Health Care Reform Articles - July 22, 2015

A Pharma Payment A Day Keeps Docs’ Finances Okay

New data on payments from drug and device companies to doctors show that many doctors received payments on 100 or more days last year. Some received payments on more days than they didn’t.

by Charles Ornstein and Ryann Grochowski Jones

Few days went by last year when New Hampshire nephrologist Ana Stankovic didn't receive a payment from a drug company.

All told, 29 different pharmaceutical companies paid her $594,363 in 2014, mostly for promotional speaking and consulting, but also for travel expenses and meals, according to data released Tuesday detailing payments by drug and device companies to U.S. doctors and teaching hospitals. (You can search for your doctor on ProPublica's updated Dollars for Docs interactive database.)

Stankovic's earnings were certainly high, ranking her about 250th among 606,000 doctors who received payments nationwide last year. What was more remarkable, though, was that she received payments on 242 different days — nearly every workday of last year.

Reached by telephone Tuesday, Stankovic declined to comment. On her LinkedIn page, Stankovic lists herself as vice chief of staff at Parkland Medical Center HCA Inc. in Derry, New Hampshire, and as medical director of peritoneal dialysis at DaVita Inc., also in Derry.

That doctors receive big money from the pharmaceutical industry is no surprise. The new data released by the Centers for Medicare and Medicaid Services shows that such interactions are widespread, with not only doctors, but thousands of dentists, optometrists, podiatrists and chiropractors receiving at least one industry payment from August 2013 to December 2014.

What is being seen for the first time now is how ingrained pharmaceutical companies and their sales reps are in the lives of those who write prescriptions for their products. A ProPublica analysis found that 768 doctors received payments on more than half of the days in 2014. More than 14,600 doctors received payments on at least 100 days in 2014.

Take Juichih Hsu, a Maryland doctor whose specialty is family medicine. She received payments on 286 days of 365, more than anyone else. Sometimes, she received meals from several drug companies on the same day. Hsu's payments totaled $5,959 in 2014. She declined to comment when reached on Tuesday.

"There are physician practices which have very deep relationships with pharmaceutical representatives, where they are a very integral part of the practice," said Dr. Aaron Kesselheim, an associate professor of medicine at Harvard Medical School who has written about industry relationships with doctors. "Every day it's another drug company coming in for a lunch. Sometimes it may be some drug companies are bringing breakfast and some are bringing lunch and it's just part of the culture of the practice."

http://www.propublica.org/article/a-pharma-payment-a-day-keeps-docs-finances-ok

Medicare to Try a Blend of Hospice Care and Treatment

JULY 22, 2015

by Margot Sanger-Katz

Most older Americans close to death have to make a difficult choice: continue with traditional medical treatment or switch to hospice care, which focuses not on a cure but on easing their remaining days.

Now, Medicare is testing a third alternative: both.

The new pilot program, designed to affect the care of about 150,000 Medicare patients over the next four years, will allow patients with terminal diseases to receive hospice care to manage suffering and counseling to plan for the end of life — but still see doctors and get medical treatments, like chemotherapy or hospitalization, intended to fight their illnesses.

The test program is based on research that shows that patients with access to both so-called palliative care and traditional medicine often end up with a better quality of life and less expensive, intense medical treatment. The approach may even offer the patients a longer life spanthan those treated with traditional medicine alone.

http://www.nytimes.com/2015/07/22/upshot/medicare-to-try-a-blend-of-hospice-care-and-treatment.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well&abt=0002&abg=0

Will Maine share in health reform’s success or follow Old Confederacy?

By Theda Skocpol

For the last five years, never-ending Obamacare battles have been accompanied by quiet progress in implementation.

Maine has been front and center in ideological warfare and quiet progress. But the state’s final health reform chapters remain to be written. When disputes in Augusta reach an end, will all the state’s people and businesses be able to reap the full benefits of reform? Let’s review the state of play.

In Washington, D.C., congressional Republicans have voted more than 50 times for repeal — even though most Americans prefer to keep the law and improve itand President Barack Obama would veto any such legislation that reaches his desk. Meanwhile, serious challenges to the health law worked their way through the federal courts to twice reach the Supreme Court.

