Health Care Reform Articles - April 27, 2018

Vote for candidates who support Medicare for all

by Dr. Thomas Claremont - Portsmouth Herald - April 26, 2018

Wednesday, April 18 will go down in history as the day when a whole new approach to health care reform took place at the Democratic congressional debate in Portsmouth. Seven of the eight candidates endorsed the idea to improve Medicare and expand it to cover everyone living in the U.S., regardless of age, income or job status.

These candidates support Medicare for all because voters are demanding action to address our broken health care system. Health care costs were the top issue in recent elections in Virginia and Pennsylvania, and the basis for the teachers’ strike in West Virginia. A majority of Americans now support Medicare for all, and here in New Hampshire, more than 80 percent of primary care doctors support this concept.

A majority of Democrats in the House support H.R. 676, the Expanded and Improved Medicare for All Act. This plan would improve Medicare to cover hearing, dental, vision, mental health, and prescriptions, and expand the program to cover everyone from cradle to grave, without copays or deductibles. Every doctor and hospital would be included “in-network.”

Workers will no longer be locked into jobs since health coverage will no longer be tied to employment. Union members can focus on improving wages and working conditions instead of fighting tooth-and-nail to retain precious health benefits. Parents working inside and outside of the home, including those caring for sick or elderly loved ones, will appreciate the continuous coverage and peace of mind that Medicare for all can provide. Business owners will be freed from the stress of employee health coverage, and their customers, unburdened by health costs, will have more money to spend on their products and services.

Besides high-quality coverage, the top selling point for single payer is the substantial administrative savings achieved by eliminating the wasteful, profit-driven private insurance middleman. Traditional Medicare operates with only 3 percent overhead and pays the top executive $210,000 per year. The top six for-profit insurers have overhead (paperwork and profits) of 14-18 percent; the total direct compensation of their executives was a stunning $161 million, or almost $1 per patient. Physicians for a National Health Program estimates that Medicare for all will slash administrative costs by $504 billion per year, while negotiated prices of prescription drugs saves another $113 billion per year. This is more than enough money to provide coverage for every American for life.

We simply can’t sit on our hands while health care costs continue to skyrocket, gobbling up an even greater percentage of GDP and squeezing the average family. The Milliman Index’s actuarial projection of health care costs for a family of four under an employer-sponsored PPO plan is $27,000. With annual increases of 5.5 percent (which is conservative), that bill will be $52,000 in 2030. Even with the Affordable Care Act, 28 million Americans remain uninsured, an equal number under-insured, with at least a million Americans filing for health-related bankruptcies every year.

Looking at those numbers, it’s easy to feel overwhelmed or hopeless. But remember that you have a choice and a voice. You have the power to make sure that no one in this country ever again has to delay or skip needed medical care because of cost. This year, you can vote for a candidate who supports single-payer Medicare for all. Together, we can bring the number of uninsured down to zero.

Thomas Clairmont MD is a primary care physician practicing in Portsmouth.

http://www.seacoastonline.com/news/20180426/vote-for-candidates-who-support-medicare-for-all

Dems and ‘single payer’ — a house divided?

by Chuck McFadden - Capitol Weekly - April 16, 2018

It goes by various names: universal health care access; national health care; Medicare for all; government-run health care; even socialized medicine. Most news reports call it “single payer.” It threatens to tear asunder California’s Democratic Party.

Single payer, in which the government ultimately covers the cost of health care, has become the bright line of demarcation between the more liberal Berniecrats and more moderate Establishment Democrats. Among party activists, it is an emerging litmus test for party purity.

“If single-payer healthcare is going to mean complete takeover by the government of all healthcare, I’m not there yet.” — Dianne Feinstein.

Opposition is fierce. The influential California Medical Association said in January that single-payer legislation in the Capitol, SB 562,  “would eliminate Medi-Cal, Medicare, all private insurance and the Covered California exchange for a singular health care insurance product provided by the state, without offering any way to pay for it.” 

The danger to Democrats is that disagreement over the issue could depress their turnout, with some more left-leaning Democratic activists refusing to support fellow Democrats who are not sufficiently enthusiastic about single payer.

The Democratic disparity is wide and public.

“If single-payer healthcare is going to mean complete takeover by the government of all health care, I’m not there yet,” Democratic Sen. Dianne Feinstein said at a town hall in April of 2017.

But three months later, her fellow Democrat, Sen. Kamala Harris, said she intended to co-sponsor Sen. Bernie Sanders’s Medicare for All bill “because it’s just the right thing to do.”

Feinstein’s likely opponent as she seeks a fifth term this November is Kevin de Leon, another Democrat and until recently the leader of the California Senate.  He’s all for single payer. So is his successor as Senate leader, Toni Atkins.

De Leon in February received an endorsement from the California Nurses Association, the chief sponsor of Single Payer in California, and declared:

“… I voted to pass single payer legislation because our representatives in Washington, D.C. have wavered on this issue for far too long,”

“We’re talking about a sea change – it’s absolutely breathtaking. Nothing in our lifetime is as significant as single payer.”– Dr.  William Bronston

But on the other side of the Capitol, Democratic Assembly Speaker Anthony Rendon shelved SB 562, the Senate-passed single-payer bill that Atkins supported. Rendon says he’s for Single Payer as a concept, but SB 562 lacked any details on financing.

That move outraged longtime single-payer supporters, such as retired Dr. William Brownston, who heads the Sacramento chapter of Physicians for a National Health Program.

Bronston contends single payer is more than merely a good idea — it’s a society-transforming phenomenon.

“We’re talking about a sea change – it’s absolutely breathtaking,” he told Capitol Weekly in a telephone interview. “Nothing in our lifetime is as significant as single payer.”

Foes of  single payer are led by vested interests who want to preserve their financial advantages, he said.

Antonio Villaraigosa believes single payer, as advocated by rival Gavin Newsom, would force seniors off Medicare.

“The insurance industry makes no contribution to health care. We’ve been flooded with corporate propaganda against single payer,” he says, arguing that significant campaign contributions from the insurance and medical industries are the reason Gov. Brown and Assembly Speaker Rendon have not been more enthusiastic about single payer.

“There has to be enough of a grass-roots uprising to force the corrupt Democratic Establishment to accept single payer,” he says.

Single payer has already become one of the major issues in the race to become California’s next governor.

Lt. Gov. Gavin Newsom, the Democrat leading the race for governor, is unabashedly in favor of single payer.  But fellow Democrat Antonio Villaraigosa, running against him, says he favors the concept of single payer, but not SB 562.

Villaraigosa says single payer, as advocated by Newsom, would force seniors off Medicare; the California Nurses Association, backing Newsom and Single Payer, called Villaraigosa’s accusation “fear mongering” and “disgracefully intended to alarm seniors about their Medicare coverage.”

In another sign of the party’s shift to the left, delegates to the February 2018 convention in San Diego refused to endorse Feinstein for re-election.

California’s most famous Democrat, Jerry Brown, voiced a similar concern in March of 2017. “Where do you get the extra money? This is the whole question,” the governor said in a Washington exchange with reporters.

Thirty-six years ago, however, Brown wasn’t so doubtful about Single Payer.

“My preference is that we create a single system, put everyone under a universal health care system. We treat health care not as a commodity to be played with for profit but rather the right of every American citizen when they’re born,” he said in April 1992 in a debate with Bill Clinton when both were seeking the Democratic presidential nomination.

The California Democratic Party’s platform is forthright on single payer:

“California Democrats believe that health care is a human right not a privilege. The CDP recognizes that the health and well-being of Californians cannot continue to be based on arbitrary private and public financial decisions and therefore advocates legislation to create and implement a publicly-funded single-payer, privately delivered, fiscally tractable, affordable, comprehensive, secure, high quality, efficient, and sustainable health care system for all Californians.”

In another sign of the party’s shift to the left, delegates to the February 2018 convention in San Diego refused to endorse Feinstein for re-election. They didn’t endorse de Leon either, but the non-endorsement of an incumbent Democratic senator was a major slap in the face to Feinstein. She had 37 percent of delegate votes and de Leon had 54 percent, just short of the 60 percent needed for endorsement.

