Pages

Friday, September 9, 2016

health care reform articles - September 9, 2016

U.S. Healthcare System Culls the Wheat from the Working Class Chaff

by Donna Smith
Americans are an oddly and beautifully diverse lot, but the healthcare industry has us all figured out.  For decades now, maintaining control over American lives and any vestige of the American dream has become increasingly the purview of big business. And no one relishes and maintains more direct control over the health and safety of every American life than the healthcare industry.

No terrorist group is stronger or more threatening. No political candidate is more menacing – not even Donald Trump.  Standing ever at the ready to pass judgement on the value or lack thereof of your life, my life, and every American life stands the health care industry and its stockholders. Until we recognize the depth of the internal threat from the collusion that drives the medical-financial-industrial-complex (the MFIC), we won’t change this system to one that truly values health and life over profits.
The MFIC includes all the obvious suspects – the for-profit health insurance industry, big Pharma, medical device manufacturers, the giant hospitals and providers’ groups, and the collection agencies and financiers who keep the flow flowing.  I have to add to that group all stockholders in these corporations who cannot reasonably assert any deniability about profiting personally from the pain of others. If you own stock in one of these areas, you are supporting the slow, sure genocide of those Americans deemed expendable by the healthcare system.

I am sorry to tell Bernie Sanders and those who worked so hard to support his campaign that the control maintained by the oligarchy is far more sinister than even what Bernie’s campaign highlighted.  For almost a decade, I have written about the need for single-payer, improved Medicare for all.  Others have supported single-payer reform much longer than I have, and the healthcare industry knows exactly how to scare the bejesus out of most Americans on this issue – so don’t anyone reading this ever deny that you know now and you have known for a very long time that people are being euthanized for the sake of profit.

My husband, Larry, and I have often talked about how exactly people who have no healthcare access or no healthcare coverage or costs too high to afford actually just go off and die.  Some commit suicide, and we hear the horrific stories.  Others needing care they cannot get or afford slowly drift into worse health over the course of months or years of denials of appropriate care, no way to afford co-pays and deductibles, and the resulting consequences to jobs and income.  It’s insidious and devastating, but it is a pattern now well known to our elected officials, their MFIC campaign contributors, our employers, and many others. There are no unknowns here.

The healthcare industry may not like to acknowledge it publicly, but every part of the industry has an incestuous relationship with the others.  Hospitals need insurance companies.  Medical device sellers need insurance companies and finance companies.  Provider groups need insurance companies.  Big Pharma needs and has everyone in their back pockets.  The only group really not vested in all of this are the patients – all of us who at some point in our lives have needed healthcare.  We pay insurance companies.  We pay medical device sellers.  We pay big Pharma.  We pay hospital and providers.  But we are only valuable to the MFIC to the extent that we are able to boost their profits.  Once that ability to boost profits is compromised by lack of coverage, no cash or credit, we are finished.  Sadder still, in some ways, are the situations in which treatment that is unnecessary or even dangerous is ordered with full knowledge of that danger by the medical professionals involved.  Trust me, our death panels have only one criteria – what is the patient’s current bank balance, insurance coverage and credit rating.  No government official stands between U.S. patients and our doctors. No sir and no ma’am.  It is the financial wing of the MFIC that decides who lives and who dies – and every single provider knows that.  Every single medical provider (sadly our physicians too) either decides to play the game and play it well or risk their own business collapse.

So, back to the question my husband and I often ask one another about how people just fade away from engagement with our healthcare system and eventually die earlier and more painfully when medical care is denied in the U.S.  Since that process has begun for me, I can now begin to document that.  I have insurance.  I always have.  But the $600/month premiums and the co-pays are making it impossible for me to actually get the care I need that would make the quality of our lives so much better.  So even if I know that I need further treatment for an infection I’ve had since March, the left hip that is now so damned painful that I use a walker sometimes (when I am not afraid an employer will see that and judge me too weak to work – oops, guess the cat is out of the bag on that), and my continued breathing issue in my post-MRSA period, I am left to self-treat and self-medicate.  And dental insurance?  What a joke, and what a racket.  We pay $50/month for that coverage too, and my teeth are slowly rotting away.  We cannot afford to do root canals and crowns, so once they hurt too much or once they get infected, my teeth get pulled.  And how do employers see people with missing teeth, people using walkers even occasionally or those seen taking medications to get through the day?  Come on.  You and I both know exactly how they see us when our health falters – we become liabilities and a drag on our employers’ bottom line(s).

So, I will slip away in my health status.  I am not having regular cancer checks.  I haven’t had a PAP smear since 2011, and I because I am a uterine cancer survivor, PAP smears were supposed to be part of the routine for me for life.  That’s just one example of the issues that start falling through the cracks.  My insurance is through Kaiser Permanente of Colorado right now, and they clearly do not have an interest in assisting a 61-year-old cancer survivor with other health issues.  I am too expensive for the MFIC.  Millions of other Americans are too.  And unless we start really exposing the slowly, steady genocide of the working class being efficiently carried out through what is laughingly labeled as a healthcare system (and every piece of its profit-sharing machine from shareholders right up to our providers who fail to speak up in order to protect their own hides), we will not upend it all and create the kind of system that values health over killing for profit – a single-payer, improved Medicare for all for life system.  