Through it all, the Affordable Care Act has survived. In its latest ruling on the law last month, the high court preserved subsidies for purchases on Obamacare insurance exchanges and even made it clear it is unlikely to entertain any more challenges. Health reform is here to stay.

For Mainers, this is excellent news, because nearly 75,000 people have purchased health insurance plans on the state’s exchange. A higher percentage of eligible Maine customers signed up — more than 60 percent — than in any other New England state except Vermont. Had the court ruled the other way, the majority of these Maine customers probably would have lost their coverage, because nine out of 10 — including rural people and lobstermen and their families in coastal communities — need the federal subsidies to help pay their insurance premiums.

Across the country, health reform surprisingly is working well. More than 10 million Americans have gained new coverage as a direct result of the law, another 9 million are newly included in employer plans and still others have better insurance for the price they pay. Of course, the health law could be improved — for example, by reducing regulations on small businesses — but that can happen only after Republicans stop pushing for repeal and join with Democrats to enact changes with bipartisan support.

Dozens of new insurance companies started offering plans on the state exchanges in 2015, creating more choices and keeping prices down. New Hampshire went from one to five insurers on its exchange, and Maine went from two to three. Depending on how regulators respond to insurance company requests, premiums may go up more for 2016 than they did this year, but consumers would be able to switch plans if they want to pay less. We need to remember health insurance premiums were rising fast before the Affordable Care Act, even though millions of Americans were losing coverage and had no recourse. Things are better now. Still, health care providers must keep looking for new ways to deliver quality care at reasonable prices. Maine hospitals and community health centers already are participating in experiments encouraged by the health reform law.

http://bangordailynews.com/2015/07/21/opinion/contributors/will-maine-share-in-health-reforms-success-or-follow-old-confederacy/?ref=OpinionBox

Surprise! That urgent care center may send you a big bill, even if you’re insured

By Julie Appleby, Kaiser Health News

Posted July 20, 2015, at 11:43 a.m.

Sallyann Johnson considers herself a pretty savvy health care consumer. When she fell and injured her hands and wrists, she didn’t head for an expensive emergency room, choosing an urgent care clinic near her Milwaukee home instead.

Before seeking treatment, she asked the key question: Did the center accept her insurance? Yes, Johnson was assured, both on the phone and then again when she arrived at the clinic.

After X-rays and a visit with a physician assistant, Johnson learned her wrists were sprained, but weeks later, it was her wallet that sustained the most damage.

“I received a bill from a doctor for $356,” said Johnson, 62. “I felt I asked all the right questions. I even re-asked the questions.”

Long seen as a lower-cost alternative to hospital emergency rooms for minor illnesses or injuries, urgent care centers are increasingly popular with consumers – and their insurers. Maine is home to more than 20 urgent care clinics, many affiliated with major health systems and others run by private, for-profit companies.

But like doctors and hospital ERs, urgent care can also present payment headaches if they are not part of a patient’s insurance network. And consumers may need to ask specifically about network participation to find out.

Earlier this month, the New York State attorney general wrote businesses that operate dozens of urgent care clinic locations, saying the health plan participation information on their websites may be “deceptive” and asking for specific information about which insurance plans they participate in as in-network partners. The inquiries went to stand-alone clinics, as well as those affiliated with hospital systems and retail outlets, including Duane Reade and CVS stores.

In New York and nationally, insurance coverage information provided on urgent care clinic websites is often unclear. Some centers’ websites say they “accept most major insurance plans” while others list specific insurers they “accept,” or “work with” or “bill.” But what does that mean?

Accepting insurance might mean a consumer will owe the balance between what the clinic charges and what an insurer pays toward an out-of-network visit, which is generally far less than payment for an in-network provider.

Such statements “may lead consumers to believe that an out-of-network urgent care center is … ‘in network’ with their health plan,” say the July 2 letters from N.Y. Attorney General Eric T. Schneiderman.

