A Medicare Option for the Uninsured
by The New York Times Editorial Board
Health policy experts have long argued that Congress should let older Americans buy into Medicare before they become eligible for it at 65. Hillary Clinton said this week that she supports this option, which could help expand coverage and cut the cost of insurance for some people.
Many lawmakers, as well as former President Bill Clinton, have said in the past that people between 55 and 65 should be allowed to buy into Medicare, which has lower administrative costs than private insurance because it pays lower reimbursement rates to doctors and hospitals and does not have to turn a profit. Congress even considered this provision when it was debating the Affordable Care Act, but did not include it in the law because of opposition from Republicans, conservative Democrats and former Senator Joseph Lieberman, the Connecticut independent.
At a campaign stop in Virginia on Monday, Mrs. Clinton discussed the Medicare buy-in idea, suggesting that it might be cheaper than buying coverage in the health care exchanges for people who don’t qualify for a public subsidy. Senator Bernie Sanders has gone further in arguing that all Americans should be eligible for Medicare, a proposal that would be very hard to enact. Donald Trump, the presumed Republican nominee, has promised to repealthe health care reform law but has not offered a detailed plan for what he would put in its place.
The Congressional Budget Office estimated in 2008 that premiums for a Medicare buy-in program would be $7,600 a year for individual coverage. That price could be reduced if the government offered the same kinds of subsidies it offers to lower-income people on the health exchanges. Mrs. Clinton did not say whether she would support such subsidies for a Medicare option, but she has talked about extending health insurance subsidies to people who earn too much to qualify for them now.
It will be difficult for Mrs. Clinton to convince Congress to create a Medicare buy-in program. Doctors and hospitals would be very likely to oppose the idea, because they prefer the higher reimbursement rates of private insurance companies. Insurers would also fight it because they don’t want to compete with the government program for customers. Those were the reasons Congress rejected the buy-in idea in 2009 and also dropped proposals for a public option in the health law even when Democrats had majorities in both houses.
That said, it is important to talk about what could be done to expand health coverage and make premiums more affordable. The Affordable Care Act has helped millions, but 33 million people, or 10.4 percent of the population, remain uninsured.
Missing From Medicare Advantage: True Competition
by Austin Frat
If you were contracting for a kitchen remodeling, you’d probably solicit bids and select the lowest one that meets your quality standard. Many goods and services purchased by the government are bought in a similar way, including certain medical equipment like walkers and wheelchairs for Medicare patients.
But a big part of Medicare isn’t: private coverage through Medicare Advantage. And that accounts for about a quarter of Medicare’s budget and a third of its enrollees.
It’s odd, since such competitive bidding approaches are part of both Republican and Democratic efforts to expand health insurance. Competitive bidding is built intoMedicare’s prescription drug program — passed by a Republican Congress and signed by President Bush in 2003. And it’s built into the insurance marketplaces established by the Affordable Care Act — passed by a Democratic Congress and signed by President Obama in 2010.
Both kinds of plans are subsidized with government payments set by a competitive bidding process. Individuals enrolled in plans that cost more than the government subsidy have to pay the difference, a source of downward, competitive pressure on costs and bids.
Now, the White House is proposing a plan for Medicare Advantage to inject more competition, which the administration says would save $77 billion over 10 years. But the plan seems doomed, if past efforts are any guide.
Infection Raises Specter of Superbugs Resistant to All Antibiotics
by Sabrina Tevernise and Denise Grady - NYT
American military researchers have identified the first patient in the United States to be infected with bacteria that are resistant to an antibiotic that was the last resort against drug-resistant germs.The patient is well now, but the case raises the specter of superbugs that could cause untreatable infections, because the bacteria can easily transmit their resistance to other germs that are already resistant to additional antibiotics. The resistance can spread because it arises from loose genetic material that bacteria typically share with one another.“Think of a puzzle,” said Dr. Beth Bell, of the Centers for Disease Control and Prevention. “You need lots of different pieces to get a result that is resistant to everything. This is the last piece of that puzzle, unfortunately, in the United States. We have that genetic element that would allow for bacteria that are resistant to every antibiotic.”The bacteria are resistant to a drug called colistin, an old antibiotic that in the United States is held in reserve to treat especially dangerous infections that are resistant to a class of drugs called carbapenems. If carbapenem-resistant bacteria, called CRE, also pick up resistance to colistin, they will be unstoppable.“This is huge,” said Dr. Lance Price, a researcher at George Washington University. “We are one step away from CRE strains that cannot be treated with antibiotics. We now have all the pieces in place for it to be untreatable.”Continue reading the main storyThe gene for resistance to colistin was first found in China, where the drug is used in pig and poultry farming. Researchers reported its discovery there in November. It has also been found in the intestine of one pig in the United States.CRE is still relatively rare, causing just 600 deaths a year, but by 2013, researchers had identified it in health care facilities in 44 states. Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, often calls it the “nightmare superbug” because it is resistant to all but one antibiotic — colistin.
