Health Care Reform Articles - January 25, 2019

U.S. healthcare stocks seen maintaining momentum after strong 2018

by Lewis Krauskopf - Reuters - January 14, 2019

NEW YORK (Reuters) - One of the rare market bright spots last year, the U.S. healthcare sector remains a Wall Street darling despite a slow start to 2019. 

As 2019 begins, healthcare .SPXHC is the most favored of the 11 main S&P 500 sectors, according to a Reuters review of ratings from 13 large Wall Street research firms, which recommend how to weigh those groups in investment portfolios.
Healthcare shares overall rose 4.7 percent last year, one of only two S&P 500 sectors, along with utilities, to post positive returns in 2018 as the benchmark index fell 6.2 percent.
Proponents cite the healthcare sector’s reasonable valuations, strong balance sheets and dividend payments among many companies, as well as the group’s upbeat outlook for earnings, which are less susceptible to economic cycles than other businesses.
If economic growth is slowing, some investors are wary of being too invested in cyclical sectors that thrive during an upswing, but do not want to be too defensive either.
“We are trying to find things that skirt both of those two categorizations, and healthcare is a really nice diversified earnings stream,” said Noah Weisberger, managing director for U.S. portfolio strategy at Bernstein.
Such diversity stems from the variety of companies comprising the sector: manufacturers of prescription medicines, makers of medical devices, such as heart valves and knee replacements, health insurers, hospitals and providers of tools for scientific research.
From a stock perspective, that means the sector includes potential fast-growing stocks, such as biotechs that can carry more risk and more reward, or large pharmaceutical companies and others that offer steadier, slower growth.
Investment advisory firm Alan B. Lancz & Associates sold some pharmaceutical holdings late last year that had posted big gains, such as Merck & Co (MRK.N), to move into biotech stocks it believed were undervalued, said Alan Lancz, the firm’s president.
“We have maintained our overweighting, which is unusual for us with a sector that has outperformed so dramatically,” Lancz said. “But mainly there are segments within the sector that still offer opportunity.”
(GRAPHIC: Healthcare is most favored sector on Wall Street - tmsnrt.rs/2HaLYKT)
For 2019, healthcare companies in the S&P 500 are expected to increase earnings by 7.5 percent, ahead of the 6.3 percent growth estimated for S&P 500 companies overall, according to IBES data from Refinitiv.
Health insurer UnitedHealth Group Inc (UNH.N), the sector’s third-largest company by market value, kicks off fourth-quarter earnings season for healthcare on Tuesday.
“Healthcare is one of the few sectors with high quality, above-market growth and it’s relatively immune to the array of macro headwinds that we see out there,” said Martin Jarzebowski, sector head of healthcare for Federated Investors.
Healthcare shares could also benefit from anticipation of increased dealmaking activity after two large acquisitions of biotechs were already announced this year.
Despite healthcare’s outperformance last year, the sector is trading at the same valuation as the S&P 500 - 14.5 times earnings estimates for the next 12 months - whereas healthcare on average has held a premium over the market for the past 20 years, according to Refinitiv data.
The sector also is valued at a discount, by such price-to-earnings measures, to defensive sectors, including consumer staples .SPLRCS, which trades at 16.6 times forward earnings, and utilities .SPLRCU, which trades at 15.8 times.
(GRAPHIC: Healthcare stocks, by the numbers - tmsnrt.rs/2H7Mnxw)
According to the Reuters review of sector weightings, healthcare is followed by financials .SPSY, then technology .SPLRCT. Real estate .SPLRCR ranks as the most negatively rated group.
The healthcare sector has lagged in the early days of 2019, rising less than 1 percent against a 3 percent rise for the S&P 500.
Some investors doubt healthcare will maintain its outperformance. JP Morgan strategists downgraded the sector to “underweight” last month, pointing in part to political rhetoric possibly turning “more negative on healthcare leading up to the 2020 presidential elections.”
The healthcare sector struggled ahead of the 2016 election, with the high U.S. cost of prescription medicines a prominent issue during the presidential campaign. With renewed scrutiny on drug pricing, such concerns linger.

UBS, global growth worries send European shares into the red

The sector could suffer if investors become more optimistic about economic growth and flee defensive stocks, while the popularity of healthcare as an investment could work against it if the trade becomes overly crowded.
“There is risk there,” said Walter Todd, chief investment officer at Greenwood Capital in South Carolina. But given issues affecting other sectors, he said, “when you look around the market...you arrive by default at healthcare, and so I think that’s why a lot of people are interested in the sector.”
https://www.reuters.com/article/us-usa-stocks-healthcare-idUSKCN1P82A6

After Falling Under Obama, America’s Uninsured Rate Looks to Be Rising

by Margot Sanger-Katz - NYT - January 23, 2019

The number of Americans without health insurance plunged after Obamacare started. Now, early evidence suggests, it’s beginning to climb again.
New polling from Gallup shows that the percentage of uninsured Americans inched up throughout last year. That trend matches other data suggesting that health coverage has been eroding under the policies of the Trump administration.
Gallup estimated that the uninsured rate for adults increased by 1.3 percentage points. That would mean an increase of more than three million people without insurance between the first quarter of 2018 and the end of the year. Gallup said this was a four-year high, although a major methodology change a year ago may make such longer-term comparisons less precise.
“There’s no question that some of the reductions in the uninsured rate that we have measured over the course of Obamacare has now been given back,” said Dan Witters, the research director for the survey.