The centers may well be in-network with some insurers. But if they’re not, “consumers may receive unexpected, and often costly, bills … when they believed that they would be responsible solely for their copayment …,” the letters say.

http://bangordailynews.com/2015/07/20/health/surprise-that-urgent-care-center-may-send-you-a-big-bill-even-if-youre-insured/print/

Medicare turns 50, and we have much to celebrate

By Theresa Chalich, R.N.
Pittsburgh Post-Gazette, Letters, July 19, 2015
Nicholas Kristof’s commentary “Poverty: Yes, It’s About Personal Responsibility but It’s Also About the Choices We Make as a Society” (July 12 Forum) on the need for collective responsibility was written at an opportune time. This July we celebrate the 50th anniversary of Medicare. What an impact this social program has made on improving health and financial stability.
This publicly funded program financed by our employee Medicare taxes has been and is a practical solution to a severe need. Fifty years ago one-half of seniors were without hospital insurance. One in three lived in poverty. Today nearly all seniors and younger people with permanent disabilities have access to affordable health care.
Mr. Kristof wrote about our nation’s blame-the-victim mentality. It is important to know that Medicare addressed our systemic problem of racism by stopping payments to segregated hospitals and by allowing African-American doctors to get hospital admitting privileges. For these doctors, the legacy of discrimination held back their economic growth. Medicare has truly been a collective response.
On July 14 Pittsburgh City Council recognized the 50th anniversary of Medicare and its goals with a proclamation sponsored by Councilman Corey O’Connor.
So, happy birthday, Medicare! May our birthday wish be that we will have Medicare for all!
Theresa Chalich, R.N., resides in Squirrel Hill. She is a member of HealthCare 4 All PA.
http://www.post-gazette.com/opinion/letters/2015/07/19/Medicare-turns-50-and-we-have-much-to-celebrate/stories/201507170176

Medicare turns 50 this month

By Ray Bellamy, M.D.
Tallahassee Democrat, July 18, 2015
In 1963 or so, a group of us UF second year medical students tramped upstairs to listen to some of a spirited discussion among Gainesville-area physicians along with UF faculty regarding providing nearly universal health coverage to seniors. I remember little of the discussion other than some inflammatory rhetoric about “government overreach and what it would do to or for Granny.”
Most folks now are not aware that in those days, the AMA had only recently come off its traditional opposition to group medical practice. (Yes, they felt all physicians should be working solo.) So now, on July 30, we will herald arguably one of this country’s most successful social programs ever — the establishment of Medicare. We should also acknowledge the role Medicare played in speeding the integration of hospitals.
There is much one can complain about Medicare — that it will begin running a deficit in 17 years, that some providers are not reimbursed adequately to cover expenses, that the first day of inpatient care costs a thousand dollars out of pocket. However, with a strong approval among seniors — 92-percent satisfaction, a low overhead of about 2.5-percent, and the benefit of safety net coverage for a part of the population which is stressed to pay bills (elderly women average a third of their income for medical expenses), the goal of sharing risk broadly over a large population has been been met. Note that the sickest 20 percent of this group accounts for 80 percent of the cost.
Presidential candidate Vermont Senator Bernie Sanders is advocating for an improved Medicare for All, properly funded, as he has for decades. Since the simplicity of everyone having the same comprehensive plan and a Smart Card to swipe at the physician’s office or pharmacy would save several hundred billion dollars a year in reduced overhead, it is easy to understand how most developed nations use some version of a single payer system. Because prevention is often less expensive than treatment, but the payoff may take years to realize, enrollees in private insurance who tend to stay with one plan for only a short time are unlikely to see this cost reduction passed to them.
But we muddle on, and costs in health care keep rising, inflammatory opposition rhetoric about “death panels” and “socialized medicine” gets bandied about, and our overall healthcare non-system struggles from day to day.
So here we are with Medicare at 50, struggling with proposals for vouchers, the higher costs of Advantage plans, the need to more adequately fund the trust fund. The latest assault comes from a “bribe” to help passage of the TPP Fast Track international deal. It would take $700 million from Medicare and use those funds to support job retraining and assistance for workers who lose their jobs due to offshoring, etc.
And with our political paralysis, along with suspicion of all things government does, even when government has demonstrated it can do many tasks better than the private sector, stay tuned.

http://www.tallahassee.com/story/opinion/2015/07/18/medicare-turns-month/30322447/

Paralyzed by Gunfire, but Denied Care

By RONI CARYN RABIN

JULY 20, 2015

There’s no video of the altercation between Monroe Bird III, a 21-year-old sitting in a car with a friend, and Ricky Leroy Stone, 56, a security guard who found them one night in the parking lot of an apartment complex in Tulsa, Okla.

