than 90 years old so expensive? He started looking into the history of insulin, and has published a paper about his findings in this week's issue of the New England Journal of Medicine.

The story of insulin, it turns out, starts back in the late 1800s. That's when scientists discovered a link between diabetes and damaged cells in the pancreas — cells that produce insulin.

In the early 1920s, researchers in Toronto extracted insulin from cattle pancreases and gave it to people who had diabetes, as part of a clinical trial. The first patient was a 14-year-old boy, who made a dramatic recovery. Most others recovered as well. Soon, insulin from pigs and cattle was being produced and sold on a massive scale around the world.

But for some, the early forms of the medicine weren't ideal. Many people required multiple injections every day, and some developed minor allergic reactions.

Over the next few decades, scientists figured out how to produce higher-quality insulin, Greene says. They made the drug purer, so recipients had fewer bad reactions. They also made the substance able to last longer in the bloodstream, which led to more stable blood sugar levels and less frequent injections.

"All of these innovations helped to make insulin a little bit safer, a little bit more effective," Greene says.

Then, in the 1970s, scientists developed a new technique they could use for insulin production, called recombinant DNA technology. It involves putting the human gene for insulin into bacteria, which then produce large quantities of the hormone.

Then, a funny thing happened, Greene says: "The older [animal] insulin, rather than remaining around on the market as a cheaper, older alternative, disappeared from the market."

Greene says there's no one reason that companies stopped producing the older animal versions, but they clearly felt it would not be profitable.

Dr. Kevin Riggs, a professor of medicine at Johns Hopkins and co-author of the new insulin study, says the newer, recombinant version of insulin may have had some advantages in terms of convenience and fewer side effects. But there was probably something else at work — doctors being influenced by marketing.

"A lot of time we get caught up in some of the hype," Riggs says. "When a new medicine comes out and it has theoretical advantages, we buy into that and think newer is better."

http://www.npr.org/blogs/health/2015/03/19/393856788/why-is-u-s-insulin-so-expensive