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Tuesday, April 21, 2015

Health Care Reform Articles - April 21, 2015

Your money or your life: Many cancer patients face painful choice

By Jim Landers, The Dallas Morning News
Posted April 16, 2015, at 10:02 p.m.
DALLAS — Kim Harris approached the communion rail at Zion Lutheran Church with a vial of pills in his hand. The thin, dying man and the Rev. Robert Preece were alone in the sanctuary.
They had met many times this way — the 62-year-old cancer patient seeking a blessing for his therapy, and the Dallas pastor who regarded Harris as the “strongest witness of faith in crisis” he’s ever known. The two men prayed for the pills to be empowered with the spirit.
On that day, Harris had a two-week supply of pills. Their price: $18,000. New cancer drugs sell for an average of $120,000 a year.
Medicare, the federal health insurance program, is barred by law from negotiating with the pharmaceutical industry over these prices. In most states, commercial insurers are compelled to offer coverage. It’s illegal to import them, even though the same drugs are far less expensive abroad.
Oncologists get most of their money from reselling drugs to their patients. The higher the cost of the drug, the more money for the doctor.
Many hospitals can get big discounts on cancer drugs under Medicare rules. But they don’t have to pass those savings on to patients. So hospitals also profit from higher-priced drugs.
Prescription drug prices are rising much faster than other health care costs. There is little competition or control to put the brakes to the trend, insurers and some oncologists say.
In 2014, the cost of prescription drugs jumped 13.1 percent, according to Express Scripts, a pharmaceutical benefits company. Specialty drugs, like cancer drugs and the hepatitis C treatments, increased 30.9 percent in 2014. Their prices are expected to go up another 44 percent this year.
The cost of specialty drugs was $87 billion in 2012. United Healthcare estimates that could reach $400 billion by 2020. Total prescription drug spending in 2014 was about $300 billion.
Cancer patients without adequate insurance have only the starkest choice: your money or your life.
“I couldn’t believe the cost of some of these drugs,” said Harris, whose insurance picked up the tab. “I mean, $18,000?”
Harris was diagnosed with colorectal cancer in August 2008 and survived years longer than his oncologist expected. He exhausted his drug options last year and entered hospice care in February. He died March 12.
Five years ago, cancer treatment accounted for just $157 billion of the nation’s annual $2.6 trillion health bill. Propelled by new drugs and an aging population, however, cancer spending is rising quickly. A forecast from the National Cancer Institute said spending could hit $207 billion by the end of the decade.
About 1.6 million Americans will be diagnosed with cancer this year. Annual spending for the average patient is already more than $20,000 higher in the U.S. than it is in Europe.
By 2030, the number of cancer diagnoses is expected to rise 45 percent. By then, oncologists predict cancer will eclipse heart disease as the nation’s leading cause of death.
The cancer drugs used by Kim Harris and other patients do not cure. In rare instances, they offer a way to stabilize a cancer. More often, they offer a few additional years, months or even a few days of life. To Harris, that was priceless.
But Dr. Hagop Kantarjian, the chair of the leukemia department at Houston’s M.D. Anderson Cancer Center, argues the prices of these new cancer drugs are “absolutely immoral.”
“Since the 2006 Medicare Reform Act (providing drug insurance), Medicare has been prevented from negotiating prices with the drug companies,” he said. “That left the drug companies as the only (entities) setting prices. They’re like a child alone in a candy store.”
His most egregious example: Gleevec.
A breakthrough treatment for some types of leukemia, Gleevec keeps cancer at bay as long as the patient continues to take the pills. It also shows results in treating colorectal cancer.
A pricing database developed at Memorial Sloan Kettering Cancer Center in New York shows Gleevec entered the market in 2001 priced at $3,401 a month.
Pharmaceutical companies enjoy a monopoly on their formulas for up to 20 years under patent laws. With Gleevec’s patent expiring in July, Swiss pharmaceutical maker Novartis now has the drug priced at $11,000 a month.
Kantarjian’s indignation with these drugs is not about their value to patients.
“I have nothing against Gleevec. Gleevec is a great drug,” Kantarjian said. “But they know that patients with cancer are desperate. It’s either pay or die.”
Novartis recorded net income of $10.3 billion last year on sales of $57.8 billion.
Gleevec, with sales of $4.7 billion, was the firm’s best seller. The profit margin for the company’s pharmaceutical sector was 26.6 percent.
In Canada, Gleevec sells for about $3,170 a month. A generic version of the medication sells there for about $735 a month. The generic won’t be available in the U.S. until next year.