In June of 2017, The Pew Research Center reported a jump in Democratic approval of single payer.

But will a civil war between two camps of Democrats really affect how voters behave this June and then in November?

It may be firing up party activists, and may affect how hard they push voters, but among the larger electorate so far, the intra-party squabbleseems to awash in contradictions.  A Public Policy Institute of California poll in February had Single Payer doubter Feinstein leading Single-Payer enthusiast de Leon 46 percent to 17 percent, with 33 percent of likelyvoters undecided.

In June of 2017, The Pew Research Center reported a jump in Democratic approval of single payer:

“Among Democrats, 52% now say health insurance should be provided through a single national insurance system run by the government, while fewer (31%) say it should be provided through a mix of private companies and government programs. The share of Democrats supporting a single national program to provide health insurance has increased 9 percentage points since January and 19 points since 2014.”

“It will cost $400 billion. Wrong. Over 90 percent of that is what we already spend on healthcare.” — Deborah Burger

The 43,000-member CMA worries about the cost. In its Jan. 17 statement, it said: “What’s more, the Legislative Analyst’s Office (LAO) found that the proposal could ‘require new state tax revenues in the low hundreds of billions of dollars and ‘could result in a lower minimum funding requirement for schools and community colleges’ under Proposition 98. In other words, SB 562 would pit health care groups against public education advocates in an annual battle for state budget dollars…”

In a Jan. 24 op-ed in the San Diego Union-Tribune, Deborah Burger, co-president of the California Nurses Association, challenged such cost assumptions:

“It will cost $400 billion. Wrong. Over 90 percent of that is what we already spend on healthcare,” she wrote.

“Savings from a single-payer system on funds insurers siphon off for profits, paperwork for denials of care insurers don’t want to pay for, and lucrative executive pay packages, and the state’s ability to use its bulk purchasing power to lower drug costs, will further reduce the overall spending. No other proposed approach to ‘cost containment starts with $37.5 billion in savings, as Senate Bill 562 does, and then constrains prices and costs in the most effective ways.”

With battle lines already drawn, the intraparty battle is probably going to become more heated in coming months, likely forcing Democratic candidates who have so far avoided the issue to take a stand for or against – either losing or gaining votes.

http://capitolweekly.net/democrats-single-payer-house-divided/

Health Care Reform Articles - April 18, 2018

It finally happened: Goldman Sachs asks 'Is curing patients a sustainable business model?'

by Walter Eininkel - The Daily KOS - April 13, 2018

On April 10 in the year of our Lord, 2018, analysts at Goldman Sachs allegedly released a report titled “The Genome Revolution.” According to numerous news reports, the report delved into a pretty awkward subject—cures.

"The potential to deliver 'one shot cures' is one of the most attractive aspects of gene therapy, genetically-engineered cell therapy and gene editing. However, such treatments offer a very different outlook with regard to recurring revenue versus chronic therapies," analyst Salveen Richter wrote in the note to clients Tuesday. "While this proposition carries tremendous value for patients and society, it could represent a challenge for genome medicine developers looking for sustained cash flow."

It isn’t “good business,” to be absolutely frank. We all know it isn’t. There are entire fringe worlds of conspiracy that continue to exist based on this one single kernel of truth. Why is this news now? Because science and medicine are getting very close to big and meaningful breakthroughs on diseases and maladies that were once only somewhat treatable with very expensive routines of medications. Gene therapy breakthroughs have been a big part of this, with the FDA approving promising gene therapy trials, and even more exciting results coming in from around the world. But as CNBC reports, solving serious problems for the public doesn’t mean you get to keep buying mega-yachts. Goldman Sachs analyst Salveen Richter has some bad news for our current “free market” system:

Richter cited Gilead Sciences' treatments for hepatitis C, which achieved cure rates of more than 90 percent. The company's U.S. sales for these hepatitis C treatments peaked at $12.5 billion in 2015, but have been falling ever since. Goldman estimates the U.S. sales for these treatments will be less than $4 billion this year, according to a table in the report.

"GILD is a case in point, where the success of its hepatitis C franchise has gradually exhausted the available pool of treatable patients," the analyst wrote. "In the case of infectious diseases such as hepatitis C, curing existing patients also decreases the number of carriers able to transmit the virus to new patients, thus the incident pool also declines … Where an incident pool remains stable (eg, in cancer) the potential for a cure poses less risk to the sustainability of a franchise."

The fact of the matter is that private industry spends a lot of money on scientific research because it’s extraordinarily profitable. But, governments spend money on scientific research as well, and some political parties believe that one of the many things our government should help to do, besides funding the arts and education, is to foster scientific research and innovation. Our current Republican-led government does not believe in that, having already laid out massive cuts to scientific research. They believe that private interests can innovate the best way possible to the best outcomes for the most people.

https://www.dailykos.com/stories/2018/4/13/1756856/-It-finally-happened-Goldman-Sachs-asks-Is-curing-patients-a-sustainable-business-model?detail=emaildkre

“Is curing patients a sustainable business model?” Goldman Sachs analysts ask

Analyst report notes that Gilead’s hep C cure will make less than $4 billion this year.

by Beth Mole - Ars Technica - April 12, 2018

One-shot cures for diseases are not great for business—more specifically, they’re bad for longterm profits—Goldman Sachs analysts noted in an April 10 report for biotech clients, first reported by CNBC.

The investment banks’ report, titled “The Genome Revolution,” asks clients the touchy question: “Is curing patients a sustainable business model?” The answer may be “no,” according to follow-up information provided.

Analyst Salveen Richter and colleagues laid it out:

The potential to deliver “one shot cures” is one of the most attractive aspects of gene therapy, genetically engineered cell therapy, and gene editing. However, such treatments offer a very different outlook with regard to recurring revenue versus chronic therapies... While this proposition carries tremendous value for patients and society, it could represent a challenge for genome medicine developers looking for sustained cash flow.

For a real-world example, they pointed to Gilead Sciences, which markets treatments for hepatitis C that have cure rates exceeding 90 percent. In 2015, the company’s hepatitis C treatment sales peaked at $12.5 billion. But as more people were cured and there were fewer infected individuals to spread the disease, sales began to languish. Goldman Sachs analysts estimate that the treatments will bring in less than $4 billion this year.

“[Gilead]’s rapid rise and fall of its hepatitis C franchise highlights one of the dynamics of an effective drug that permanently cures a disease, resulting in a gradual exhaustion of the prevalent pool of patients,” the analysts wrote. The report noted that diseases such as common cancers—where the “incident pool remains stable”—are less risky for business.

To get around the sustainability issue overall, the report suggests that biotech companies focus on diseases or conditions that seem to be becoming more common and/or are already high-incidence. It also suggests that companies be innovative and constantly expanding their portfolio of treatments. This can “offset the declining revenue trajectory of prior assets." Lastly, it hints that, as such cures come to fruition, they could open up more investment opportunities in treatments for “disease of aging.”

Ars reached out to Goldman Sachs, which confirmed the content of the report but declined to comment.

This post has been updated.

https://arstechnica.com/tech-policy/2018/04/curing-disease-not-a-sustainable-business-model-goldman-sachs-analysts-say/

Republicans Couldn’t Knock Down Obamacare. So They’re Finding Ways Around It.

by Margot Sanger-Katz - NYT - April 11, 2018

The Trump administration has always seen Obamacare as an abominable roadblock to the less regulated insurance market it prefers. Last year, it tried to knock it down and failed. 

Now, it’s building a set of detours.

More customers who want to avoid buying health insurance can now find a way out of the law’s individual-mandate penalty, which will disappear completely next year. Those who want skimpy plans not covering maternity care or bills exceeding a set annual amount may soon have that option in many states — provided they don’t have pre-existing conditions. 

The downside: Many who do want Obamacare-style coverage are going to have to pay more.

Obamacare’s many rules about insurance — meant to make coverage accessible to Americans regardless of their health status, and comprehensive enough to cover their needs — still exist. Obamacare plans will still have to cover a basic set of health benefits and accept customers who have a history of illness. But, through a series of regulatory maneuvers, the Trump administration is making the insurance market governed by those rules increasingly optional. Alongside the Obamacare market it couldn’t destroy, it is helping to build a second market, free of many rules, and more like the market that Obamacare replaced. 