But the tragic culmination of their encounter is not disputed: Mr. Stone drew his gun and shot Mr. Bird, leaving him paralyzed from the neck down.

Three months later, as he lay in the hospital hooked to a ventilator, Mr. Bird’s insurance company declined to cover his medical bills. The reason? His injuries resulted from “illegal activity.”

Yet Mr. Bird was not convicted of any crime in connection with the incident. He was not even charged.

Without insurance, Mr. Bird’s family could not move him to a rehabilitation center specializing in spinal cord injuries. He was discharged from the hospital and died at home last month from a preventable complication often seen in paralyzed patients.

The incident joins a disturbing litany of cases in which black men have been shot by white men in law-enforcement capacities. Mr. Bird’s family and their supporters believe racial bias motivated the shooting, at least in part, and protected the guard from criminal prosecution.

But Mr. Bird’s story comes with a particularly bitter sequel relevant to Americans of any background: The plan’s refusal to pay has left his family owing as much as $1 million in medical bills and, experts say, shines a light on a little-known loophole buried in the fine print of many health plans.

http://mobile.nytimes.com/blogs/well/2015/07/20/illegal-activity-fine-print-leaves-some-insured-but-uncovered/

Will Hospitals Lose Money Under Obamacare?

By Kimberly LeonardJuly 17, 2015

The portion of President Barack Obama's health care law aimed at lowering the number of uninsured in the country has largely rolled out, leaving the administration increasingly turning its attention to another goal of the Affordable Care Act: controlling health care costs. It doesn't appear, however, that the proposals will make a significant dent in government spending, and questions remain over whether providers – particularly hospitals – could see any benefit from the initiatives.

In recent months, Obama and Sylvia Burwell, the secretary for Health and Human Services, have touted a move toward payment models that reward better quality of care, rather than the current model that compensates health care providers for the number of medical services they provide.

"The message is: 'We are going to pay you less to do more,'" Dr. Kavita Patel, managing director of clinical transformation at the Brookings Institution's Center for Health Policy, says of the planned measures. 

The government has been testing several initiatives aimed at slowing or reducing health care spending, which grows faster than the rest of the economy and makes up one-fifth of the country's expenditures. By 2018, the administration plans to place half of payments on Medicare – the government's program for adults 65 and older – under new models. 

http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2015/07/17/hospitals-have-little-to-gain-from-new-payment-models

'It's the Prices, Stupid': An Interview with Health Policy Expert Gerard Anderson

By Gerard Anderson,  Elizabeth Palmberg  June 2011

Sojourners: What are some of the most important causes for why the U.S. is paying a lot more than other wealthy countries [in the OECD] for health care without getting improved results?

Anderson: A higher health-care cost is pretty much because of what I call, “It’s prices, stupid.” We just pay approximately twice as much for each good and service that we utilize in the U.S. vis-a-vis other industrial countries. So if we’re talking about brand name drugs, we could spend twice as much. If we’re talking about a physician visit, we’re talking about twice as much. In fact, for a hospital visit it’s about three times more than other industrialized countries for a similar visit—in a shorter period of time that you’re in the hospital, we still spend about three times more. So it seems to be that we just pay more for identical services compared to other industrialized countries.

Sojourners: Why?

Anderson: Because, in most other countries they have a single purchaser, which is a very tough negotiator, whereas in the United States we have so many different purchasers that nobody has a lot of power. Medicare is an important player, but the private sector is paying about 30 percent more than Medicare. So if Medicare tries to keep prices down too much, the doctors, the hospitals will say, “I’m not going to play with Medicare.” They can play one player off with another payer in order to keep the prices very high.

Sojourners: What about U.S. obesity and higher rates of cancer and HIV?