Public vs. Private Health Insurance on Controlling Spending

7:05 am ET
Apr 16, 2015 
No single fact can settle the long-running debate of whether public or private health insurance is preferable. But by one basic metric, the rate of increase in per capita spending, public insurance has an edge.
The Federal Office of the Actuary in the Centers for Medicare and Medicaid Services has charted the annual rate of increase in spending for Medicare, Medicaid, and private health insurance. As the chart above shows, by cumulative growth in per capita spending, Medicare and Medicaid have generally grown more slowly than private insurance and are projected to continue doing so through 2023. Per capita spending is an especially useful measure for comparing public and private health insurance spending because it shows how much Medicare, Medicaid, and private insurers spend on each person irrespective of the number of people covered.
Advocates of public coverage tend to like its relative simplicity, uniform guaranteed benefits, and lower overhead costs, as well as the ability of large public insurance programs to use their purchasing power to leverage changes in the health-care system. Advocates of private coverage favor the greater choice it can offer consumers and the competition that can foster in the marketplace. For some people, preferences for public or private coverage are largely ideological.
When it comes to analyzing health spending, there are always multiple factors at play. Sometimes changing demographics can have a role. As younger baby boomers join Medicare, the average amount that the program spends per beneficiary will be slightly reduced over the next decade. Overall, however, it appears that public programs control per capita spending somewhat more effectively than private coverage does. That may be just the opposite of what many would presume in a country where the private market is generally expected to outperform the public sector.
Here’s another way to think about it: While Medicare and Medicaid are far from perfect, the purchasing power and policy levers available to large public programs appear to give them an edge over our fragmented private insurance system when it comes to controlling spending.
Drew Altman is president and chief executive officer of the Kaiser Family Foundation. He is on Twitter: @drewaltman.

Doctors See Benefits and Risks in Medicare Changes

By  and 

Dr. Robert Wergin, president of the American Academy of Family Physicians, made little effort to contain his glee Wednesday over the news that Congress had voted to end a reviled payment system for doctors, simultaneously averting a 21 percent physician pay cut and overhauling the way Medicare will pay doctors in the future.
“I just can’t be more positive about it,” said Dr. Wergin, who is a family doctor in rural southeast Nebraska. “The one word is yahoo.”
Then he added: “Now, what next?”
President Obama has signaled that he will sign the bill, resolving an issue that frustrated lawmakers in both parties for more than a decade because it repeatedly required Congress to step in to avert cuts to doctor fees. Doctors and health policy experts have begun to take stock of the practical implications of the legislation, which seeks to move away from paying doctors solely on the volume of their services and toward reimbursing them based on the quality and value of the care they provide. Many said the legislation was short on details about how such quality will be measured, and others expressed apprehension about whether the system will be fair.
“It’s very important legislation in that it aims to support better care and lower costs, but there are a whole lot of details that still need to be filled in,” said Dr. Mark McClellan, a senior fellow at the Brookings Institution and a Medicare administrator in the George W. Bush administration.
Under the new legislation, Medicare will increase the amount it reimburses doctors by 0.5 percent for the next five years. Doctors will earn a 5 percent bonus if they participate in newer payment models that seek to better coordinate care. One example is the so-called medical home, in which a medical team coordinates a patient’s care. They could also work in groups, called accountable care organizations, that receive a set fee to take care of a patient while still meeting quality standards.
“It’s a very big boost to these models,” said Paul B. Ginsburg, a health economist at the University of Southern California, although he and others noted that how these payment models will be defined is still not clear.

California Parents Opposing State-Mandated Vaccinations of Children Delay Vote

By ROBERT B. GUNNISON

SACRAMENTO — Several hundred Californians swarmed the State Capitol on Wednesday to oppose a bill that would eliminate their right not to vaccinate their children against contagious diseases like measles. They were able to help stall a committee vote on the legislation by a week.
The bill, introduced after a measles outbreak over the winter that originated at Disneyland, would require nearly all children to be vaccinated, eliminating the growing use of the so-called personal belief exemption that has contributed to the spread of preventable diseases. Parents who refused to immunize their children and did not have a medical exemption would be forced to teach their children at home.
The bill, which was passed by the State Senate’s Health Committee, was up for a hearing on Wednesday before the Senate Education Committee. There, the small but vocal minority of parents who object to scientifically proven vaccinations showed up in force and helped stall the measure.
“I strongly oppose injection of questionable materials into the bodies of our children as a condition of education,” said Steve Wall, an environmental engineer from Bay Point, who lined up with hundreds of others to denounce the bill before the Education Committee.