On Monday, the Centers for Medicare and Medicaid Services, which oversees the marketplaces, unveiled a series of policies that Seema Verma, the agency’s administrator, made clear were aimed at working around the health law’s requirements. 

“Americans shouldn’t be punished by its failure to provide choices,” she said, referring to the Affordable Care Act. “Until the law changes, we won’t stand idly by as Americans suffer.”

Rules and other guidance released Monday provide some ways out. People who live in a county where only one insurer offers Obamacare-compliant health plans now can get an exemption to the law’s individual mandate penalties right away. (They’ll go away for everyone next year under legislation passed as part of the tax overhaul.) The administration is allowing older plans that predated Obamacare and that don’t follow all its rules to stick around another year. It’s also allowing health plans to cover a slightly less robust set of benefits, although those changes are mostly marginal.

Bigger changes are coming. The administration has proposed regulations that would allow so-called short-term health plans to be offered for nearly a year of coverage. Those plans aren’t subject to any Obamacare rules in most states, and are likely to be marketed aggressively. They are likely to cover fewer health services and be available only to the healthy — but at a lower price. Another pending rule would expand the availability of association health plans, a form of group insurance purchasing that may be attractive to small businesses looking for cheaper, less comprehensive options.

It’s hard to predict precisely who will choose what. The administration wrote in its rule proposals that it didn’t anticipate either the short-term or association plans to be very popular, even as it lauded them as important alternatives to the current options under the health law. The new options may mostly attract people who are uninsured now, because they were priced out of the current market. Outside experts think the alternatives could siphon away a substantial percentage of healthy people from the Obamacare markets. 

People buying those plans may face some unpleasant surprises. The plans are likely to require applicants to fill out detailed health histories, and to exclude those with prior illnesses. They also are likely to exclude or limit services — like addiction treatment, maternity care or prescription drugs — that all Obamacare plans require. Association plan buyers have tended to have problems with fraud. And some short-term plans have a history of declining to pay for serious illnesses after the fact.

But even if the new plans serve their customers well, their popularity could leave the remaining markets a bit shakier. Because the short-term plans will be open only to the healthy, the remaining customers will tend to be sicker, and more expensive to insure. 

Subsidies set up under the law were devised to automatically rise when prices increase, which means that customers who earn little enough to qualify won’t notice if Obamacare prices go up. But people who pay the full cost of their own insurance — somewhere in the neighborhood of six million people — will feel the sting of increased prices. 

Those healthy enough to be able to access the new, cheaper options may choose them instead if the Obamacare prices get too high. But people with pre-existing health conditions may face a choice between more expensive insurance and nothing. 

“They will still have access to those plans, even if they are prohibitively expensive,” said John Graves, an assistant professor of health policy at Vanderbilt University. Mr. Graves has seen up close what can happen when consumers are given Obamacare alternatives. Tennessee has allowed its farm bureau to offer health plans that don’t follow Obamacare rules. And that option has been attractive to healthy customers, leaving the remaining market more expensive. Mr. Graves predicts that options like the farm bureau are likely to become even more attractive once the mandate to buy comprehensive coverage disappears.

The administration has left one more potential disruptive option on the table. Last year, when President Trump canceled a disputed set of payments to insurers, state insurance regulators allowed the health plans to shuffle around prices to absorb the loss. In a call with reporters Monday, Ms. Verma said her agency was considering barring that practice. Without the price adjustment, consumers in the Obamacare-compliant market will have a harder time finding an affordable plan.

The result may look a lot like the kind of markets that Republicans in Congress imagined when they wrote their health bills last year. One plan, proposed by Senators Ted Cruz of Texas and Mike Lee of Utah, would have allowed unregulated health plans, as long as there were also options that would cover people with pre-existing conditions. Another leading plan would have established “high-risk pools” for people too sick to buy unregulated insurance.

Those bills failed, in the face of large public protests. But the new regulations will quietly bring us closer to the reality they imagined. 

https://www.nytimes.com/2018/04/11/upshot/republicans-couldnt-knock-down-obamacare-so-theyre-finding-ways-around-it.html

Spreading 'Like Wildfire': Majority of Americans—Including 74% of Democrats—Now Support Single-Payer

"When people see the justice of an idea, it spreads like wildfire," responded Sen. Bernie Sanders. "The American people know that healthcare should be a right."

by Jessica Corbett - Common Dreams - April 12, 2018

"Five years ago, could you have believed that half of Americans would agree we need a single-payer healthcare system?"

That's how Sen. Bernie Sanders (I-Vt.)—a longtime advocate of guaranteeing healthcare for all Americans—responded to a new poll that found that 74 percent of Democrats and 51 percent of all adults surveyed support implementing a single-payer healthcare system in the United States.

"When people see the justice of an idea, it spreads like wildfire," Sanders tweeted Thursday morning. "The American people know that healthcare should be a right."

The Washington Post-Kaiser Family Foundation (KFF) poll asked: "Do you support or oppose having a national health plan—or a single-payer plan—in which all Americans would get their insurance from a single government plan?" More than half said they support it:

The results align with other polls conducted within the past year. In September, as Common Dreams reported, 49 percent of all voters and two-thirds of Democrats surveyed by Politico/Morning Consult said they supported "a single-payer healthcare system." A KFF poll from July found that 53 percent of Americans somewhat or strongly favor a single-payer plan.

The growing public support for a single-payer system has coincided with action in Congress. Backed by medical professionals, activists, business leaders, and a "groundbreaking " number of Democratic senators, last September Sanders introduced a Medicare for All bill that would transition the nation's current for-profit healthcare system toward a single-payer one.

Ahead of the 2018 midterm election and amid mounting demands from the American public that federal lawmakers sign on to Sanders's bill, studies and political analysts are finding that support for Medicare for All is a politically viable and increasingly popular stance among candidates.

As Washington Post reporter Jeff Stein pointed out, the recent poll also asked about the nation's current healthcare law—the Affordable Care Act (ACA) or Obamacare—which garnered a similar amount of support from Americans, challenging the notion that advocating for a Medicare for All solution to the problems that still exist under the ACA is an "extreme left-wing" position.

https://www.commondreams.org/news/2018/04/12/spreading-wildfire-majority-americans-including-74-democrats-now-support-single

Des Moines Register editorial writer wins Pulitzer Prize

Des Moines Register - Editorial - April 18, 2018

Andie Dominick, an editorial writer at the Des Moines Register, was named a Pulitzer Prize winner for editorial writing.

Andie Dominick, an editorial writer at the Des Moines Register, on Monday won the 2018 Pulitzer Prize for editorial writing for a selection of Iowa-focused editorials criticizing policies that restrict access to health care.

It is the Register’s 17th Pulitzer Prize, and its first since 2010.

The Pulitzer Prize citation states that Dominick won "for examining in a clear, indignant voice, free of cliché or sentimentality, the damaging consequences for poor Iowa residents of privatizing the state’s administration of Medicaid."

The Register invited Iowans to share the experiences they have had with Medicaid under privatized management, which allowed Dominick to put a human face on denials of care, loss of access to services, and providers going out of business because they were not being reimbursed by for-profit insurers.

Other editorials decried state lawmakers’ efforts to impede fetal tissue research and said the Trump administration’s handling of the Affordable Care Act was jeopardizing access to coverage.

Speaking to a crowd of Register employees who raised glasses of champagne to toast her, Dominick said she was in shock at the win.

Dominick called health care "a passion of mine" and said she was honored to be recognized for her work on such an important topic.

"It’s such an honor to be recognized for the whole paper’s work on Medicaid and ensuring Iowans have access to health care," Dominick said. "And we’ll continue to work to make Iowa a better place to live."

Register Executive Editor Carol Hunter echoed that sentiment, calling the paper's work on health care coverage and Medicaid in particular "a team effort" driven by strong investigative reporting.

But Dominick's editorials are also driven by her own research and reporting, Hunter said, calling the win "a real credit to her work ethic and her journalism credentials."