He added: “The medicine cabinet is empty for some patients.”
http://www.nytimes.com/2016/05/27/health/infection-raises-specter-of-superbugs-resistant-to-all-antibiotics.html?hpw&rref=science&action=click&pgtype=Homepage&module=well-region®ion=bottom-well&WT.nav=bottom-well
Former high school basketball star can’t get kidney transplant without insurance
Posted May 26, 2016
PORTLAND, Maine — Thiwat Thiwat remembers stealing the ball during the first play of a basketball game the summer before his senior year at Deering High School and, instead of feeling a surge of adrenaline, being suddenly overcome with fatigue.
“It was a good play,” said the 21-year-old, who was a standout on Deering’s 2012 state championship team. “But I was so tired, I told the coach I had to come out.”
That fatigue was the first indication he ever had that something might be amiss, Thiwat said Thursday from a bed at Maine Medical Center. Not long after, he was diagnosed with kidney failure and began medication.
Three years later, Thiwat has completed two years of college, and he is registered to begin summer accounting and psychology classes on Tuesday at the University of Southern Maine. The classes are prerequisites that would allow him to transfer to the University of Maine, where Bob Walsh — who recruited Thiwat and Deering teammate Labson Abwoch to play at Rhode Island College when Walsh coached there — is now head coach.
Thiwat attended Southern Maine Community College during the past year, although he said, “[I] could definitely tell my body wasn’t 100 percent. But I told myself, I just gotta keep doing what I’m doing.”
In recent weeks, he felt more fatigued and suffered from headaches, back pain and water retention. During a routine visit on Monday, his nephrologist told Thiwat that his kidney function was dangerously low, and he was admitted to the hospital.
“When he came in on Monday it was at 1 percent,” said Cindi Taylor, a Portland teacher who has been Thiwat’s second mom since he was in her English Language Learner kindergarten class shortly after arriving in the United States from South Sudan in 1999. “He’s teetering on the edge of kidney failure.”
Thiwat came to the United States when he was 4 years old with his father, an uncle, and several siblings and cousins. The family left war-torn Sudan and spent time in an Ethiopian refugee camp, where Thiwat was born, before coming to Maine. He became a citizen the summer after graduating from high school.
“I’m a Mainer,” he said Wednesday. “There’s no way around that.”
Taylor said Thiwat came to live with her during his high school years, but his longtime AAU (Amateur Athletic Union) coach, Walter Phillips, remembers that if he needed to find Thiwat when he was 10 or 11, “He was at Cindi’s house. Cindi took care of that boy.”
Thiwat attended Portland schools and, in 2012, was a member of the state championship Deering High School basketball team.
That fall, after the basketball game in Massachusetts, a nephrologist found a protein leak and traces of blood in his urine, and a biopsy determined his kidneys were failing. He’d just turned 18.
Thiwat completed his first year at Rhode Island College, but he didn’t play ball. As his kidney function deteriorated, he returned to Maine to live with his “foster grandmother,” Bonnie Kam. He has just completed his sophomore year at Southern Maine Community College while working as a security guard at Texas Instruments.
“Thiwat is just a special kid,” Phillips said Thursday. “There’s no question about it. Not only is he a great kid, but coming from what he has had to deal with in his life … he’s unbelievable. And as far as a basketball player, he’s everything a coach would want in a player. He’s one of those kids who’s able to be a sweetheart off the court and then be able to switch and be aggressive on the court.”