The Incredible Shrinking Obamacare

by David Brooks - NYT

During the debate over Obamacare, both supporters and opponents assumed the giant law would transform the American health care system. The supporters argued that the system would help Americans purchase health insurance through carefully regulated state exchanges. President Obama envisioned a day when consumers could shop for health coverage “the same way you’d shop for a plane ticket on Kayak or a TV on Amazon.”
In 2010, the Congressional Budget Office estimated there would be 21 million Americans using the exchanges by now. Many supporters argued that the exchanges would eventually replace the current dominant employer-based system.
The promise of Obamacare was that it would foster competition and offer lower premiums while covering tens of millions of Americans without, as Obama often put it, adding a dime to the deficit.
Unfortunately, most of the exchanges are in serious trouble. As many critics pointed out at the time, the law is poorly designed to induce younger, healthier people to get into the system. The penalties attached to the individual mandate are too weak. The subsidies are too small. The premiums are too costly. The deductibles are too high. Many doctors aren’t participating in the networks.
Only about 12 million people are in exchanges. More important, the exchanges are attracting sicker, poorer people, who drain money, and are not attracting the healthier people who pour money in.
Many insurers are suffering catastrophic losses and pulling out. As James Capretta of the American Enterprise Institute has noted, Aetna has lost $430 million since January 2014 on insurance plans sold through Obamacare and is withdrawing from 11 of its 15 states. United Healthcare has lost $1.3 billion on the exchanges and will cut its participation to three states from 34.
That means less coverage; 24 million Americans still lack health insurance. That means less competition. Before too long, a third of the exchanges will have just one insurer in them. That also means higher premiums. Blue Cross Blue Shield has requested a 62 percent increase for next year in Tennessee and an average 65 percent increase in Arizona. Some experts put the national requested increase at 23 percent.
The exchanges are also producing less coverage. The insurers that are staying offer pared-down restrictive plans that look more like Medicaid.


Does this mean Obamacare is failing? No. The law has produced many positive outcomes across the health care world. More than 20 million more Americans have coverage because of it, and the evidence suggests their health has improved.
But it does mean Obamacare is not what we thought it would be. It’s a much more modest add-on to the pre-existing system. Sarah Kliff put it well in Vox: “Obamacare’s insurance expansion is on the path to looking like other safety net programs we know, offering limited services to a predominantly low-income population.”
Kliff quotes former administration official Michael Adelberg: “The exchange population — 85 percent of which qualifies for financial assistance — looks a lot like the Medicaid population. And with it, we’re seeing the start of the Medicaid-ization of exchange plans: narrow networks with no frills.”
Again, this is not bad. But we’d have had a very different debate if we knew the law was going to be a discrete government effort to subsidize health care for more poor people. For one thing, Democrats would have probably paid a much smaller political price if their effort wasn’t billed as an extravagant government grab to take over the nation’s health care system. The administration imagined something transformational; it ended up with something significant but incremental.
There are also lessons for people who think about policy making. First designing technocratic systems that will actually work is really hard. Second, designing effective technocratic systems that can pass politically is really, really hard. Third, designing politically plausible technocratic systems in a country divided on fundamental philosophy is hardness on stilts.
Philosophically, Obamacare tried to split the difference between European-style government coercion (the individual mandates) with a traditionally American respect for competition and freedom of choice (the exchanges).
But lawmakers couldn’t stomach a law involving forceful coercion (punishing penalties to make the young take part) and they couldn’t stomach a more purely market-based system. They wound up with a nonfunctioning compromise.
From here on out the health care debate will return, but in polarized form. Democrats are already really pushing for the public option, a heavier state player. Republicans are pointing out that technocrats are bad at designing dynamic systems and the insurance markets should work more like traditional markets. The next president will have to deal with all this, especially if the exchanges go into a death spiral, even though the subject has been basically ignored in the campaign.
It will be hard to govern after a campaign about nothing.