"She does so much original reporting to inform her editorials," Hunter said of Dominick. "She has long made health care a subject of study and research. These editorials reflect her in-depth knowledge of the subject and how much she cares about access to good health care for all Iowans."

The effects of Iowa's Medicaid privatization will continue to be a focus of the Register's reporting and editorial writing, Hunter said, adding that she hopes the prize will focus more attention on health care in Iowa.

How privatized Medicaid is systematically denying hundreds of disabled Iowans the medical equipment their doctors say they need

Care Denied: How Iowa's Medicaid maze is trapping patients in endless appeals

"One can hope that the additional attention on this set of editorials might persuade our legislators and the governor’s office to take an even harder look at taking steps to ensure the management of the Medicaid program is benefiting Iowans," Hunter said.

Register President and Publisher David Chivers, who sits with Hunter and Dominick on the paper's editorial board, said he's seen up close Dominick's passion and focus on the topic of Medicaid privatization.

"In every meeting since this Medicaid privatization thing has been unfolding, Andie has said very passionately that this has been an important topic for Iowa and for our citizens," Chivers told the Register newsroom Monday afternoon.

"This topic is such a crucial topic affecting the lives of Iowans that it’s just a terrific acknowledgment of the important work that we do every day here for the state and all the communities that make up the state," Chivers added in an interview.

Dominick's Pulitzer-winning editorials:

• Editorial: Fetal tissue bill is anti-life, anti-science
• Editorial: Blaming sick people does not lower drug prices
• Good riddance, AmeriHealth: One private Medicaid insurer down, two to go
• Lawmakers should pay for own health insurance
• Editorial: Branstad's private Medicaid 'success' that wasn't
• Editorial: Privatized Medicaid is worst prank ever
• Editorial: Private Medicaid’s latest victim is Iowa teen
• Editorial: Iowans' health insurance is in Trump's hands
• Editorial: The misadventures of anti-vaccine lawmakers

Dominick was a 2014 Pulitzer Prize finalist in editorial writing for challenging Iowa's arcane licensing laws that regulate occupations ranging from cosmetologists to dentists and often protect practitioners more than the public.

Dominick has been an editorial writer at the Register since 2001. She holds bachelor's and master's degrees in English from Iowa State University.

She is the author of "Needles: A Memoir of Growing Up with Diabetes," published by Simon and Schuster in the U.S. and translated into several languages.

She and her husband live in Des Moines and have three adult children.

https://www.desmoinesregister.com/story/news/2018/04/16/pulitzer-prize-des-moines-register-andie-dominick-editorial-writing/521710002/

How Profiteers Lure Women Into Often-Unneeded Surgery

by Matthew Goldstein and Jessica Silver-Greenberg - NYT - April 14, 2018

Jerri Plummer was at home in Arkansas, watching television with her three children, when a stranger called to warn that her life was in danger.

The caller identified herself only as Yolanda. She told Ms. Plummer that the vaginal mesh implant supporting her bladder was defective and needed to be removed. If Ms. Plummer didn’t act quickly, the caller urged, she might die.

Ms. Plummer, 49, didn’t ask many questions. Her implant was causing her discomfort, and she was impressed by how much Yolanda knew about her medical history. She was scared. “It was like I had a ticking time bomb inside of me,” she said. Yolanda assured Ms. Plummer that all her expenses would be covered and that she would be set up with a lawyer to help her sue the mesh manufacturer, Boston Scientific.

Days later, court records show, Ms. Plummer was lying on an operating table in a medical office in a shopping mall in Orlando, Fla.

Just like that, she had stumbled into a growing industry that makes money by coaxing women into having surgery — sometimes unnecessarily — so that they are more lucrative plaintiffs in lawsuits against medical device manufacturers.

Lawyers building such cases sometimes turn to marketing firms to drum up clients. The marketers turn to finance companies to provide high-interest loans to the clients that have to be repaid only if the clients receive money from the case. Those loans are then used to pay for surgery performed by doctors who are often lined up by the marketers.

Interviews with dozens of women, lawyers, finance executives and marketers, as well as a review of court records and confidential documents, indicate that hundreds, perhaps thousands, of women have been sucked into this assembly-line-like system. It is fueled by banks, private equity firms and hedge funds, which provide financial backing.

The profits are immense. So are the costs to women. Some suffer physical problems from the surgery. Others say they have become depressed or unable to work. Still others have to get mesh reinserted.

Ms. Plummer’s brush with the industry left her wearing diapers.

Faulty Products

The industry of providing financing to law firms involved in litigation is not new. In recent years, it has expanded into a diverse array of businesses. A spate of companies, such as a Brooklyn outfit named Law Cash, have popped up to provide upfront cash to plaintiffs hoping for big legal settlements.

The litigation surrounding mesh implants is a lucrative niche. These so-called mass tort cases, some of which began six years ago when problems with the implants started to arise, encompass claims brought by tens of thousands of women who say they were harmed by the same products.

Millions of women worldwide received mesh implants. They are used to correct a condition called pelvic organ prolapse, which occurs when a woman’s organs fall and press against her vagina because of weakened pelvic muscles. That causes urinary and other problems. The mesh reinforces the pelvic wall.

But many women complained that the implants caused problems such as bleeding and discomfort during sex.

Litigation against the implants’ manufacturers, including Boston Scientific and Johnson & Johnson, proliferated. There are more than 100,000 plaintiffs in federal court alone. Many more are involved in litigation at the state level or outside the United States.

Representatives of Boston Scientific and Johnson & Johnson said they stood by the quality of their products. The mesh manufacturers have set aside more than $3 billion to cover potential mesh-related settlements.

Not all plaintiffs are equal. Some law firms — which are paid a percentage of any settlements — realized that women with the implants still in their bodies tended to receive smaller settlements than those who had them taken out.

“Defendants have offered next to nothing to settle cases involving mesh products that have not been removed,” Ms. Plummer’s lawyers at McSweeney Langevin, a small Minneapolis personal injury firm, wrote in a letter advising her to get the implant taken out.

Rhett McSweeney, a co-founder of the law firm, said in a statement that the firm never forced clients to undergo unnecessary surgery and “never directed a client to a particular doctor.”

Plaintiffs’ firms turned to marketers to recruit clients. Women with mesh implants said they soon started receiving torrents of unsolicited phone calls, some originating overseas. The women said they didn’t know how these marketers had found them and seemed to know their medical histories.

“I think my privacy was breached,” said Jennifer Godsoe, 66, who lives in Cumberland, Me. “The more I think about it, the more upset I get.”

Some women had vague memories of answering an online ad about mesh problems. The only thing linking some other women was that they previously had the same doctors, court records show.

Women who took the marketing bait were connected to doctors willing to perform the mesh-removal surgery — although that process remains murky. One critical player was Surgical Assistance, a Florida company led by Wesley Blake Barber, which acted as a middleman between the women, doctors and funding companies. Mr. Barber’s lawyer declined to comment.

In a deposition last summer, Mr. Barber outlined how the company had lined up doctors in Florida and Georgia to perform the surgery. In one online ad, an actor in a white lab coat assures women suffering from their mesh implants that relief is near. By calling a toll-free number, the women will be set up with a “network of qualified surgeons” who remove the mesh without requiring upfront payments.

Women who opted for surgery were flown to Florida and Georgia, put up in motels and sent to walk-in clinics, court filings show. The women generally didn’t meet the doctors who would be operating on them until shortly before the procedure. Before going under the knife, few women got a second opinion.

Dan Christensen, a lawyer who ran MedStar Funding, which financed mesh removal surgery, said in an interview that it was “ludicrous” to argue that women had undergone unnecessary surgery.

“You have to have a doctor willing to put his license on the line,” he said. “Why jeopardize your license?”

$14,000 a Day

The work was lucrative. Doctors stood to make $14,000 a day.

Doctors sometimes churned through four or five removals in a day. Each procedure typically cost about $21,000, according to lawsuits brought by women against the mesh manufacturers. Of that, doctors pocketed roughly $3,500 per surgery; most of the rest went to the medical centers where the surgery took place.