On Monday, when he arrived at Maine Medical Center, Thiwat learned that his MaineCare health insurance ended when he turned 21 in October.
Maine Medical Center will provide free care while he’s an inpatient — and on Thursday agreed to cover outpatient dialysis until he can find insurance — but until he finds insurance, he can’t get on the list for a kidney transplant.
Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study
- Jose F Figueroa, instructor of medicine1 3,
- Yusuke Tsugawa, research associate1,
- Jie Zheng, statistician1,
- E John Orav, associate professor2 3,
- Ashish K Jha, professor of medicine1 4
Abstract
Objective To determine the impact of the Hospital Value-Based Purchasing (HVBP) program—the US pay for performance program introduced by Medicare to incentivize higher quality care—on 30 day mortality for three incentivized conditions: acute myocardial infarction, heart failure, and pneumonia.
Design Observational study.
Setting 4267 acute care hospitals in the United States: 2919 participated in the HVBP program and 1348 were ineligible and used as controls (44 in general hospitals in Maryland and 1304 critical access hospitals across the United States).
Participants 2 430 618 patients admitted to US hospitals from 2008 through 2013.
Main outcome measures 30 day risk adjusted mortality for acute myocardial infarction, heart failure, and pneumonia using a patient level linear spline analysis to examine the association between the introduction of the HVBP program and 30 day mortality. Non-incentivized, medical conditions were the comparators. A secondary outcome measure was to determine whether the introduction of the HVBP program was particularly beneficial for a subgroup of hospital—poor performers at baseline—that may benefit the most.
Results Mortality rates of incentivized conditions in hospitals participating in the HVBP program declined at −0.13% for each quarter during the preintervention period and −0.03% point difference for each quarter during the post-intervention period. For non-HVBP hospitals, mortality rates declined at −0.14% point difference for each quarter during the preintervention period and −0.01% point difference for each quarter during the post-intervention period. The difference in the mortality trends between the two groups was small and non-significant (difference in difference in trends −0.03% point difference for each quarter, 95% confidence interval −0.08% to 0.13% point difference, P=0.35). In no subgroups of hospitals was HVBP associated with better outcomes, including poor performers at baseline.
Conclusions Evidence that HVBP has led to lower mortality rates is lacking. Nations considering similar pay for performance programs may want to consider alternative models to achieve improved patient outcomes.
Drug Prices Too High? Sometimes, They’re Not Costly Enough
by Austin Frat
For some of the most important drugs, prices may be too low.
You hear a lot about high drug prices. You hear politicians calling for lower drug prices. But you may not be hearing about how low prices contribute to drug shortages.
The drugs most prone to shortage are generic injectable ones, administered to patients in the hospital or a doctor’s office. They include anticancer agents, heart attack medications and anesthetics, many used in life-threatening, emergency situations. When such drugs are in short supply, they cause dangerous delays in careas hospitals seek alternatives. Even when good substitutes can be found — and sometimes they cannot — they may be less familiar to doctors, come with different side effects or not work as well, all of which pose risk to patients.
For example, when morphine is in short supply, doctors might switch to hydromorphone, an alternative opiate painkiller. Hydromorphone is seven times more powerful than morphine. Failing to account for that difference can kill. In 2011, during a morphine shortage, two fatalities were linked to the accidental dosing of hydromorphone as if it were morphine. This year, the generic injectable form of nitroglycerin — used to treat serious heart attacks in emergency departments — is among the drugs in shortage, prompting the Food and Drug Administration to seek additional supplies overseas.
Hospital pharmacists say drug shortages are their biggest problem. “Clinicians are spending time making sure patients aren’t impacted by drug shortages,” said Erin Fox, a pharmacist and director of the University of Utah’s Drug Information Service, which tracks drug shortages. “But it’s incredibly frustrating to not have access to basic essentials.”
The number of drugs in short supply peaked in 2014 at 320, the vast majority of which were generic injectables. That doesn’t mean the problem has faded. According to a recent study in the journal Health Affairs by Ms. Fox and colleagues, the number of emergency and critical care drugs in short supply has grown in recent years. These include pain medications, sedatives, electrolyte solutions, antibiotics, antidotes and drugs that undo the effects of anesthesia.