Despite law, glaring differences in insurance coverage persist

by Tom Murphy - Associated Press

Tracey Stahl lost part of a leg to bone cancer last fall, and she has to wince through bouts of crippling pain from an ill-fitting artificial limb because of a strange health insurance limit: Her plan covers just one limb per lifetime.
She now has to weigh whether to dump the nearly $9,000 cost of a new leg on her credit card as she fights her insurance company over the restriction. “I feel – it’s embarrassing to say – paralyzed about what to do,” said Stahl, from her home in Penfield, New York.
Caiti Riley’s left leg was amputated below the knee at age 4 due to a rare birth defect. The San Antonio resident is 31 now and covered by the best insurance she’s ever had. Her plan is paying most of the roughly $5,000 bill for a new running leg to complement the one she uses every day.
“I work out every day, there’s nothing really that I can’t do now,” she said.
Glaring differences in insurance coverage persist for amputees, children with autism and others in need of certain expensive treatments even after the Affordable Care Act set new standards as part of its push to expand and improve coverage, and despite efforts by states to mandate coverage for some treatments.
These differences don’t develop simply because some people pay more for better coverage. Instead, they stem from random factors like what state someone lives in or who happens to provide their coverage – and often people can do nothing about it. The federal health care law largely leaves decisions on what actually gets covered up to states or employers who provide insurance for their workers.
These gaps can bury patients in debt or force them to skip care. And they may become more common as health care costs continue to rise and insurers and employers look for ways to control that expense.
Researcher Sabrina Corlette thinks nothing short of federal action can close these coverage gaps, and she doesn’t see that happening anytime soon.
“I think you would need to see Congress say, ‘OK, we need more uniformity here,'” said Corlette, a Georgetown Health Policy Institute professor. “And I just don’t see this Congress or any near-term Congress stepping in and wanting to do that.”
States have passed about 1,800 mandates requiring the coverage of various treatments or conditions, according to the National Conference of State Legislatures. But those mandates don’t extend beyond state borders, and they don’t apply to the self-funded coverage offered by nearly all large employers.
North Carolina, for example, recently became one of 44 states to require coverage of autism treatments – and it won’t help Iris Castillo one bit.
The Raleigh, North Carolina, resident said it felt like a cold bucket of water had been tossed on her when she learned that insurance from her new job won’t cover applied behavior analysis therapy for her 9-year-old son, Alex.
Hours of this daily therapy, which is a standard treatment for autistic children, have helped Alex learn simple tasks like how to brush his teeth or greet another kid. Castillo worries that her son will regress if treatment stops. But it can cost more than $40,000 a year, far beyond what Castillo’s family can afford.
“You don’t feel like you’re in control,” she said.
Her employer’s coverage is self-funded, which means it pays its own health care bills instead of buying coverage from an insurer. That also means it doesn’t have to comply with most state coverage mandates.
Employers have been slowly switching to this type of coverage for several years to help control what has become one of their largest expenses and to avoid some of the requirements imposed by the ACA, said Robert Laszewski, a health care consultant and former insurance executive. He expects gaps or differences in coverage to become more common as health expenses grow.
Insurers and employers routinely cover organ transplants, heart procedures and other expensive surgeries. But coverage still varies widely for a range of patients that also includes people recovering from eating disorders like anorexia and women who need breast reduction surgery to ease back pain.
The cost of a particular treatment, the need for it in a covered population and lingering disagreements over necessity help explain some coverage differences.
Bariatric surgery, which can improve the health of obese patients by limiting food intake, can cost $7,000 to $30,000. Coverage is improving, and Dr. John Morton estimates that about 75 percent of patients who need the surgery have some insurance for it.
But the quality of that coverage varies widely, according to the Stanford School of Medicine surgeon. Some plans only cover the procedure for severely obese patients, while others may charge deductibles of around $10,000, which can dissuade many from having surgery.
An annual survey of large employers by the benefits firm Mercer found that 40 percent offered no coverage for infertility treatment last year. Some companies don’t view it as essential to a person’s health, while others with an eye toward attracting and keeping good workers, have started offering the coverage to help LGBT patients conceive.
“We see a lot of variation between employers, and it’s extremely confusing to the consumer,” said Dr. David Kaplan, a senior partner at Mercer.
Tracey Stahl, who lost her leg to cancer, got a prosthesis in January, but her leg shrank so the artificial limb no longer fits. This forces her to use crutches or a wheelchair when she has to walk more than a short distance. If the pain grows too intense, she retreats to bed and keeps her leg elevated.
She bought her coverage on New York’s public insurance exchange. Her insurer, Excellus BlueCross BlueShield, said the coverage it sells there follows a model set by the state. The insurer rejected Stahl’s claim for a new limb in May and then rejected her appeal in July.
In Texas, Caiti Riley said her previous insurance capped limb coverage at $2,500 every four years, which she likened to “a smack in the face.” Now her coverage is so good she says she almost feels bad about it.
“I know what the challenges are,” she said. “If you go out and get in a car accident and lose your leg, you’re not going to be prepared for something like this.”


Knopf: Slaying myths around ColoradoCare and single-payer health care (column)

Susan Knopf -COLORADO SUMMIT DAILY


I am a mother of three of children, one of who is a doctor. I’m a former award-winning journalist who covered medicine, a former pharmaceutical rep., a ski instructor. And I’m a health-care consumer who currently spends 25 percent of my household income on health insurance. We expect our local professionals to present accurate information. 

Based on Dr. Erin Sain’s erroneous and misleading op-ed on ColoradoCare(published in the Summit Daily on Aug. 31), it appears in her research, she missed some key facts. 

ColoradoCare represents the first time ever that a tax replaces an expense you already pay and provides the same service for less money. ColoradoCare is paid primarily through a payroll deduction – 3.33 percent for employees and 6.67 percent for employers. If a Colorado resident has non-payroll income, say from investments, that income will be subject to a 10-percent deduction to pay for health care. Seniors enjoy a hefty exemption, up to an estimated $75,000 for couples. 

This is a huge savings over what health-care costs now. Health care in the US currently costs on average 17 percent of income. Employers pay an average of 13.5 percent of payroll for employee health care, and that average includes those employers who currently contribute nothing. 
Here in Summit County, we are told to expect health insurance rate hikes of 30 to 40 percent for 2017 — after suffering record rate hikes for the past two years and living with the highest health-insurance rates in the country. 
ColoradoCare rates can not go up unless we, the residents of Colorado, vote for a rate increase. And multiple economists calculate the initial rates will cover health-care costs with no increase for 10 years. When was the last time your health-insurance company asked your permission to raise your rates? 
ColoradoCare gives us the opportunity to be exempted from the Affordable Care Act (ACA). To qualify for this exemption, ColoradoCare is required by federal law to provide “Silver Plan” coverage. That is a very specific standard of care, easily verified. 
The ColoradoCare model exceeds the standards of benefits provided by the ACA and is built on a model providing ”Platinum Plus” level benefits, with no deductibles ever and no co-pays on preventative care and primary care. As to more specifics, it is not legal to articulate such things for an entity, such as ColoradoCare not yet legally constituted. 
Senator and Dr. Irene Aguilar, M.D., T.R. Reid, several economists and policy experts have worked tirelessly for eight years to bring this gift to Coloradans: An opportunity to provide comprehensive health care for all Coloradans at a substantial cost savings for 80-85 percent of our residents. 
ColoradoCare is a co-op, organized similarly to an agricultural co-op or a federal credit union. The ColoradoCare Board of Directors will be elected by its members (the people of Colorado), regardless of political parties. When was the last time you elected a director to the board of your health-insurance provider? But don’t take my word for it, find out for yourself at www.ColoradoCare.org
Currently, all insurance is written on a state-by-state basis, and, generally, there is no guarantee of out-of-state and out-of network service. ColoradoCare represents that such charges will be submitted to ColoradoCare and paid. That means if you travel out of the state of Colorado and get hurt or sick, you will be covered. Services easily scheduled when you are home — and services generally available within the state of Colorado — are expected to be rendered in the state. This is not a mystery, nor does it differ in any way from our current insurance products and policies. In fact, it may be better than your current policy. 
ColoradoCare will also cover the medical portion of Workman’s Comp insurance premiums currently paid by employers. It does not affect any other current benefits of Workman’s Comp insurance. Most small businesses find ColoradoCare covers health care for all employees for about the same money business owners were spending on the medical portion of Workman’s comp (59 percent of the premium cost) plus health-care coverage for management. No deductibles ever, and no co-pays on primary care and preventative care. Do the math and find out how much money you will save: www.coloradocare.org/for-you/calculate-your-savings/
Contrary to Dr. Sain’s baseless predictions, ColoradoCare will be a far more valuable tax deduction for individuals and businesses because, instead of being medical insurance, it will come off the top of income, as a far more valuable and deductible state tax. Under the current for-profit health-insurance regime, small businesses pay much higher insurance rates. ColoradoCare finally levels the playing field and everybody, every size business pays the same percentage. 
As for those who oppose ColoradoCare … follow the money. One quarter of every health-care dollar we now spend pays for health-care administration, mostly flowing out-of-state to United Healthcare, headquartered in Minnesota; and Anthem Blue Cross Blue Shield in Indiana. There is also a burgeoning group of executives, administrators, medical billing and collection services — all of which will be adversely affected when we cut the red tape and reduce medical administration from 25 percent to 4-5 percent. 
And how do we know this is possible? Medicare operates with low administrative costs, and universal health-care plans in 34 countries operate with the same level of efficiency. The fact is, for-profit health care is inefficient and expensive. Currently, the U.S. pays more than twice per person what other nations pay for health care; and our health-care outcomes rank at the bottom behind other nations whose citizens pay far less. 
Isn’t it time we covered everyone and enjoyed the same quality health care as citizens of Australia, Austria, Belgium, Canada, Chile, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Korea, Latvia, Luxembourg, Mexico, Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Slovenia, Spain, Sweden, Switzerland, Turkey, and the United Kingdom? And ColoradoCare keeps our health-care dollars in Colorado, employing Coloradans. 
Isn’t it time we got our money’s worth?