Obamacare repeal falls off Republicans' to-do list as law takes hold
After five years and more than 50 votes in Congress, the Republican campaign to repeal the Affordable Care Act is essentially over.
GOP congressional leaders, unable to roll back the law while President Obama remains in office and unwilling to again threaten a government shutdown to pressure him, are focused on other issues, including trade and tax reform.
Less noted, senior Republican lawmakers have quietly incorporated many of the law's key protections into their own proposals, including guaranteeing coverage and providing government assistance to help consumers purchase insurance.
And although the law remains very unpopular with GOP voters, more than 20 million Americans now depend on it for health benefits, making even some of the most conservative Republicans loath to cut off coverage.
Facing the prospect that the Supreme Court this year could strip away insurance subsidies provided through the law in most states, several GOP lawmakers have proposed extending the aid, perhaps even until a new president takes office.
At the same time, the presumed Republican presidential front-runner, former Florida Gov. Jeb Bush, has shown little enthusiasm for a new healthcare fight. Last year, he even criticized the repeal effort.
Republicans who still demand a repeal, including Sen. Ted Cruz of Texas and Louisiana Gov. Bobby Jindal, appear to be long shots for the presidential nomination.
"Only 18% of Americans want to go back to the system we had before because they do not want to go back to some of the problems we had," Whit Ayres, a veteran Republican pollster who works for presidential candidate Sen. Marco Rubio of Florida, said at a recent breakfast hosted by the Christian Science Monitor.
"Smart Republicans in this area get that," he added.
On Obamacare's 5th anniversary, Americans are starting to feel appreciation

Michael Hiltzik

LOS ANGELES TIMES
Coverage of the Affordable Care Act's fifth anniversary Monday -- it was signed into law March 23, 2010--will undoubtedly focus on the gains in coverage and reductions in healthcare costs that have followed its rollout. To get the raw figures out of the way first, 16.4 million previously uninsured people now have insurance, the uncompensated care expenses of hospitals have fallen by more than 20%, and the rate of medical inflation is at a historic low.  
But a less-noticed trend also may be unfolding: Americans are beginning to appreciate that Obamacare has improved the nation's healthcare system, and their lives.
Evidence for that comes from the Kaiser Family Foundation's health tracking poll, the latest results of which were released Thursday. According to the poll, Americans' favorable opinion of the ACA has been rising almost steadily since November 2013, when the botched launch of the federal enrollment website, Healthcare.gov, brought the favorable/unfavorable split to its worst showing, 33%/49%. (See graphic above.)
The latest survey shows that the "favorable" camp has risen to 41%, vs. 43% unfavorable. An additional 16% say they have no opinion or refused to give it; that figure has declined modestly since November 2013, when it was 18%. If you factor out that group, then among those who expressed an opinion, 49% are favorable. 
Another statistic in the Kaiser survey reinforces the trend. The public's opinion of how the ACA has affected them personally also has been improving steadily. Of those who say the ACA has had some effect, 47% say it's been positive; in November 2013 that figure was only 34%.
Well more than half of all respondents, 57%, say the ACA has had no effect on them personally. That's not surprising for a couple of reasons. One is that some 85% of all Americans get their insurance from their employer or a government program such as Medicare, where the effects of the ACA are hard to perceive. Another is that most people typically don't have an interaction with the healthcare system in any given year; that's where the availability of coverage and its cost would be felt most acutely.
Yet as we enter year six of the ACA era, some flaws in the rollout persist. One is that too many people don't understand how the law works--indeed, how health insurance works. In part, that reflects the situation in the pre-ACA days, when fewer people had an insurance choice. They were either given a limited menu of selections by their employer, or took whatever they could get in the individual insurance market, often an overpriced, low-benefit plan.
Now millions of people have to figure out how to balance premiums, co-pays and deductibles, and plainly they're not getting much help. Just last week, in a piece asserting that "many" uninsureds are opting to pay a tax penalty for going without coverage rather than buying a plan, the Wall Street Journal interviewed Florida retiree Richard Gonzalez, 59, who chose to pay a $250 penalty for going without insurance because insurance would cost him $400 a month for a plan with a $6,000 deductible. The penalty, he said, "beats paying more than $10,000 a year."