Anderson: So the first [thing] is prices. The second one is chronic disease. We have a higher prevalence of chronic disease in the United States vis-a-vis other industrialized countries, primarily due to obesity. Our smoking rates are traditionally lower than most other countries, our alcohol consumption is lower. Our exercise and our diet, which goes into obesity, are not doing very well. So if I had to pick one thing that is making us having more chronic disease, it’s obesity in the United States. Many—about half of us—have at least one chronic disease and a quarter of us have two or more and they represent both a high percentage of health-care spending; people with two or more chronic diseases represent almost two-thirds of all spending, especially people with two or more chronic conditions.

Sojourners: So, basically, fat trumps smoking and alcohol.

Anderson: It does. About 19 percent of us [U.S. adults] smoke, whereas if you go to France it’s [about] 25 percent.

Sojourners: So, looking down my list of reasons for health-care costs, is the cost of medicine covered under the bargaining explanation you gave for higher U.S. medical prices?

Anderson: That’s prices. A brand-name drug in the United States will twice as expensive as a brand-name drug in most other industrialized countries. That’s because [other wealthy countries] go around and they buy all the Lipitor, all the whatever the brand name drug is, they buy it all for the country. Whereas we have the VA buying some, different health plans buying things, the Medicaid program buys stuff. Everybody needs those drugs, but there is nobody that has such a dominant position; the drug countries can play one company off each other. But we don’t get more drugs than other countries. France gets substantially more drugs than we do, but because they pay less, they actually spend less per capita than we do.

https://sojo.net/magazine/june-2011/its-prices-stupid-interview-health-policy-expert-gerard-anderson

Private Health Care as an Act of Terrorism

by

Paul Buchhei

The FBI defines terrorism as "Acts dangerous to human life...intended to intimidate or coerce a civilian population." Much of the behavior of our current health care system meets that definition. The facts show intention on the part of corporations to intimidate the population by using market strategies to charge whatever they like for their medical products and services, and an effort to coerce the public into accepting the current system as the only option. 

The Average American Family Pays $4,000 for Medical Fraud and Subsidies 

Medical billing fraud is estimated at 10 percent of all health care, or about $270 billion, while patent monopolies raise the price of prescription drugs by another $270 billion a year. Combined, this represents an astonishing annual cost of over $4,000 to an average American household. As The Atlantic puts it, "The people most likely to bilk the system are doctors and medical providers, not 'welfare queens.'" 

Intimidation by Outrageous Markups 

In a recent analysis of 50 hospitals (49 for-profit) with the highest charge-to-cost ratios in 2012, the average markup was 1,000 percent, which means that a procedure costing a hospital $100 is marked up to $1,000 for us. 

Some of the markups test the limits of sanity: an 80-cent needle for $143.25 (a 17,000 percent markup). A 25-cent IUD device for $1,000. A blood test that costs $10 in one hospital and $10,000 in another. 

A Johns Hopkins professor explained, "They are marking up the prices because no one is telling them they can’t." 

Cheating and Coercion 

Pharmaceutical companies have successfully lobbied Congress to keep Medicare from bargaining for lower drug prices. Americans are further cheated when corporations pay off generic drug manufacturers to delay entry of their products into the market, thereby forcing consumers to pay the highest prices for medicine. 

We're cheated again by certificate-of-need laws, which force many patients to accept established money-making procedures while denying access to modern technologies such as virtual colonoscopies. 

And cheated yet again when the doctors we trust accept payoffs from pharmaceutical companies to promote the most expensive products. 

And, like the hospitals, corporations are fleecing the public with unfathomable markups. After Gilead Sciences was criticized for charging $1,000 for a hepatitis pill that costs $10 in Egypt, the company responded by introducing a new pill that costs $1,350. 

http://www.commondreams.org/views/2015/07/20/private-health-care-act-terrorism

Doctors challenge Vertex over high price of cystic fibrosis drug

By Robert Weisman GLOBE STAFF

California scientist Paul M. Quinton learned that he has cystic fibrosis at age 19 and has spent his long career in his lab working on ways to cure it.

He is, in short, not the kind of person you’d expect to be fighting with Vertex Pharmaceuticals Inc., the company developing a new class of breakthrough drugs for the obstructive lung disease.