Mass. makes progress in containing health care spending

By  - Boston Globe


The growth of health care spending moderated in Massachusetts last year, the state reported Wednesday, a sign that its ground-breaking experiment to rein in medical costs is making tentative progress.

Outlays rose 3.9 percent, a figure that is down from a 4.2 percent increase in 2014 and that matches the state’s economic growth, according to the new data. Spending most likely rose at a slower pace here than nationally, a change from years past — and an accomplishment given that Massachusetts has some of the most expensive hospitals and doctors in the country.

While the numbers from the state’s Center for Health Information and Analysis show some success on the spending front, cost control remains a significant challenge at a time when more people are gaining insurance coverage and prescription drug prices are rising. Growth in expenditures in 2015 exceeded the state’s goal of 3.6 percent for the second straight year. Moreover, health care spending rose much faster than the state’s 0.6 inflation rate.

Massachusetts, which mandated health insurance coverage for all residents in a landmark 2006 law, is also considered a leader for monitoring medical costs and encouraging insurers and hospitals to adopt new business models designed to provide more cost-effective care.
“We’re really the only state that is trying to do something about total health care spending,” said Stuart Altman, chairman of the Health Policy Commission, a state watchdog agency that tracks health costs.
All together, Massachusetts spent $57 billion on health care in 2015, or $8,424 per resident, according to the report. That includes spending through private health insurance as well as the big government programs Medicare and Medicaid.
Nationwide, the report says, health spending was projected to increase 4.6 percent last year.
A good sign, industry experts said, is that the spending growth in Massachusetts kept pace with the state’s economic growth. That means health care expenditures didn’t account for a larger proportion of total output of goods and services.
Altman, a health economist, said he was “pleased but cautious” about the report’s findings. “I still believe there’s a real potential for [medical] inflation to rear its head again,” he said, “but right now I give credit to the people who are running our delivery systems and the people running our insurance companies that they are sticking to the letter of the law.”
Higher prescription drug prices contributed to the growth in spending again last year. Spending on medicines jumped 10.1 percent in 2015 after rising 13.5 percent the previous year. Many pharmaceutical companies have implemented substantial price hikes in recent years for both brand-name and generic drugs. Most recently, the drug company Mylan faced an outcry after it raised the price on its popular EpiPen, which treats allergic reactions.
“It’s unsustainable,” Lora Pellegrini, president of the Massachusetts Association of Health Plans, said about rising drug prices. “The health plans, providers, and pharmaceutical community all need to be held accountable.”
Robert K. Coughlin, president of the Massachusetts Biotechnology Council, a trade group, said it’s important to remember that drug companies often offer discounts and rebates to reduce the cost of medicines.
“As the report clearly points out, there is certainly more work to be done to get a truly accurate picture of the costs and value of innovative medicines, and we look forward to continuing the conversation,” Coughlin said in a statement.
The state’s largest insurers — Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, and Tufts Health Plan — all kept spending increases below the state benchmark. But large health care providers had mixed results, meeting the goal for some insurers but not for others. 
The state Health Policy Commission can require organizations that exceed the benchmark to submit plans to curb spending and fine organizations that don’t comply with those plans. So far, it has not taken those steps.
Timothy F. Gens, executive vice president of the Massachusetts Hospital Association, said doctors and hospitals are working to become more efficient and control costs by, for example, monitoring patient care through technology and trying to prevent unnecessary hospital visits. New types of insurance contracts, which encourage doctors and hospitals to focus on quality of care over the amount of services they provide, are pushing such changes. But these so-called alternative payment models account for only 35 percent of the commercial health insurance market, the report found.
“When looking at costs, whether you’re looking at Massachusetts or the country, it’s a challenge, but I think we continue to make progress,” Gens said.
Meanwhile, spending on the state’s Medicaid program, called MassHealth, moderated last year after thousands of people who had received temporary coverage from the program moved over to commercial insurers. Spending on the program rose 4.6 percent, after a 17.9 percent spike the previous year. MassHealth covers more than one in four poor and low-income residents.
The report released Wednesday is the third to measure overall health spending, after a 2012 state law set a benchmark for containing spending. The same law established the Center for Health Information and Analysis and the Health Policy Commission, sister agencies that monitor the health care industry.
The figures are preliminary and could change as more data become available. The estimate for spending growth in 2014, for example, was revised from 4.8 percent to 4.2 percent.