Law Cash offered Danette Charnetzky, a hospice worker in Waynesburg, Ohio, financing for a removal surgery in December 2014. Ms. Charnetzky, another McSweeney client, agreed to pay the money back, at a double-digit interest rate, if the litigation was successful. Within a week, she and her husband were on a plane to a surgical center in a Florida strip mall. The process was a terrifying blur.

“I wish I could have changed my mind, but we were already there,” said Ms. Charnetzky, 49, who hasn’t received any money from the pending litigation against the mesh manufacturer. “I just prayed for the best.”

She got the worst — or something close to it. Ms. Charnetzky said she had needed two more procedures to repair scar tissue left by the Florida surgery.

Rhonda Espeland, 63, who was living in Arizona, also had a bad experience. Since her mesh implant was removed in January 2015, she has developed incontinence. “I may need another surgery,” she said.

The bladder problems have left Ms. Espeland unable to work, and she hasn’t received any money from litigation against her mesh manufacturer. Boxes of diapers are regularly delivered to her door.

The doctor who performed her surgery — and similar procedures on hundreds of others — was Earle M. Pescatore. In March 2014, around the time that he started doing lots of procedures, Mr. Pescatore and his wife filed for bankruptcy, citing liabilities of $1.5 million, including $38,000 they owed to the Internal Revenue Service, according to court filings. Dr. Pescatore said in a deposition that he had little memory of women he operated on.

“Any treatment that Dr. Pescatore provided would have been medically necessary,” his lawyer, Mark DiCowden, said.

While studies have shown that up to 15 percent of women with mesh implants will encounter problems, removing the mesh is not always recommended. Taking it out is more complicated than inserting it because the mesh is made of fiber that is designed to bond with tissue.

Many of the women who got the surgery had limited or no health insurance. They rarely discussed the surgery with their primary care physicians before arriving at the clinics. Some said they had felt rushed into getting surgery.

Dr. Victor Nitti, a surgeon specializing in complex pelvic issues at NYU Langone Health in New York, said serious mesh problems should be addressed with surgery. But, he said, “scaring a patient who has limited to no symptoms into removal is just dangerous and irresponsible.”

Dr. Nitti said he had grown concerned about such scare tactics after some patients told him that they had been contacted by marketers.

Funding Machine

A handful of specialized finance firms funded the surgery that Ms. Plummer, Ms. Espeland and other women got. Court filings show that the two main players are Law Cash and Banyan Finance of Boca Raton, Fla., and that the firms charge double-digit interest rates.

Ross Elgart, Banyan’s chief executive, did not respond to requests for comment.

Lew Fidler, Law Cash’s general counsel, said financing surgical procedures such as Ms. Plummer’s is a small portion of the company’s business. He said the firm, which typically provides cash advances to help plaintiffs pay for everyday expenses, ensures that each surgery is necessary.

“I feel for anyone who didn’t get the outcome they were looking for, but we are not doctors,” Mr. Fidler said. “We don’t substitute our judgment for a licensed physician.”

Law Cash, like other firms, is paid back for a surgical advance only if the person gets a settlement. The firms contend that high interest rates cover the risk that some borrowers will never collect settlements. Some women, however, said the high interest rates had never fully been explained to them.

As a result of those steep interest rates, plaintiffs who do collect settlements see much of the money go to the financing firms. Another large slice goes to their lawyers.

Medical funding for personal injury litigants was a topic of discussion Friday in Las Vegas at the mass tort industry’s big annual conference, titled “Mass Torts Made Perfect.” Law firms are eyeing mesh used to treat hernias as the next gold mine.

The industry has grown thanks in part to a gusher of money from mainstream financial institutions. Law Cash gets funding from DZ Bank, Germany’s second-largest bank, and Melody Capital Partners, a hedge fund with $1.8 billion in assets.

McSweeney Langevin, which has represented more than 1,000 women in mesh litigation, got backing from EJF Capital, a Virginia hedge fund with $10 billion in assets, according to corporate records.

Many of McSweeney’s clients initially were signed up by a now-defunct law and marketing firm, Alpha Law. The Washington firm had signed up 14,000 women for the mesh litigation. Its unusual role in the litigation was the subject of a series of Reuters articles.

The industry tries to keep the network of marketers and financiers out of sight — and some participants have refused to answer questions in depositions, citing their Fifth Amendment right against self-incrimination.

“People are claiming the Fifth and so on and so forth,” said Magistrate Judge Cheryl Eifert in West Virginia, who is hearing one of the mesh cases in federal court. “They don’t have to talk about necessarily how much money they make, per se, but if someone would just give them an idea of how the arrangement works. But nobody’s willing to do that.”

Mr. Barber of Surgical Assistance, for example, asserted the privilege nearly two dozen times in a deposition.

Swollen Like Balloons

Jerri Plummer never figured out whom Yolanda worked for. But in December 2014, Dr. Whitney Shoemaker performed the implant-removal surgery. Until the day of the operation, Ms. Plummer had never spoken to Dr. Shoemaker. Her lawyer declined to comment.

Hours after Ms. Plummer went under the scalpel, she said, she was hustled back to a Hampton Inn just off the freeway, with a catheter sticking out of her side. The next day, a nurse arrived at the motel, removed the catheter and put her in a taxi to the airport.

Soon after she arrived home in Arkansas, she said, complications developed. Her legs swelled like balloons. Her stomach seized up. Ms. Plummer went to her original doctor for help, she said. He informed her that the damage was irreversible. Worse, she said in court records, he told her that there had been no need for the removal surgery.

Before the surgery, Ms. Plummer loved to take walks with her two pit bulls and to eat with her husband at Red Lobster. Now chronic incontinence forces her to wear diapers all day and has left her too worried about wetting herself to venture outside.

With the help of a local lawyer, James R. Baxter, she is suing Law Cash; Dr. Shoemaker; Mr. Barber and his firm, Surgical Assistance; and lawyers at the McSweeney firm.

Mr. McSweeney declined to comment on the lawsuit. His firm is trying to get Ms. Plummer’s lawsuit moved from federal court into private arbitration, where there is no judge or jury. In his statement, he said the firm “had no role” connecting clients with surgical funders like Law Cash or Banyan Finance.

The law firm now has clients sign a waiver that advises them that cash advances to pay for surgery “are terrible loans with extremely high interest rates.”

Ms. Plummer said she had never received such a warning. She feels that she was victimized twice — first by the mesh manufacturer and then by her lawyers and doctor. “I was taken advantage of through this whole process,” she said.

https://www.nytimes.com/2018/04/14/business/vaginal-mesh-surgery-lawsuits-financing.html

Would Americans Accept Putting Health Care on a Budget?

by Austin Frakt - NYT - April 16, 2018

If you wanted to get control of your household spending, you’d set a budget and spend no more than it allowed. You might wonder why we don’t just do the same for spending on American health care.

Though government budgets are different from household budgets, the idea of putting a firm limit on health care spending is far from unknown. Many countries, including Canada, Switzerland and Britain, pay hospitals entirely or partly this way. 

Under such a capped system, called global budgeting, a hospital has an incentive to deliver less care — including reducing hospital admissions — and to increase the efficiency of the care it does deliver.

Capping hospital spending raises concerns about harming quality and access. On these grounds, hospital executives and patient advocates might strongly resist spending constraints in the United States.

And yet some American hospitals and health systems already operate this way, including Kaiser Permanente and the Veterans Health Administration. To address concerns about access and quality, these programs are usually paired with quality monitoring and improvement initiatives.

That brings us to Maryland’s experience with a capped system. The evidence from the state is far from conclusive, but this is a weighty and much-watched experiment for health researchers, so it’s worth diving into the details of the latest studies. 

Starting in 2010 with eight rural hospitals, and expanding its plan in 2014 to the state’s other hospitals, Maryland set global budgets for hospital inpatient and outpatient services, as well as emergency department care. Each hospital’s budget is based on its past revenue and encompasses all payers for care, including Medicare, Medicaid and commercial market insurance. Budgets for hospitals are updated every year to ensure that their spending grows more slowly than the state’s economy.