But he and a group of prominent cystic fibrosis doctors are doing just that. For the past three years, they have engaged in a private and largely fruitless dialogue with Vertex over their complaints that the Boston biotechnology firm is overcharging for its medicines.

Now, nearly three weeks after Vertex won US approval for a two-drug therapy called Orkambi that eventually could treat roughly half of the 30,000 Americans with cystic fibrosis, Quinton and his medical colleagues are going public with their objection to the company’s decision to price the drug at $259,000 per patient annually.

“It’s egregious,” Quinton, 70, a professor of biomedical science at the University of California at San Diego, said in an interview. “This is more than five times the annual salary of the average American family. How can they in good conscience charge that much?”

The question resonates with health insurers and consumer groups that have raised alarms about the soaring prices of specialty therapies for everything from cancers to rare genetic disorders. Vertex’s prices have come under scrutiny, initially in a 2013 article in a leading medical journal, partly because they seemed to crystallize the broader debate over how to hold down health costs while rewarding makers of treatments for relatively small numbers of patients.

Vertex spokesman Zach Barber said the company, which has lost money in all but one of its 26 years, has invested billions of dollars in its cystic fibrosis program. Vertex needs to generate the revenue and profit that will enable it to expand the market for Orkambi worldwide and develop treatments for cystic fibrosis patients with other mutations, Barber said.

“Right now, two-thirds of the patients in the United States don’t have medicines’’ to treat the cause of the cystic fibrosis, Barber said. “We want to help those people. That work is going to take a very long time, hundreds of people, and a very significant continued investment.’’

http://www.bostonglobe.com/business/2015/07/20/researcher-and-group-doctors-challenge-vertex-price-new-cystic-fibrosis-drug/d5PZMlj6T6uzq0usm2xLEL/story.html?s_campaign=email_BG_TodaysHeadline&s_campaign=%25%25__AdditionalEmailAttribute1%25%25#

Greece's Costly Health Care Craze

By MARTY MAKARYJULY 20, 2015

Greece’s bloated pension program is often cited as a primary cause of its crushing national debt, but its government-run health care system has been a significant and under-recognized contributor to the country’s crisis. The sad and appalling tale of how this came about has important lessons for other countries, especially the United States.

Under a spate of new programs between 2000 and 2007 Greece’s health care spending soared, reaching nearly 10 percent of gross domestic product — high by European standards — in the year before the financial crisis hit. This spending spree, coupled with a lack of accountability, fostered an epidemic of excessive medical care following a frenzy of hospital construction and hiring that began in the 1980s.

The country’s health care culture became one of overtreatment and overspending. Cardiac stenting, bone grafting and other expensive operations ruled the day. Caesarean-section rates hit 40 to 50 percent in some hospitals for no clinically justifiable reason. Doctors who faced disciplinary problems in other European countries set up shop in Greece, which requires only minimal credentials proving that the doctor has been practicing for three of the five years before applying for certification to practice medicine.

Corrupt administrators and unscrupulous doctors often received kickbacks from the makers of medical devices and pharmaceutical companies that flocked to Greece to take advantage of the health care free-for-all. Antibiotics were and still are widely overused. Nearly a quarter of Greek adults have taken antibiotics without a prescription, the general secretary for public health, Christina Papanikolaou, reported last year.

Meanwhile, important public health priorities have suffered. In a country where 32 percent of adults use tobacco — the highest rate reported last year among the 34 nations of the Organization for Economic Cooperation and Development — anti-smoking efforts were hobbled.

http://www.nytimes.com/2015/07/21/opinion/greeces-costly-health-care-craze.html?smprod=nytcore-iphone&smid=nytcore-iphone-share

Over Objections of Legislature, Alaska’s Governor Says He Will Expand Medicaid

By ABBY GOODNOUGHJULY 16, 2015

WASHINGTON — After failing to persuade his Legislature to expand Medicaid, Gov. Bill Walker of Alaska said Thursday that he planned to unilaterally accept the federal funds available to cover more low-income residents under the program.