Report: Health care costs top benchmark in Massachusetts

An analysis is a mixed bag for consumers struggling to keep up with premiums and out-of-pocket costs.
by Bob Salzburg - Portland Press Herald
BOSTON — Health care expenses totaled $57 billion in Massachusetts last year and the rate of increase was once again higher than what state officials had hoped for, according to a new report on Wednesday that nonetheless pointed to some encouraging developments in the fight to rein in soaring medical costs. 
The Center for Health Information and Analysis said in its annual review of the state’s health care system that total costs – both private and public – rose in 2015 by 3.9 percent over the previous year. 
The growth rate exceeded the 3.6 percent benchmark that was established by the state’s Health Policy Commission under the guidelines of a 2012 cost containment law. It was also well above last year’s .06 percent inflation rate.
The center, also created by the 2012 law, pegged per capita health care costs at $8,424 per resident, up from $8,010 in 2014. 
Overall, the report presented a mixed bag of sorts for Massachusetts consumers struggling to keep up with ever-rising health insurance premiums and out-of-pocket expenses for medical treatment. 
While it was the second year in a row that spending exceeded the benchmark, it missed the goal by less than in 2014, when expenditures rose 4.8 percent. Health care costs in Massachusetts also grew at a slower clip than the U.S. as a whole last year.
Spending by the state’s Medicaid program moderated significantly in 2015, rising 4.6 percent as compared to 18 percent during implementation of the federal Affordable Care Act in 2014, the center found. Enrollment in subsidized and non-subsidized coverage offered through the Massachusetts health connector more than doubled as officials resolved technical glitches that plagued the initial rollout of the state’s health insurance marketplace.
Still, for many consumers it was another year in which benefit levels declined and companies shifted more risk to their workers.
“To mitigate premium increases, Massachusetts employers and members continue to adopt high deductible health plans, which by design, may subject consumers to higher out-of-pocket costs,” the report stated. High deductible plans made up 21 percent of the commercial insurance market in 2015, up from 19 percent the previous year.
Spending on prescription drugs also continued to outpace overall health care costs, rising by more than 10 percent to $8.1 billion last year. 
Lora Pellegrini, president of the Massachusetts Association of Health Plans, called on the state to demand greater transparency from drug-makers. 
In a statement, she pointed to “the need for aggressive steps to address pharmaceutical prices.”


What’s the Value of Exercise? $2,500

By  GRETCHEN REYNOLDS 


For people still struggling to make time for exercise, a new study offers a strong incentive: You’ll save $2,500 a year.

The savings, a result of reduced medical costs, don’t require much effort to accrue — just 30 minutes of walking five days a week is enough.

The findings come from an analysis of 26,239 men and women, published today in the Journal of the American Heart Association. Researchers from a number of universities and hospitals around the country, including Baptist Health South Florida, Yale, Johns Hopkins, Emory and Baylor, decided to see if they could determine what being active or inactive costs each of us annually in health care spending.

Scientists and health policy experts have known for some time that inactivity is expensive at the public health level. Sedentary people are more likely than physically fit people to develop a number of diseases.
The costs associated with treating these ills are enormous. A startling study published in July in The Lancet looked at data from 142 nations about time lost from work, insurance claims, health care billing, and other costs that the researchers determined were most likely caused by people being sedentary and now suffering from heart disease, stroke, Type 2 diabetes, breast cancer or colon cancer. Each of these conditions is believed to be much more common among people who do not exercise.
Continue reading the main story
The study concluded that inactivity costs the world economy almost $68 billion annually in medical expenses and lost productivity. In the United States alone, the total was almost $28 billion. Most of the global costs were borne by governments and businesses, the authors write, but almost $10 billion worldwide was paid out of the pockets of individuals.
But those kinds of aggregate numbers, while concerning, are also abstract. They don’t tell us how much each of us, individually, might be paying out or saving in future health costs when we decide either to go for that walk at lunchtime or skip it.
So for the new study, the researchers set out to quantify the value of exercise for each individual.
To do so, they first turned to a huge storehouse of data about what we spend on health care. The annual Medical Expenditure Panel Survey, which is conducted by federal agencies, asks a large, representative group of Americans what they have spent on health care in the past year. The survey includes detailed questions about insurance coverage, prescription costs, doctor visits, hospitalizations, medical devices, other out-of-pocket spending, reimbursements, and so on.
It also asks about health, such as any diagnosed illnesses.
A separate part of the survey covers lifestyle issues, such as the person’s income, educational level, and whether he or she smokes, as well about physical activity, and how often the person engages in moderate or vigorous exercise. (Moderate activities, according to the survey, would include brisk walking, bicycling gently, or raking leaves; vigorous exercise would be running, strenuous cycling or other activities that significantly increase heart rate and sweating.)
For the study, the researchers pulled data from the 2012 survey.
Because they wanted to look at costs related to inactivity, the researchers decided to focus on expenses among this group related to cardiovascular disease, since its incidence and severity are known to be affected by whether someone exercises.
They also stratified the people into two broad groups: those who did or did not meet national exercise guidelines, which recommend that someone work out moderately for 30 minutes five times per week.
Then they looked at how much each person had spent on health care in 2012 and whether being physically active had changed that outlay.
It turned out that it had, substantially. On average, someone who met the exercise guidelines paid $2,500 less in annual health care expenses related to heart disease than someone who did not walk or otherwise move for 30 minutes five times per week.
Those numbers included annual savings of about $400 on prescription medicines and far fewer emergency room visits and hospitalizations for people who regularly exercised.
The researchers arrived at these figures after controlling for insurance coverage, meaning that people with good insurance who did not meet the exercise guidelines paid more annually for their health care than those with skimpier coverage who regularly exercised.
The costs declined for exercisers even if they had been given a diagnosis of heart disease or had multiple risk factors for heart disease — such as high blood pressure and poor cholesterol profiles. If they met the exercise guidelines, they generally spent significantly less on annual health care than someone with heart disease or multiple risk factors who rarely worked out.
Overall, the data strongly suggest that “being physically active is good for your wallet,” says Dr. Khurram Nasir, a preventive cardiologist and director of the Center for Healthcare Advancement and Outcomes at Baptist Health South Florida hospital in Miami, who oversaw the study, which was funded by Baptist Health South Florida.
He also pointed out that this study focused only on expenses related to cardiovascular disease and that the actual annual cost savings from being physically active could be substantially higher than $2,500.
Of course, this was an associational study, meaning that it cannot directly prove that working out causes someone to spend less on health care, only that the two are linked.
But Dr. Nasir says he hopes that people who are reluctant to exercise might now consider the possibility that not moving is costing them money.