I.R.S. Ruling Is Obstacle to Health Care Networks Promoted by Obama
by Robert Pear - NYT
WASHINGTON — A ruling by the Internal Revenue Service creates a significant obstacle to a new type of health care network that the Obama administration has promoted as a way to provide better care at lower cost, industry lawyers and providers say.
Health care markets are rapidly changing as independent doctors and hospitals race to form networks, known as accountable care organizations, in which they coordinate care for patients. The doctors and hospitals have financial incentives to keep patients healthy and to control costs, and they can share in the savings if they meet performance goals.
The new entities, which now cover more than 28 million people, according to Leavitt Partners, a health care consulting firm, help manage care for Medicare beneficiaries, for people with employer-sponsored insurance and for consumers who buy coverage through online marketplaces under the Affordable Care Act.
In its recent ruling, the I.R.S. denied a tax exemption sought by an accountable care organization that coordinates care for people with commercial insurance. The tax agency said the organization did not meet the test for tax-exempt status because it was not operated exclusively for charitable purposes and it provided private benefits to some doctors in its network.
The name and location of the organization, formed by a nonprofit health care system, were not disclosed. The ruling does not affect accountable care organizations formed solely to participate in Medicare, but it could affect similar entities serving privately insured patients. Many accountable care organizations coordinate care for both Medicare beneficiaries and privately insured patients.
Everything Will Be Fine As Soon As The Obamacare Market "Stabilizes"––Not
by Robert Laszewski
North Carolina Family Plans Already Cost More Than $10,000 a Year With Rates Going Up By Double Digits for 2017
With one state after another announcing big 2017 Obamacare rate increases the latest refrain from Obamacare supporters is that with maybe one or two more years of rate increases everything will be fine.
Talk about missing the forest for the trees.
The latest example is in North Carolina where market leader Blue Cross, the biggest insurer with 330,000 people covered, is asking for an 18.8% 2017 rate increase. Aetna, with 130,000 customers is asking for 24.5%.
Talk about missing the forest for the trees.
The latest example is in North Carolina where market leader Blue Cross, the biggest insurer with 330,000 people covered, is asking for an 18.8% 2017 rate increase. Aetna, with 130,000 customers is asking for 24.5%.
UnitedHealth, who covered 155,000 people in 2016, is withdrawing altogether.
Blue Cross says it lost $405 million in its Affordable Care Act (ACA) North Carolina plans the last two years.
And what is the typical response to all of this?
This from The Charlotte Observer:
Mark Hall, a health law professor at Wake Forest University in Winston-Salem, said the ACA will require more time to create a stable insurance market.“We’re seeing a mixed bag but no immediate reason for despair,” Hall said. “It’s plausible that last year and this year are catch-up years because the rates were too low. This is the first year that they really have good data, and this could well be the final catch-up year.”
This has become the typical response in state after state–”no reason for despair,” “just need to catch-up…”
Here is why these people are missing the forest for the trees.
Take a look at what Obamacare policies already cost in North Carolina.
I went to HealthCare.gov and took a look at the cheapest unsubsidized Bronze and Silver plans offered in 2016 in a Winston-Salem zip code (27104) for a family of four with mom and dad age 40, as well as for a single male age 40:
Now the next thing Obamacare supporters will say is that these premiums don’t matter because anyone getting a subsidy has their premium share capped and they are therefore insulated from these prices and the follow-on big rate increases. The worst that can happen to them is that they will have to shop for a lower cost plan.
Those shoppers may well have to settle for plans with bigger deductibles and narrower networks to keep their premiums flat.
But the bigger thing these arguments are missing is that half of the individual market does not get a subsidy in order to buy Obamacare health plans. The CBO has estimated that in 2017 both on and off the exchanges 12 million will get subsidies and 12 million won’t. Half the market has to pay these full prices and the new rate increases to boot.
And then there is the argument that after one or two more years of more rate increases this market will be stable.