Mr. Walker, an independent who took office in December, said in a news conference in Anchorage that he could not wait any longer to offer health coverage to the roughly 42,000 people his administration projects will be eligible under the expansion. Expanding Medicaid — an option for every state under President Obama’s Affordable Care Act — was a campaign priority for Mr. Walker, who couched it as a “common-sense decision” for the state’s economy and for the health of its people.

Mr. Walker said he had sent a letter to the state’s Legislative Budget and Audit Committee on Thursday, giving it a required 45-day notice of his intention to accept the federal expansion funds. The committee can issue a recommendation, but Mr. Walker said he had the authority under state law to proceed even if the committee did not approve.

http://www.nytimes.com/2015/07/17/us/over-objections-of-legislature-alaska-governor-bill-walker-says-he-will-expand-medicaid.html?smprod=nytcore-iphone&smid=nytcore-iphone-share

This $153,000 rattlesnake bite is everything wrong with American health care

By Christopher Ingraham July 20

Todd Fassler was bitten by a rattlesnake in San Diego, Calif., and the hospital billed him $153,000. (KGTV – 10News.com)

Earlier this month a guy named Todd Fassler was bitten by a rattlesnake in San Diego, KGTV San Diego reports. In itself this isn't terribly unusual — the CDC estimatesthat roughly 7,000 to 8,000 people a year get bitten by a venomous snake in the United States. And somewhere between five and six people die from these bites each year.

What raised eyebrows, though, was Fassler's hospital bill — all $153,000 of it. KGTV reporter Dan Haggerty shared it on Twitter. Take a look.

Remember the Rattlesnake bite story I did Monday? Guy just sent me this pic of his bill. Uhhhhhhh..... pic.twitter.com/ahK2W9KxVg

— Dan Haggerty (@10NewsHaggerty) July 16, 2015

It’s not clear whether Fassler has insurance — and whether these are dollar amounts that he will in fact have to pay out of pocket. But the confusion over health-care pricing is common for Americans who receive bills and can’t be sure where the numbers come from. I reached out to Fassler for comment, but he wasn't immediately available.

Here's what we do know based on that photo: The bulk of his hospital bill — $83,000 of it — is due to pharmacy charges. Specifically, charges for the antivenin used to treat the bite. KGTV reports that Fassler depleted the antivenin supplies at two local hospitals during his five-day visit. Nobody expects antivenin to be cheap. But $83,000?

There's currently only one commercially available antivenin for treating venomous snakebites in the United States -- CroFab, manufactured by U.K.-based BTG plc. And with a stable market of 7,000 to 8,000 snakebite victims per year and no competitors, business is pretty good. BTG's latest annual report shows CroFab sales topped out at close to 63 million British pounds, or $98 million dollars, last fiscal year. The antivenin costs hospitals roughly $2,300 per vial, according to Bloomberg, with a typical dose requiring four to six vials. In some cases multiple doses are needed, according to CroFab's promotional Web site.

BTG has fought aggressively to keep competitors off the market. A competing product, Anavip, just received FDA approval this year and likely won't be on the market until late 2018. This lack of competition is one reason that snakebite treatments rack up such huge hospital bills -- $55,000. $89,000. $143,000. In May of this year, a snakebit Missouri man died after refusing to seek medical care, saying he couldn't afford the bill.

http://www.washingtonpost.com/blogs/wonkblog/wp/2015/07/20/this-153000-rattlesnake-bite-is-everything-wrong-with-american-health-care/?tid=HP_more?tid=HP_more

California Senate Votes To Open Up Obamacare To 2.5 Million Illegal Residents

Robert LaszewskiContributor

King V. Burwell opponents said killing subsidies would blow up Obamacare­­–now in California they want to open up unsubsidized care to illegal Californians.

State Senator Richard Lara has already moved a bill through the California State Senate that would allow illegal immigrants to buy unsubsidized health insurance in the state’s Obamacare exchange. The state would have to receive a federal waiver from the Obama administration before implementing it.

The bill would also extend coverage to illegal residents under the age of 19 to enroll in California’s fully paid-for Medicaid program.

The Pew Research Center has estimated that there are 2.5 million illegal immigrants in California.

To say that granting any kind of access to Obamacare for illegal immigrants is controversial is an understatement. But for now, I want to focus just on the insurance issues.