Release Your Medical Records? First, You Must Collect Them

by Margot Sanger-Katz - NYT

One of Donald J. Trump’s recent attack lines against Hillary Clinton focuses on her health: If she has nothing to hide, he asks in a tweet, why doesn’t she release her medical records to the public?
For the moment, put aside Mr. Trump’s own revelations about his medical history, which consist of a hyperbolic, undated letter with little detail from his gastroenterologist. And put aside Mrs. Clinton’s own recent disclosures, which include a somewhat more detailed accounting of her health and medication history from the internist who has overseen her care in recent years. Put aside, finally, the question of whether complete medical records would allay the conspiracy theories of some of Mrs. Clinton’s critics, who say a recent cough is a sign of disqualifying illness or believe she experienced a seizure during a recent news conference.
Instead, assume that Mrs. Clinton wished to take Mr. Trump’s request seriously, and release full and detailed medical records. It would not be easy, even for a V.I.P. with an army of staffers. Mrs. Clinton is 68 years old, has lived in multiple states and been treated by many doctors and hospitals over the years. The notion of a single file, containing “medical records,” is a fiction. Her medical records are in bits and pieces, in doctors’ filing cabinets, hospital records departments, and in hard-to-access computers. Just like yours, probably.
The federal government has invested billions in helping to digitize medical records, but the process is still in its infancy, with data that is often nonstandard and hard to transfer between systems. And even as a growing number of medical professionalshave made the transition to digital records, most of our medical histories exist only in the old world of paper, assuming they still exist at all. (Mrs. Clinton’s pediatrician is unlikely to still be alive, and records of Mrs. Clinton’s possible polio vaccination or childhood ear infections may be lost to history.)
“Getting someone’s records is a nightmare, because they are in paper, and they’re scattered everywhere,” said Dr. William Tierney, the department chairman of population health at the Dell Medical School at the University of Texas, who has studied and worked on electronic health records systems, and used them as a physician.
Obtaining a complete set of Mrs. Clinton’s health records would require a perfect accounting of every doctor’s office she has visited in her life, and then requests for copies of the records that still exist. Collecting records can be challenging for patients: Doctors and hospitals, fearful of inadvertently violating federal medical privacy laws or simply reluctant to put in the legwork, often refuse to email or even mail records to patients. And even when medical providers comply with requests, the results can be confusing and inconvenient — requiring fax machines, CD-ROM discs with unfamiliar file formats, or photocopies of pages in a physician’s scrawl.
“Average people encounter a huge amount of difficulty,” said David Blumenthal, a former national coordinator for health information technology for the Obama administration, now president of the Commonwealth Fund. He said he had heard countless stories of patients sent to the basement and asked to pay by the page for printouts of digital records.
Good luck reading those records when you get them: pages of lab readings, check-box answers, billing codes and illegible handwriting. Few patients can understand the records, and neither can many physicians. That’s why, even in the most wired of medical offices, receptionists still hand you a clipboard and ask you to write your medical history before the doctor will see you.
“It’s the last bastion of paper,” said Casey Quinlan, a Virginia-based writer who became a patient advocate after the frustrations of managing care for her parents and then herself, when she was treated for breast cancer. “The fax machine is still strong in this one.”
Ms. Quinlan, who travels to health and technology conferences arguing for a better system, has had a large QR code — a type of bar code to store and track data — tattooed on her sternum. Medical providers are invited to scan the image, which she linked to a password-protected site with key medical information.
In 1999 and again in 2008, Senator John McCain released more than a thousand pages of his medical records to reporters. But his was the exception that proved the rule. A Navy veteran and a former prisoner of war, Mr. McCain was part of a long-term study in the military health system, so many of the relevant records really were all in one place. But in later years, he was treated at the Mayo Clinic, and the campaign said it had been forced to postpone the records release because of difficulties with wrangling different doctors within that one system.
By historical standards, neither candidate in this election has been particularly forthcoming about matters of health, despite being older than typical for the job they seek. While candidates in the past may not have published comprehensive reams of documents, most did provide more than a short doctor’s note. Given the complexity of collecting and interpreting medical records, something in between might help the public better assess the health of the candidates hoping to lead the country. (Dan Diamond at Politico recently wrote about one intriguing idea: a panel of independent physicians who would evaluate every candidate on the public’s behalf.)
But if the standard is detailed medical records, Mr. Trump might also struggle with the same challenges of technology, logistics and clarity that afflict college freshmen trying to confirm their vaccination records; or weekend warriors wishing to bring an M.R.I. to a sports medicine doctor; or cancer patients seeking a second opinion. Or anyone with a chronic illness who has ever moved. (Even someone with “astonishingly excellent” test results has probably seen a few medical providers in 70 years.)
Dr. Tierney worked for years in Indiana to help the state develop a cutting-edge health information exchange, a place where most of the state’s hospitals shared patients’ medical data. After 44 years in the state, he queried the exchange for his records before leaving. He paid $100 for an inch-and-a-half-thick stack of papers.
“I went to my new doctor,” he said. “I put it on the table. And she said, fill out the form.”