The lowest cost Bronze plan this family can buy already costs $980 and Blue Cross has said it will go up again––(to well over $1,150 a month based upon their announced average 18.8% increase) and it already has a $13,700 family deductible ($6,850 per person).
Goodness, this family already pays $11,760 a year for a plan with a $13,700 deductible and it could go up to $13,971 in premium next year based upon the 18% rate increase.
This is a “stable” health insurance market and there is no reason to “despair?”
What are these people thinking?
Hospital chief holds three outside paid positions
by Liz Kowalczyk - Boston Globe
Dr. Elizabeth Nabel is paid well — $1.3 million in salary alone in 2013 — to run Brigham and Women’s Hospital, one of the nation’s premier medical centers. She also finds time to hold three other paying positions, which is unusual for a Boston hospital president.
The National Football League last year hired Nabel — a prominent national leader in cardiac medicine and research who holds six honorary doctorates — to serve as its lead medical consultant for an undisclosed amount of money.
She also earns $175,000 annually plus stock to sit on the board of the Dublin-based technology company Medtronic, and a confidential fee as a director for a Cambridge biotechnology company.
While other chief executives of large nonprofit hospitals engage in extracurricular work, Nabel stands out for the number of outside jobs on her plate as she tries to build the hospital’s national reputation. Brigham trustees approved the positions — and said they closely monitor her hours — because they also help Nabel build her business acumen, said Scott Sperling, board chairman and co-president of Boston investment firm Thomas H. Lee Partners.
But certain hospitals limit the practice. The outside positions, while they can be personally lucrative and bolster an institution's standing, carry with them potential risks.
A congressional committee report last week pointed to Nabel as part of an NFL effort to “steer funding” for a landmark concussion study from the National Institutes of Health away from a group of respected brain researchers. The scientists had previously helped establish a link between football and long-term brain damage. In a statement to the Globe, Brigham spokeswoman Erin McDonough said Nabel “was working through the appropriate channels to ensure this important research be conducted in a way that would yield the best possible science.”
Nabel, 64, has been president of the Brigham since 2010, and is a former director of the National Heart, Lung, and Blood Institute. She graduated from Cornell University Medical College and trained at the Brigham. Dr. Thomas Lee, a former Partners executive and chief medical officer at Press Ganey, a hospital consulting company, developed a friendship with Nabel during medical school and residency.
He said he can’t imagine her giving any job less than full attention.
Lee said Nabel “doesn’t like to make mistakes” and is unfailingly thorough about her work. During training, her notes about patients were so all-encompassing that other residents kidded her about them.
“I once made a joke about how she had omitted the family history of the dog,” Lee wrote in an e-mail. “All I can say is that her entire life, she has been known as someone really compulsive about doing a good job.”
According to a Globe survey, Boston hospitals have adopted a range of practices and policies on outside work. Beth Israel Deaconess Medical Center, which like the Brigham is a Harvard teaching hospital located in Boston, prohibits its chief executive from holding outside paid positions — though it declined to discuss its reasons.
Hustling Dollars for Public Health
by The Editorial Board - NYT
On Tuesday, a woman infected with the Zika virus gave birth to a girl with microcephaly, a malformed head, in New Jersey. Federal officials say there are more than 300 pregnant women possibly infected with Zika around the country. Yet every time an emergency like this happens, public health officials must go begging bowl in hand to Congress for the funds to deal with it. And as the current squabble between Republicans and President Obama over money for the Zika virus shows, there’s no guarantee of significant or even timely relief.
The obvious answer is to establish a permanent pool of money that federal health authorities can tap into quickly, much like the disaster relief fund that enables the Federal Emergency Management Agency to respond quickly to hurricanes and other natural disasters.
Such a fund would allow agencies like the Centers for Disease Control and Prevention to mobilize their resources to contain emerging threats like Zika and Ebola before they become large-scale problems. The money would be used for research, for vaccine development and to prevent the spread of the disease in the United States and overseas.
Zika is just such a threat. It is primarily transmitted by mosquitoes, can cause birth defects and has been linked to neurological disorders in adults. A study published in The New England Journal of Medicine last week estimated that the risk of microcephaly in newborns ranged from 1 percent to 13 percent for women infected with Zika in the first trimester.
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