Last month, Obamacare supporters were adamant, and rightly so, that a Supreme Court decision in favor of the King v. Burwell plaintiff would have killed the insurance subsidies in at least 34 states and would have forced the collapse of Obamacare. Their argument was that without subsidies millions of people would have been forced to drop their coverage leaving only the sickest willing to pay for the then far more expensive cost of unsubsidized insurance. The program would have no longer been sustainable.

When Obamacare first passed, the President and the Democrats argued that the individual mandate, and its penalty, was crucial to the new health law’s being able to get adequate enrollment so that we would have enough healthy people joining to pay for the sick. They repeated those arguments three years ago before the Supreme Court in the NFIB v. Sebelius case that could have killed the individual mandate’s penalties.

So, in two Supreme Court cases as well as the original selling of Obamacare, advocates have argued that the combination of the subsidies and the individual mandate were crucial to Obamacare’s being able to get enough healthy people to offset the costs of the sick and its ability to survive.

http://www.forbes.com/sites/robertlaszewski2/2015/07/21/california-senate-votes-to-open-up-obamacare-to-2-5-million-illegal-residents/

Giving Doctors Grades

Sandeep Jauhar

ONE summer day 14 years ago, when I was a new cardiology fellow, my colleagues and I were discussing the case of an elderly man with worsening chest pains who had been transferred to our hospital to have coronary bypass surgery. We studied the information in his file: On an angiogram, his coronary arteries looked like sausage links, sectioned off by tight blockages. He had diabetes, high blood pressure and poor kidney function, and in the past he had suffered a heart attack and a stroke. Could the surgeons safely operate?

In most cases, surgeons have to actually see a patient to determine whether the benefits of surgery outweigh the risks. But in this case, a senior surgeon, on the basis of the file alone, said the patient was too “high risk.” The reason he gave was that state agencies monitoring surgical outcomes would penalize him for a bad result. He was referring to surgical “report cards,” a quality-improvement program that began in New York State in the early 1990s and has since spread to many other states.

The purpose of these report cards was to improve cardiac surgery by tracking surgical outcomes, sharing the results with hospitals and the public, and when necessary, placing surgeons or surgical programs on probation. The idea was that surgeons who did not measure up to their colleagues would be forced to improve.

But the report cards backfired. They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates. When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements.

http://mobile.nytimes.com/2015/07/22/opinion/giving-doctors-grades.html?referrer=

Health Care Tax Faces United Opposition From Labor and Employers

By REED ABELSONJULY 21, 2015

At the paper mill in Longview, Wash., Kurt Gallow and his wife, Brenda, are worrying about his company’s proposed new health care plan, which would require workers to pay as much as $6,000 toward their families’ medical bills.

Mrs. Gallow’s diabetic condition almost certainly will mean thousands of dollars more a year for her care alone, if the new plan is put in place, which may happen as early as next year.

“Some of the people with health problems will definitely pay more,” said Mr. Gallow, who is president of the local unit of the Association of Western Pulp & Paper Workers.

The union is now in heated negotiations with the mill’s owner, KapStone Paper and Packaging, over benefits, among other issues. The couple and many other employees have been enrolled in a popular Kaiser Permanente health maintenance organization, which charged just $25 for a doctor’s visit.

But that may change by January. Pointing to the looming new tax on high cost insurance plans imposed under the federal health care law, KapStone wants to replace its existing policies with plans that could prove far more expensive for workers and their families. By doing so, the company would save almost $3 million in additional taxes in just the first two and a half years.

Called the Cadillac tax, it applies to an individual policy costing more than $10,200 a year and a family policy over $27,500. The tax goes into effect in 2018.

With less than three years before the tax is imposed, KapStone and other employers are weighing their options.

“If you look into the future, it’s part of the reason they want out,” Mr. Gallow said. And while companies have long been trimming their benefits as a way to lower costs, they now have another reason.

KapStone declined to comment.

http://www.nytimes.com/2015/07/22/business/labor-and-employers-join-in-opposition-to-a-health-care-tax.html?smprod=nytcore-iphone&smid=nytcore-iphone-share