50 hospitals charge uninsured more than 10 times cost of care, study finds
by Lena H. Sun - The Washington Post

Fifty hospitals in the United States are charging uninsured consumers more than 10 times the actual cost of patient care, according to research published Monday.
All but one of the facilities are owned by for-profit entities and the largest number of hospitals — 20 — are in Florida. For the most part, researchers said, the hospitals with the highest markups are not in pricey neighborhoods or big cities, where the market might explain the higher prices.
Topping the list is North Okaloosa Medical Center, a 110-bed facility in the Florida Panhandle about an hour outside of Pensacola. Uninsured patients are charged 12.6 times the actual cost of patient care.
Community Health Systems operates 25 of the hospitals on the list. Hospital Corporation of America operates 14 others.
“They are price-gouging because they can,” said Gerard Anderson, a professor at the Johns Hopkins Bloomberg School of Public Health, co-author of the study in Health Affairs. “They are marking up the prices because no one is telling them they can’t.”
He added: “These are the hospitals that have the highest markup of all 5,000 hospitals in the United States. This means when it costs the hospital $100, they are going to charge you, on average, $1,000.”
The researchers said other consumers who could face those high charges are patients whose hospitals are not in their insurance company’s preferred network of providers, patients using workers’ compensation and those covered by automobile insurance policies.
Carepoint Health-Bayonne Med­ical Center in Bayonne, N.J., for example, also charges rates 12.6 times the actual cost of patient care. State law limits the maximum that hospitals can charge uninsured patients to 115 percent, a spokesman said.
By comparison, the researchers said, a typical U.S. hospital charges 3.4 times the cost of patient care.
Officials representing the 50 hospitals disputed the findings, saying that they provide significant discounts to uninsured and underinsured patients.
Understanding hospital pricing and charges is one of the most frustrating experiences for consumers and health-care professionals. It is virtually impossible to find out ahead of time from the hospital how much a procedure or stay is going to cost. Once the bill arrives, many consumers have difficulty deciphering it.
Most hospital patients covered by private or government insurance don’t pay full price because insurers and programs such as Medicare negotiate lower rates for their patients. But millions of Americans who don’t have insurance don’t have anyone to negotiate for them. They are most likely to be charged full price. As a result, uninsured patients, who are often the most vulnerable, face skyrocketing medical bills that can lead to personal bankruptcy, damaged credit scores or avoidance of needed medical care.
Researchers said the main factors leading to overcharging are the lack of market competition and the fact that the federal government does not regulate prices that health-care providers can charge. Only two states, Maryland and West Virginia, set hospital rates.
In the United States, hospitals have the chargemaster, a lengthy list of the hospital’s prices for every procedure performed and for every item used during those procedures, such as the cost of one Tylenol tablet or a box of gauze.
To determine the size of markups, researchers used what Medicare allows for the costs of care. That includes direct patient costs, such as emergency-room care, and indirect costs such as administration. It does not include private doctors’ costs.
Using data for all Medicare-certified hospitals between May 2012 and April 30, 2013, researchers tallied up total charges, then divided them by the patient care costs, which they defined as total costs Medicare agrees to pay.
“For-profit players appear to be better players in this price-gouging game,” said Ge Bai, an assistant accounting professor at Washington and Lee University and a study co-author.
Carepoint Health, which owns the Bayonne hospital and two others in Hudson County, N.J., said charge-pricing affects less than 7 percent of its total patient interactions. Without it or adequate reimbursements, “our safety-net hospitals risk closure,” a spokesman said. Urban hospitals receive lower reimbursements than suburban ones, a spokesman said.
Officials at Community Health Systems of Franklin, Tenn. and Hospital Corporation of America, based in Nashville, said hospital charges rarely reflect what consumers actually pay. They said their hospitals offer significant discounts to uninsured patients and charity care for those who qualify. Community Health Systems said in a statement that it provided $3.3 billion in charity care, discounts and other uncompensated care for consumers last year. It also noted that several of its hospitals were not owned by CHS at the time the data were reported.
HCA said in a statement that its uninsured patients are eligible for free care through its charity care program or they receive discounts that are similar to discounts that patients covered by a private insurance plan receive.
The Federation of American Hospitals, which represents for-profit hospitals, said the listed hospitals provided nearly $450 million in uncompensated care in 2012 alone. Including the discounts “would have had a significant effect on the charge-to-cost-ratio reported, and therefore the implications of the study’s results,” it said in a statement.
It makes little economic sense to “mark something up 10 times what it actually costs and then give a discount,” Anderson said. “Clearly they expect someone to pay these inflated prices.”
He noted that the cost of workers’ compensation and auto insurance polices are higher in the states where hospital charges are unregulated because companies have to pay the higher rates.