There’s a Trojan horse in the Medicare bill

By Laurence S. Jacobs, M.D.
Santa Fe New Mexican, April 10, 2015
Bipartisanship can work. The old flawed formula for physician reimbursement in Medicare (SGR) will finally be permanently canceled and replaced, so that physicians will no longer be looking at roughly 20 percent cuts in reimbursement every year, absent one-year congressional fixes.
That’s the good news about the bill recently passed by the House of Representatives (HR 2); the Senate will vote on it right after the current recess. Now here’s the bad, alarming news: The bill contains provisions intended to undermine and eventually destroy traditional Medicare, and replace it with progressive privatization.
This bill requires the payment of deductibles not coverable by Medigap policies, expands means-testing of Medicare premiums and imposes burdensome new documentation requirements on physicians in traditional Medicare. The results of these provisions will make Medicare more costly for everyone, restrict access and choice of physician in Medicare, and preferentially benefit private insurance plans, including Medicare Advantage plans.
The only way to avoid paying the deductible out of pocket will be to leave Medicare and join a private plan, like a Medicare Advantage plan. Such plans are more costly overall than traditional Medicare, and it has been estimated that their excess cost since 1985 amounts to over $282 billion. The expansion of means-testing, requiring higher- income seniors to pay higher premiums, seems likely to undermine support for Medicare by this relatively influential voting bloc.
The documentation requirements are sufficiently onerous that many physicians may opt out of traditional Medicare, or retire altogether, thus limiting choice of physician and access to care in traditional Medicare. The bill exempts from this documentation requirement “alternative payment methods,” which are more likely to be associated with contracts with private plans.
GOP members see this bill as part of their long-held goals of turning Medicare into a voucher-based program for private insurance plans (remember Paul Ryan’s plan?), and shifting more and more costs onto patients. Speaker John Boehner stated that this bill represents a step in the direction of “entitlement reform.”
This bill should not be passed unless the documentation, deductible and means-testing provisions are removed from it. If we had a single-payer health insurance system, like so many other industrialized nations, we wouldn’t be playing political ideology games with people’s health and their lives.
Laurence S. Jacobs, M.D., is emeritus professor of medicine at the University of Rochester in New York. He lives in Santa Fe.

Payment reforms in federal bill will add burdens to doctors

By Stephen B. Kemble, M.D.
Honolulu Star-Advertiser, April 16, 2015
Medicare’s “Sustainable Growth Rate” (SGR) formula, passed in 1997, required drastic cuts to physician fees annually. Each year Congress postponed the cuts in response to warnings that implementation would lead to severe problems with access to care for Medicare beneficiaries, but without changing the formula, effectively “kicking the can down the road.”
The U.S. House and Senate have finally passed a bipartisan “Doc-Fix” bill, H.R. 2., which will eliminate the SGR formula for good. Everyone welcomes the end of the SGR, but instead of a clean bill, H.R. 2 contains add-ons from both parties that will have serious consequences for the Medicare program.
The Republicans got increased patient cost-sharing for Medicare recipients. “Medi-gap” policies, that cover what regular Medicare doesn’t, will no longer be allowed to cover the Medicare deductible, so the required deductible will become a deterrent to needed care for those with limited means. Those with higher incomes will be subjected to means testing and higher Medicare premiums.
The Republican goal is privatization of Medicare, so the “required deductible” will be waived for seniors that leave regular Medicare and join private Medicare Advantage plans. These are the plans that have been gaming risk adjustment formulas to increase their reimbursement and using marketing and restricted networks and formularies to “cherry-pick” healthier seniors and push sicker ones back onto regular Medicare, while costing the government 14 percent more than regular Medicare.
The Democrats got a 2-year extension of funding for the Children’s Health Insurance Program and the Community Health Centers, and those are good things. However, they also included provisions to accelerate the push toward “value-based” payment for doctors by implementing a “merit-based incentive payment system,” relying on detailed data from diagnosis and treatment coding, to be used for “pay-for-quality” or “pay-for outcomes.” There are escalating penalties for failure to adequately computerize so as to provide the required data.
Physicians seeing patients under “alternative payment models” and Medicare Advantage plans are exempted from these penalties, but this means older doctors who are not up to all the changes are more likely to retire early. The rest will be pushed into large “clinically integrated networks” controlled by hospitals and insurance plans, or else into direct employment by hospitals and health plans. Independent physician practices will soon become extinct.
Unfortunately, these reforms are not based on evidence-based policy.  Experience so far with “value-based” payment and “alternative payment models” shows no significant progress toward the stated goals of improving care coordination and quality of care, improving population health, or reducing cost. National evidence shows that small independent primary care practices, even without advanced computerization, actually do much better than large group practices in preventing avoidable admissions, most likely because independent doctors tend to know their patients better.
In Hawaii, efforts to implement “pay-for-performance” have been associated with a dramatic increase in health insurance costs and administrative burdens imposed on doctors and hospitals. These efforts also coincide with a severe and worsening physician shortage across most specialties, and with rapid decline in physician acceptance of Medicaid due to managed care burdens.
The payment reforms in the bill will accelerate the trends of increasing administrative burdens on doctors, worsening physician shortages, and worsening access to care problems.
A clean repeal of the SGR would have been far preferable, but we must now live with H.R. 2. Instead of administratively expensive attempts to micromanage doctors, our best hope in Hawaii would be to design our own “alternative payment model” that focuses on reducing administrative burdens and improving access to necessary health care for all, controlling cost with administrative savings instead of restrictions on care.
Stephen B. Kemble, M.D., is a member of the Hawaii Health Authority. 
http://www.staradvertiser.com/s