Because physician services are not part of the budgets, there is an incentive to provide more physician office visits, including primary care. According to some reports, Maryland hospitals are responding to this incentive by providing additional support outside their walls to patients who have chronic illnesses or who have recently been discharged from a hospital. Greater use of primary care by such patients, for example, could reduce the need for future hospital admissions.

In 2013, early results found, rural hospital admissions and readmissions were both down from their levels before the system was introduced.

In the first three years of the expanded program, revenue growth for Maryland’s hospitals stayed below the state-set cap of 3.58 percent, saving Medicare $586 million. Spending was lower on hospital outpatient services, including visits to the emergency department that do not lead to hospital admissions. In addition,preventable health conditions and mortality fell.

According to a new report from RTI, a nonprofit research organization, Maryland’s program did not reap savings for the privately insured population (even though inpatient admissions fell for that group). However, the study corroborated the impressive Medicare savings, driven by a drop in hospital admissions. In reaching these findings, the study compared Maryland’s hospitals with analogous ones in other states, which served as stand-ins for what would have happened to Maryland hospitals had global budgeting not been introduced.

But a recent study, published in JAMA Internal Medicine, was decidedly less encouraging.

Led by Eric Roberts, a health economist with the University of Pittsburgh, the study examined how Maryland achieved its Medicare savings, using data from 2009-2015. Like RTI’s report, it also compared Maryland hospitals’ experience with that of comparable hospitals elsewhere.

However, unlike the RTI report, Mr. Roberts’s study did not find consistent evidence that changes in hospital use in Maryland could be attributed to global budgeting. His study also examined primary care use. Here, too, it did not find consistent evidence that Maryland differed from elsewhere. Because of the challenges of matching Maryland hospitals to others outside of the state for comparison, the authors took several statistical approaches in reaching their findings. With some approaches, the changes observed in Maryland were comparable to those in other states, raising uncertainty about their cause.

A separate study by the same authors published in Health Affairs analyzed the earlier global budget program for Maryland’s rural hospitals. They were able to use other Maryland hospitals as controls. Still, after three years, they did not find an impact of the program on hospital use or spending.

Changes brought about by the Affordable Care Act, which also passed in 2010, coincide with Maryland’s hospital payment reforms. The A.C.A. included many provisions aimed at reducing spending, and those changes could have led to hospital use and spending in other states on par with those seen in Maryland.

A limitation of Maryland’s approach is that payments to physicians are not included in its global budgets. “Maryland didn’t put the state’s health system on a budget — it only put hospitals on a budget,” said Ateev Mehrotra, the study’s senior author and an associate professor of health care policy and medicine at Harvard Medical School. “Slowing health care spending and fostering better coordination requires including physicians who make the day-to-day decisions about how care is delivered.”

A broader global budget program for Maryland is in the works. The U.S. Centers for Medicare and Medicaid Services is reviewing a state application that commits to global budgets for Medicare physician and hospital spending. An editorial that accompanied the JAMA Internal Medicine study noted that a few years may be insufficient time to detect changes. It suggests that five to 10 years may be more appropriate. 

“Maryland hospitals are only beginning to capitalize on the model’s incentives to transform care in their communities,” said Joshua Sharfstein, a co-author of the editorial and a professor at the Johns Hopkins Bloomberg School of Public Health. “This means that as Maryland moves forward with new stages of innovation, there is a great deal more potential upside.” As former secretary of health and mental hygiene in Maryland, he helped institute the Maryland hospital payment approach. 

Global budgets are unusual in the United States, but their intuitive appeal is growing. A California bill is calling for a commission that would set a global budget for the state. And soon Maryland won’t be the only state using such a system. Pennsylvania is planning a similar program for its rural hospitals. 

Can this system work across America? 

How much spending control is ceded to the government is the major battle line in health care politics. An approach like Maryland’s doesn’t just poke a toe over that line, it leaps miles beyond it. 

But the United States has been trying to get a handle on health care costs for decades, spending far more than other advanced nations without necessarily getting better outcomes. A successful Maryland experiment could open an avenue to cut costs through the states, perhaps one state at a time, bypassing the steep political hurdle of selling a national plan.

https://www.nytimes.com/2018/04/16/upshot/would-americans-accept-putting-health-care-on-a-budget.html

The Disappearing Doctor: How
Mega-Mergers Are Changing
the Business of Medical Care

Big corporations — giant retailers and health insurance
companies — are teaming up to become your doctor.

by Reed Abelson and Julie Crewel - NYT - April 7, 2018

Is the doctor in?

In this new medical age of urgent care centers and retail clinics, that’s not a simple question. Nor does it have a simple answer, as primary care doctors become increasingly scarce.

“You call the doctor’s office to book an appointment,” said Matt Feit, a 45-year-old screenwriter in Los Angeles who visited an urgent care center eight times last year. “They’re only open Monday through Friday from these hours to those hours, and, generally, they’re not the hours I’m free or I have to take time off from my job.

“I can go just about anytime to urgent care,” he continued, “and my co-pay is exactly the same as if I went to my primary doctor.”

That’s one reason big players like CVS Health, the drugstore chain, and most recently Walmart, the giant retailer, are eyeing deals with Aetna and Humana, respectively, to use their stores to deliver medical care.

People are flocking to retail clinics and urgent care centers in strip malls or shopping centers, where simple health needs can usually be tended to by health professionals like nurse practitioners or physician assistants much more cheaply than in a doctor’s office. Some 12,000 are already scattered across the country, according to Merchant Medicine, a consulting firm.

On the other side, office visits to primary care doctors declined 18 percent from 2012 to 2016, even as visits to specialists increased, insurance data analyzed by the Health Care Cost Institute shows.

There’s little doubt that the front line of medicine — the traditional family or primary care doctor — has been under siege for years. Long hours and low pay have transformed pediatric or family practices into unattractive options for many aspiring physicians.

And the relationship between patients and doctors has radically changed. Apart from true emergency situations, patients’ expectations now reflect the larger 24/7 insta-culture of wanting everything now. When Dr. Carl Olden began watching patients turn to urgent care centers opening around him in Yakima, Wash., he and his partners decided to fight back.

They set up similar clinics three years ago, including one right across the street from their main office in a shopping center.

The practice not only was able to retain its patients, but then could access electronic health records for those off-site visits, avoiding a bad drug interaction or other problems, said Dr. Olden, who has been a doctor for 34 years.

“And we’ve had some folks come into the clinics who don’t have their own primary care physicians,” he said. “So we’ve been able to move them into our practice.”

Merger Maneuvers

The new deals involving major corporations loom over doctors’ livelihoods, intensifying pressure on small practices and pushing them closer to extinction.

The latest involves Walmart and Humana, a large insurer with a sizable business offering private Medicare plans. While their talks are in the early stages, one potential partnership being discussed would center on using the retailer’s stores and expanding its existing 19 clinics for one-stop medical care. Walmart stores already offer pharmacy services and attract older people.

In addition, the proposed $69 billion merger between CVS Health, which operates 1,100 MinuteClinics, and Aetna, the giant insurer, would expand the customer bases of both. The deal is viewed as a direct response to moves by a rival insurer, UnitedHealth Group, which employs more than 30,000 physicians and operates one of the country’s largest urgent-care groups, MedExpress, as well as a big chain of free-standing surgery centers.

While both CVS and UnitedHealth have large pharmacy benefits businesses that would reap considerable rewards from the stream of prescriptions generated by the doctors at these facilities, the companies are also intent on managing what type of care patients get and where they go for it. And the wealth of data mined from consolidation would provide the companies with a map for steering people one way or another.

On top of these corporate partnerships, Amazon, JP Morgan and Berkshire Hathaway decided to join forces to develop some sort of health care strategy for their employees, expressing frustration with the current state of medical care. Their announcement, and Amazon’s recent forays into these fields, are rattling everyone from major hospital networks to pharmacists.

Doctors, too, are watching the evolution warily.

“With all of these deals, there is so much we don’t know,” said Dr. Michael Munger, president of the American Academy of Family Physicians. “Are Aetna patients going to be mandated to go to a CVS MinuteClinic?”

Constant Changes in Care

Dr. Susan Kressly, a pediatrician in Warrington, Pa., has watched patients leave. Parents who once brought their children to her to treat an ear infection or check for strep, services whose profits helped offset some of the treatments she offered, are now visiting the retail clinics or urgent care centers.