A Push to Lower Drug Prices That Hit Insurers and Employers the Hardest

by Katie Thomas - NYT

Americans have expressed outrage at drug companies for raising prices on products like EpiPen, the severe allergy treatment needed by thousands of children, and Daraprim, a rarely used but essential drug to treat a parasitic infection.
But insurers and employers — who pay the bulk of the cost for drugs — say that a bigger financial shock has come from a largely overlooked source: expensive anti-inflammatory medications like Humira and Enbrel, drugs taken by millions of people for conditions like rheumatoid arthritis. In recent years, the prices of the medications have doubled, making them the costliest drug class in the country by some calculations.
Now, one of the most powerful forces on the side of drug payers is pushing back. On Thursday, Express Scripts, the nation’s largest drug benefits manager, changed its recommendations to insurers and employers, saying they should cover fewer drugs for many inflammatory conditions. The idea is that the new limits will force drug companies to lower their prices, saving insurers and employers money.
The approach has already set off some complaints among patients, who rely on regular injections of the drugs to keep painful and uncomfortable symptoms in check. If an approved drug does not work, patients will have to take extra steps to get a different drug. But Express Scripts said that the move was necessary to contain costs. The drugs account for nearly 10 percent of all drug spending among its members in the United States, the company says — costing an estimated $7.5 billion — even though fewer than 1 percent of its members use them.
“This is a category of drugs that are used for crippling, very painful conditions, yet they don’t affect huge numbers of people,” said Dr. Glen Stettin, the chief innovation officer at Express Scripts. The rising costs, he said, are due less to a rising number of patients who need the products and “much more because of the increase in the prices of these medications.”
The approach is the latest effort by insurers and drug benefit managers to more closely manage drugs in high-cost diseases, limiting which ones are covered or requiring patients to take additional steps to get approval for certain products. In 2014, Express Scripts shook up the market for hepatitis C drugs when it required its patients to use a new treatment by AbbVie rather than more expensive competitors. It made similar moves last year with the approval of expensive new treatments for high cholesterol.
Like those previous efforts, the effort for inflammatory conditions will most likely help the company’s mail-order specialty pharmacy, Accredo. Express Scripts said patients getting the anti-inflammatory medications through the new program would need to use Accredo, not a competing pharmacy, giving the service a bigger base of customers.
As a drug benefit manager, Express Scripts provides services like negotiating with drug companies and approving or denying drug claims. The new program is voluntary for employers and insurers who use the company, but its recommendations are usually widely adopted.
Humira, made by AbbVie, and Enbrel, made by Amgen, each carry a monthly list price of just over $4,000, and each have increased those prices by about 130 percent from 2011 to 2016, according to the Gold Standard Drug Database compiled by Elsevier Clinical Solutions. That price does not include rebates that the manufacturers negotiate with insurers. Express Scripts said that the actual monthly cost of anti-inflammatory drugs, before the new program, was about $3,000.
Representatives for large employers, who subsidize the health insurance of their employees, said the efforts were welcome. Drugs like Humira and Enbrel are known as specialty drugs, a category of products that treat serious conditions and whose rising costs have increasingly alarmed those who are paying the bills.
“If you go back to 2014, it wasn’t even on the radar screen for employers, and now it’s No. 1,” said Brian J. Marcotte, the chief executive of the National Business Group on Health, which advocates for large employers.
But some patients questioned whether it would further limit the options for some people or make it more cumbersome to get the medications they needed. The program would apply only to new patients; those already stable on drugs would be allowed to remain on them.
“Jumping through hoops may not seem like a big thing to somebody that doesn’t have to live with the condition,” said Nicole Martin, 33, of Blaine, Ky., who has rheumatoid arthritis and takes Enbrel. “But even being a day or two behind can cause massive issues for somebody.”
Traditionally, patients were offered all the drugs that were covered by their plans no matter which inflammatory condition they had — from rheumatoid arthritis to psoriasis and ulcerative colitis. Under the new guidelines, Express Scripts has devised a separate list of preferred and nonpreferred drugs for each condition. Patients who want to use a drug on the nonpreferred list will need a letter from their doctor.
The company said the move would require drug companies to compete more directly. The motivation to get on the preapproved list, the company said, would push drug companies to offer better discounts to employers and insurers. Express Scripts declined to provide specifics about the discounts that it had negotiated through the new program.
“We expect to make a big dent in the cost of caring for people in this category, without compromising the care that people get,” Dr. Stettin said.
Dr. Stettin said the company looked at patient data first when deciding which drugs would be preferred. “Clinical always comes first, and the cost is second,” he said.
Representatives for drug companies, including AbbVie and Amgen, said they believed doctors and patients — and not insurance companies — should decide which therapy is best. And they said the list price does not reflect the rebates and other discounts that insurance companies and drug-benefit managers negotiate, which make the actual cost lower.
“Because of the magnitude of these rebates,” said Kristen Davis, a spokeswoman for Amgen, “price increases have become part of the competitive dynamic.”
The program will also refund up to $2,000 a month to employers and insurers if a patient has to switch from a preferred drug to a different medication in the first three months, a potential savings of about $250 million a year. About a quarter to a third of patients end up switching to a new drug in the first few months, Express Scripts said.
But that money-back guarantee does not necessarily go to the patient, even if the patient has a high-deductible plan and paid for all or most of the drug. Employers will decide whether to pass that refund along to the patients, Express Scripts said.
A reason that the rising cost of drugs like Humira and Enbrel hasn’t stoked greater outrage is that many patients are shielded from the costs. In addition to the discounts the companies negotiate with drug benefit managers, AbbVie and Amgen run assistance programs that often reduce patients’ out-of-pocket costs. The average Express Scripts member paid $127 in monthly co-payments for a drug to treat an inflammatory condition, the company said.
Dr. Stettin said patients would be better served by using the company’s specialty pharmacy, Accredo, which has pharmacists that specialize in inflammatory conditions. He cited company data showing that patients with those conditions were more likely to take their drugs when they used Accredo compared with other pharmacies.
But some industry observers said the move was a ploy to build Accredo’s mail-order business, by essentially locking in patients whose employers opt in to the new program, then making money by filling the prescription.
“They really, really want their hands on that script,” said Michael Rea, the chief executive of Rx Savings Solutions, which advises employers on how to reduce drug costs.




Posted by at

No comments:

Post a Comment

Subscribe to: Post Comments (Atom)