Patient advocates help people deal with doctors, hospitals, insurers
By 
Navigating the murky waters of hospital bills, insurance statements and medical claims can be jarring.
When Thomas Fefer's wife of 22 years was diagnosed with pancreatic cancer last summer and died just 66 days later, the onslaught of bills and bureaucratic hurdles was overwhelming for him.
"The things I was suddenly facing upon her death were truly insurmountable for me to consider," says Fefer, 63, a director of accreditation for the Tri-County Better Business Bureau in Santa Barbara. "An extraordinary number of expenses were piling up."
He needed help. An online search led him to a little-known industry of patient advocates and billing specialists that provide guidance on dealing with doctors, hospitals and insurance companies.
They handle negotiations and work to find satisfactory billing agreements. Often a fee is involved, but many employers will cover the cost.
"It's about dealing with the sheer volume of paperwork," Fefer says. "When a family member is beset with a terrible illness, it's never just one bill. It's a host of clinics and doctor and hospitals."
Fefer chose Martine G. Brousse, a patient advocate in Santa Monica, to make sense of his wife's medical bills.
Professionals such as Brousse work with patients and their families. They fight denied medical claims, file appeals, secure insurer authorization for medical care and generally help navigate complicated insurance rules. Some help find medical care, such as specialists and nursing homes.
These patient advocates — also called medical billing advocates or claims assistance professionals — have been around for decades. But the field has taken off in recent years as patients face higher out-of-pocket medical costs and the healthcare system becomes increasingly difficult for the average person to navigate.
"People just don't understand what's on their bill. The language is written in medical terminology. Sometimes clients just want a translation," says Maureen Lamb, a medical billing advocate and chief executive of Medical Bill Support in Holderness, N.H.
Larger organizations and an estimated 300 independent advocates practice nationwide, according to the Alliance of Professional Health Advocates, an advocate trade group.There is no uniform training or licensing requirements for advocates or specific type of service they offer.
A host of organizations provide education and support to advocate professionals, many of whom are former nurses, attorneys or medical coding professionals. Some are certified in medical bill coding by organizations such as the American Academy of Professional Coders and the American Health Information Management Assn.

Federal Panel Revisits Contested Recommendation On Mammograms 

By KATHERINE HOBSON
In 2009, I was among the scrum of reporters covering the controversial advice from the U.S. Preventive Services Task Force that women in their 40s think twice about regular mammograms. The task force pointed out that the net benefits in younger women were small and said women should weigh the pros and cons of screening before making a decision. 
Those guidelines kicked off a heated debate about the benefits and harms of mammography that is rekindled with every new study. 
I wasn't yet 40 back then, but what I learned about mammograms stuck with me: I haven't yet had the test. I took to heart the warnings of the task force and of many other physicians that mammography has minuses as well as pluses. I wasn't so worried about a false positive result. But I was very concerned about overdiagnosis, or being diagnosed with and treated for a cancer that would never have caused me any harm. 
I'm now 43 and am thinking that I should get a mammogram. So when I found out the USPSTF was doing a routine update of its breast cancer screening recommendations, I hoped it would help me decide. 
As it turns out, the suggested changes to the recommendations — which are in draft form and may be altered after a public comment period — are small ones. 
What is new? For the first time, the task force looked at the evidence behind 3-D mammography, also known as tomosynthesis. The USPSTF said there's not enough evidence to make a recommendation for or against using the technology to screen women. It also said there was insufficient evidence to say whether women with dense breasts should have screening with MRI, ultrasound or other methods in addition to mammography. 
But the task force's basic advice has not changed. The group recommends that women ages 50-74 get a screening mammogram every two years. And women between 40 and 49 should make their own decision, in consultation with their doctors, based on "health history, preferences and how they value the different potential benefits and harms of screening." (Women with a family history of breast cancer may benefit more from screening in their 40s, the task force says.) 

State questions rise in overdose drug price

Naloxone vital in emergency efforts

By  GLOBE STAFF  
 
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