What is worse, some patients haven’t been getting the right care. “Some of the patients with coughs were being treated with codeine-based medicines, which is not appropriate at all for this age group,” Dr. Kressly said.

Even doctors unfazed by patients going elsewhere at night or on weekends are nervous about the entry of the corporate behemoths.

I can’t advertise on NBC,” said Dr. Shawn Purifoy, who practices family medicine in Malvern, Ark. “CVS can.”

Nurse practitioners allow Dr. Purifoy to offer more same-day appointments; he and two other practices in town take turns covering emergency phone calls at night.

And doctors keep facing new waves of competition. In California, Apple recently decided to open up its own clinics to treat employees. Other companies are offering their workers the option of seeking medical care via their cellphones. Investors are also pouring money into businesses aiming to create new ways of providing primary care by relying more heavily on technology.

An Absence of Proof

Dr. Mark J. Werner, a consultant for the Chartis Group, which advises medical practices, emphasized that convenience of care didn’t equal quality or, for that matter, less expensive care.

“None of the research has shown any of these approaches to delivering care has meaningfully addressed cost,” Dr. Werner said.

Critics of retail clinics argue that patients are given short shrift by health professionals unfamiliar with their history, and may be given unnecessary prescriptions. But researchers say neither has been proved in studies.

“The quality of care that you see at a retail clinic is equal or superior to what we see in a doctor’s office or emergency department,” said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School, who has researched the retail clinics. “And while there is a worry that they will prescribe antibiotics to everybody, we see equal rates occurring between the clinics and doctor’s offices.”

Still, while the retail clinics over all charge less, particularly compared with emergency rooms, they may increase overall health care spending. Consumers who not long ago would have taken a cough drop or gargled with saltwater to soothe a sore throat now pop into their nearby retail clinic for a strep test.

Frustration with the nation’s health care system has fueled a lot of the recent partnerships. Giant companies are already signaling a desire to tackle complex care for people with a chronic health condition like diabetes or asthma.

“We’re evolving the retail clinic concept,” said Dr. Troyen A. Brennan, the chief medical officer for CVS. The company hopes its proposed merger with Aetna will allow it to transform its current clinics, where a nurse practitioner might offer a flu shot, into a place where patients can have their conditions monitored. “It requires new and different work by the nurse practitioners,” he said.

Dr. Brennan said CVS was not looking to replace patients’ primary care doctors. “We’re not trying to buy up an entire layer of primary care,” he said.

But people will have the option of using the retail clinic to make sure their hypertension or diabetes is well controlled, with tests and counseling provided as well as medications. The goal is to reduce the cost of care for what would otherwise be very expensive conditions, Dr. Brennan said.

If the company’s merger with Aetna goes through, CVS will initially expand in locations where Aetna has a significant number of customers who could readily go to CVS, Dr. Brennan said.

UnitedHealth has also been aggressively making inroads, adding a large medical practice in December and roughly doubling the number of areas where its OptumCare doctors will be to 75 markets in the United States. It is also experimenting with putting its MedExpress urgent care clinics into Walgreens stores.

Big hospital groups are also eroding primary care practices: They employed 43 percent of the nation’s primary care doctors in 2016, up from 23 percent in 2010. They are also aggressively opening up their own urgent care centers, in part to try to ensure a steady flow of patients to their facilities.

HCA Healthcare, the for-profit hospital chain, doubled its number of urgent care centers last year to about 100, according to Merchant Medicine. GoHealth Urgent Care has teamed up with major health systems like Northwell Health in New York and Dignity Health in San Francisco, to open up about 80 centers.

“There is huge consolidation in the market right now,” said Dr. Jeffrey Le Benger, the chief executive of Summit Medical Group, a large independent physician group in New Jersey. “Everyone is fighting for the primary care patient.” He, too, has opened up urgent care centers, which he describes as a “loss leader,” unprofitable but critical to managing patients.

Eva Palmer, 22, of Washington, D.C., sought out One Medical, a venture-backed practice that is one of the nation’s largest independent groups, when she couldn’t get in to see a primary care doctor, even when she became ill. After paying the annual fee of about $200, she was able to make an appointment to get treatment for strep throat and pneumonia.

“In 15 minutes, I was able to get the prescriptions I needed — it was awesome,” Ms. Palmer said.

Patients also have the option of getting a virtual consultation at any time.

By using sophisticated computer systems, One Medical, which employs 400 doctors and health staff members in eight major cities, allows its physicians to spend a half-hour with every patient.

Dr. Navya Mysore joined One Medical after working for a large New York health system, where “there was a lot of bureaucracy,” she said. She now has more freedom to practice medicine the way she wants and focus more on preventive health, she said.

By being so readily available, One Medical can reduce visits to an emergency room or an urgent care center, said Dr. Jeff Dobro, the company’s chief medical officer.

As primary care doctors become an “increasingly endangered species, it is very hard to practice like this,” he said.

Long-Term Lifelines

But more traditional doctors like Dr. Purifoy stress the importance of continuity of care. “It takes a long time to gain the trust of the patient,” he said. He is working with Aledade, another company focused on reinventing primary care, to make his practice more competitive.

One longtime patient, Billy Ray Smith, 70, learned that he needed cardiac bypass surgery even though he had no symptoms. He credits Dr. Purifoy with urging him to get a stress test.

“If he hadn’t insisted,” Mr. Smith said, “it would have been all over for me.” Dr. Purifoy’s nurse routinely checks on him, and if he needs an appointment, he can usually see the doctor that day or the next.

“I trust him 100 percent on what he says and what he does,” Mr. Smith said.

Those relationships take time and follow-up. “It’s not something I can do in a minute,” Dr. Purifoy said. “You’re never going to get that at a MedExpress.”

https://www.nytimes.com/2018/04/07/health/health-care-mergers-doctors.html

Weighing the Pros and Cons of Statins

by Jane Brody - NYT - April 16, 2018

Are you among the 73 million Americans with cholesterol levels that current guidelines suggest should be lowered by taking a statin for the sake of your cardiovascular well-being? Have you and your doctor discussed the pros and cons of statin therapy and whether it is appropriate for your circumstances?

If not, now is the time to do so. Too often, patients are given a prescription with little or no discussion of what the drug can mean for their health, and that affects their willingness to take it or stay on it.

Dr. Seth Martin, a preventive cardiologist at Johns Hopkins Hospital, strongly recommends that taking a statin be a fact-based, collaborative and personalized decision between doctor and patient, following one or more discussions of the individual’s medical and personal concerns.

Maybe you’ve already been prescribed a statin and are among the 45 percent of such patients who never took the medication or who abandoned it within six months, perhaps because you’ve heard scary stories about possible side effects.

If so, I’m not surprised. Bad news about drugs travels fast, and reports of side effects are often exaggerated and rarely presented in a way that is meaningful to those who might be affected. (The same is true for a drug’s benefits, which are often described with statistics that mean little to the average person.) Misinformation, or misinterpretation of factual information, can result in what doctors call the “nocebo” effect — the experience of an anticipated side effect even when the patient is given a dummy pill.

A personal example: After being on a statin for nearly two decades to lower a genetically influenced high cholesterol level, I recently decided to take a drug holiday after reading about how the medication can affect muscle metabolism and sometimes cause muscle pain and damage.

Was the statin, I wondered, and not my age, the reason I was finding it harder to cycle, walk and swim? Could this otherwise valuable medication contribute to my back pain?

“A person’s expectation of the effects of statins can result in the experience of symptoms and relating those symptoms to the drug,” Dr. Martin explained. Thus, I may feel better without the statin even if the drug is not responsible for my symptoms. Regardless of the outcome, I expect to return to the statin lest I succumb to a “premature” heart attack, as my father and grandfather did.

As an international team of researchers pointed out in The Lancet in 2016, “exaggerated claims about side-effect rates with statin therapy may be responsible for its underuse among individuals at increased risk of cardiovascular events. For, whereas the rare cases of myopathy and any muscle-related symptoms that are attributed to statin therapy generally resolve rapidly when treatment is stopped, the heart attacks or strokes that may occur if statin therapy is stopped unnecessarily can be devastating.”

Unlike medications prescribed to treat a symptom or illness, statins are often given to healthy people to prevent a potentially devastating health problem, and the drug must be taken indefinitely to do the most good. Nearly half of Americans with cholesterol levels that put them at high risk of a heart attack or stroke are not taking medication to reduce that risk, according to the Centers for Disease Control and Prevention. Under current guidelines, among people 60 and older, 87 percent of men and 54 percent of women not already taking a statin would be considered eligible for treatment.

There is no question that statins can protect the health of people who have already had a heart attack or stroke (or even angina) and thus face a significant risk of a recurrence that could prove fatal. But many people — especially those who are uncomfortable taking drugs for any reason — resist taking a daily statin if they have no history or symptoms of cardiovascular disease, only a risk of developing them, especially since it has not yet been proven that the drugs help such people live longer.

Furthermore, people correctly regard “risk” as a possibility, not a probability, and vary in the degree of risk they are willing to tolerate. One chance in 100 may be acceptable to one person, while another may regard one chance in 1,000 as too risky.

Doctors define cardiovascular risk as a percentage chance of a heart attack or stroke occurring within the next 10 years based on the presence of well-established risk factors: high cholesterol, high blood pressure, smoking, diabetes, age, gender and race (and, in some cases, family history). You can determine your own risk using the calculator developed by the American College of Cardiology and American Heart Association at cvriskcalculator.com.

If your calculated risk is 7.5 percent or higher, your doctor is likely to suggest you consider taking a statin, although a relatively high cholesterol level may not result in such a recommendation if you have no other heart risk factors. The risk score is meant “to start a conversation, not to write a prescription,” according to Dr. Don Lloyd-Jones, professor of preventive medicine at Northwestern University Feinberg School of Medicine and a spokesman for the heart association.

Let’s say your risk is 19 percent. That means among 100 people with similar risk factors, 19 are likely to have a heart attack or stroke within the next decade. Is that a risk you’re willing to take? Or would you rather reduce your risk by a third by taking a statin? Only you can make that determination, and it should be based on a full understanding of the known benefits and risks of statins, not something you may have heard from a friend or read online.

The current labeling on statin prescriptions doesn’t help matters. In 2012, the Food and Drug Administration ruled that the warnings should include several reversibleside effects: confusion and memory loss, liver problems, increases in blood sugar and muscle weakness, as well as interactions with certain other medications.

But the label doesn’t state how rarely such problems occur, and reading the list of possibilities could scare off some people, especially those already timid about taking a lifelong drug.

The longer someone is on statin therapy, the greater the reduction in the risk of a cardiovascular event. The drug works primarily by lowering blood levels of harmful LDL cholesterol that can otherwise collect inside arteries that feed the heart and brain. It also helps to stabilize existing plaque, lowering the chances that a chunk will break loose and trigger a heart attack or stroke. There are also several different statins available that vary in potency and side effects, and all leading brands are now available as inexpensive generics.

https://www.nytimes.com/2018/04/16/well/weighing-the-pros-and-cons-of-statins.html

Drug Company ‘Shenanigans’ to Block Generics Come Under Federal Scrutiny

by Robert Pear - NYT - April 14, 2018

WASHINGTON — Trump administration officials, seeking ways to lower drug costs, are targeting pharmaceutical companies that refuse to provide samples of their products to generic drug companies, making it impossible to create inexpensive generic copies of a brand-name medicine.

Dr. Scott Gottlieb, the commissioner of the Food and Drug Administration, said recently that drug makers must “end the shenanigans” that prevent competing products from reaching the market.

Generic drug developers need samples of brand-name drugs to show that a generic copy is equivalent to the original. The maneuvers by brand-name drug firms, Dr. Gottlieb said, “frustrate the ability of generic firms to purchase the doses of a branded drug that they need to run their studies.”

The Federal Trade Commission is investigating the practice, which it says can forestall generic competition and “potentially preserve a brand firm’s monopoly indefinitely.”

Federal officials said they were focusing on the anticompetitive practices of brand-name drug makers under the impetus of a vow by President Trump to hold down prices set by drug companies, which he has said are “getting away with murder.”

Legislation to ensure access to drug samples for generic drug manufacturers has broad support in Congress, from Senator Patrick J. Leahy, Democrat of Vermont, on the left to Senator Mike Lee, Republican of Utah, on the right. A similar bill in the House also has diverse backers, including Representatives Peter Welch, Democrat of Vermont, and Mark Meadows, Republican of North Carolina, who is the chairman of the conservative House Freedom Caucus.

Under the bill, a generic drug developer could file a lawsuit, and a federal court could require a brand-name drug maker to provide samples of its product to a generic company “on commercially reasonable, market-based terms.” The court could also award damages if it found that a drug maker had refused to sell samples “without a legitimate business justification.”

Brand-name drug companies make several arguments against the legislation. First, they say, it is not needed. The F.D.A. approved 1,027 generic drugs last year, a record number, and nearly 90 percent of prescriptions are filled with generic medicines, suggesting that generic manufacturers have generally been able to obtain the samples they need, the brand-name companies say.

Second, they say, the bill would be a boon to trial lawyers, giving them an incentive to sue brand-name pharmaceutical companies for damages, which could be worth more than sales of the proposed generic drug.

Finally, they say, the legislation could endanger patients because generic drug developers might not follow the strict safety protocols that the government requires for some brand-name drugs.

But the F.D.A. says that “no additional requirements are needed to protect patient safety” in tests to show the equivalence of generic and brand-name drugs. The “testing typically involves a relatively small number of human subjects and a small number of doses and therefore a relatively low level of risk,” the agency said.

At a time when researchers are using sophisticated science to develop new treatments and cures, the fight over physical samples — a few thousand pills — sounds mundane. But it has huge implications for consumers’ access to affordable medicines.

The F.D.A. says it has received more than 150 inquiries from generic drug companies unable to obtain the samples needed to show that a generic product works the same as a brand-name medicine. Some of the disputes over samples involve drugs that are costly to patients and to the Medicare program and that have experienced sharp price increases in recent years.

“Without generic competition, there is no pressure to drive down the costs of these medications,” the food and drug agency said. Under current law, it said, it cannot compel a brand-name drug manufacturer to sell samples to a generic company.

The Congressional Budget Office estimates that the legislation would save the federal government $3.8 billion over 10 years, mainly because Medicare, Medicaid and other health programs would spend less on prescription drugs. Savings for consumers and private health insurance plans could be much greater.

Lawmakers of both parties pushed for the legislation to be included in a far-reaching budget bill signed by Mr. Trump in February, but it was dropped at the last minute.

Even without action by Congress, generic drug companies say the denial of drug samples needed for testing may violate federal antitrust law because it tends to perpetuate a monopoly for the makers of some brand-name medications. But it typically takes years for courts to resolve such claims.

Mylan, a generic drug company, wants to obtain samples to develop a generic version of Revlimid, a brand-name cancer medicine sold by Celgene. At a court hearing in Newark in December, Jonathan M. Jacobson, a lawyer for Mylan, told a federal district judge that “Revlimid costs patients who are dying $20,000 a month.”

“These are some of the most ill patients in the world,” he said, and “if there were generics on the market, the price would be much lower, and people would live longer.”

Celgene said in court papers that it had no obligation to help a potential competitor and that it had “valid business justifications for declining to sell samples on the terms demanded by Mylan.” Moreover, Celgene said its overriding concern was for the safety of patients.

But Mylan, the generic drug company, said this was no excuse because it had devised safety protocols similar to those followed by Celgene.

The secretary of health and human services, Alex M. Azar II, has repeatedly said that drug prices are too high. The administration, he said, will soon roll out “a whole slate” of proposals to reduce those prices.

Mr. Azar has suggested that private companies — pharmacy benefit managers — should have a role in negotiating prices for drugs under Part B of Medicare. Those drugs are typically administered by infusion or injection in doctor’s offices and hospital outpatient departments.

https://www.nytimes.com/2018/04/14/us/politics/drug-companies-generic.html