That may not be a surprise given the White House’s approach to health policy. It has consistently criticized the Affordable Care Act. And it has sought to weaken it legally, pulling back on funding to publicize coverage opportunities, and approving policies that make it harder for eligible people to enroll and stay enrolled in state Medicaid programs.
The administration has signaled that the use of certain public health insurance programs, like Medicaid, might count against immigrants applying for green cards. Other, more complex policy changes increased the cost of individual health insurance last year, although prices were on track to fall slightly, on average, this year.
Still, the increase in uninsured Americans could be a new pattern, even for the Trump administration. Although earlier surveys from Gallup and the Commonwealth Fund, a health research group, measured a rising uninsured rate, big government surveys from the census and the Centers for Disease Control and Prevention found coverage rates that were holding steady.
The employment picture has continued to improve during the Trump presidency, and more Americans have found full-time jobs. That trend is usually associated with improvements, not declines, in health coverage.
Data about initial sign-ups for last year’s Obamacare marketplace plans showed a decline of about 1.2 million people. There is less information about the number of Americans who buy their insurance directly from health insurers. But a report from the Department of Health and Human Services suggested that about one million fewer people bought coverage in 2017 than 2016, largely because of price, and declines may have continued last year.

The federal government has allowed states to impose new barriers to Medicaid, and enrollment declines appear to be occurring there, too. States have asked people to provide more documentation to enroll, or to verify their eligibility more often, policies that have been shown to depress enrollment.
Two states have imposed work requirements for some users of their programs, with five more about to start. Overall numbers from federal reports on Medicaid enrollment show 1.5 million fewer people insured through the program from December 2017 to October 2018, the most recent month with available data. The biggest declines came in Tennessee and Texas, which have begun to reconsider eligibility more often. In both states, Medicaid numbers fell by 11 percent.
Eliot Fishman, the policy director at the consumer health advocacy group Families USA and a former Medicaid official, has been tracking the Medicaid numbers. He said the big drops in several states were largely the result of state policy changes that might have attracted more federal pushback under the Obama administration.
“There’s a number of states where you’re looking at a high proportion of Medicaid enrollment and a high proportion of the state’s population losing health insurance flying under the radar,” he said. “That has public health effects.”
Several states will expand their Medicaid programs this year, after voters approved ballot initiatives, so further declines from work requirements and other policies in some states may be balanced out by gains in coverage elsewhere.
Measuring the precise shape of any coverage declines may take some time. It will be several months before results from the federal surveys on 2018 are final. Benjamin Sommers, an associate professor at the Harvard School of Public Health, who has worked extensively with Gallup data, said he was waiting for more research before drawing firm conclusions about how many Americans had lost coverage, given the recent changes in the Gallup survey. (After years of conducting its surveys by telephone, Gallup in 2018 changed to mail and internet responses.)
“It’s suggestive, and definitely merits us digging deeper into this,” he said.
https://www.nytimes.com/2019/01/23/upshot/rate-of-americans-without-health-insurance-rising.html

 Health-care industry preps offense against Medicare-for-All 
by Paige Winfield Cunningham - The Washington Post - January 22, 2019

With support growing for universal health coverage, just what does "single-payer" mean? Here's the breakdown. (Jenny Starrs, Danielle Kunitz/The Washington Post)

Democrats newly in control of the House are sending quivers of fear throughout the U.S. health-care industry as they begin advancing Medicare-for-All measures that could result in a big financial blow to private health insurers, hospitals and doctors.
Industry leaders — who have united to fight what they view as a threat to the country’s existing patchwork system of public and private payers — told me they're planning to ramp up advertising and lobbying efforts this year to argue against such a dramatic overhaul of the health insurance system, saying education is all that’s needed to turn more Americans against the idea.
“I get the sense that progressives have gotten a total free pass. There is no pushback against those calling for Medicare-for-All,” said David Merritt, executive vice president for public affairs at America’s Health Insurance Plans.
“The people who are going to be impacted, like patients, like doctors who treat patients, like insurance plans that cover patients — no one has started to say in an organized and sustained way, ‘Here are the consequences if we do go down that path,' ” Merritt said.
Last summer, AHIP joined with the Federation of American Hospitals, the American Medical Association, the Pharmaceutical Research and Manufacturers of America, and 14 other groups in what they’ve named the Partnership for America’s Health Care Future.
Their mission: to convince Americans that a single-payer system would deeply hurt their access to vital health-care services. Their aim is to dissuade Democrars from fully embracing Medicare-for-All -- once a progressive hobby horse that has moved mainstream as House Democrats announced they'll hold hearings on such proposals this year.
Their argument goes like this: If the government is the sole payer, it could deny coverage for certain services and demand lower rates from providers, potentially forcing them out of business altogether. A single-payer option, especially one as dramatic as the Medicare-for-All plan offered by Sen. Bernie Sanders (I-Vt.), would also cost the government considerably more money, probably requiring tax hikes.
“It became quite clear [Medicare-for-All] was something a small but increasing number of policymakers were pushing for,” said Jeff Cohen, executive vice president for public affairs at the Federation of American Hospitals. “And so we all looked at each other and said, ‘We might have a problem on our hands if we’re not doing the education and awareness campaign we need to be doing.' ”
As the Intercept detailed in November, a leaked planning document from the group says its campaign is intended to “change the conversation around Medicare for All” and “minimize the potential for this option in health care from becoming part of a national political party’s platform in 2020.”
The U.S. Chamber of Commerce has also vowed to use its deep lobbying pocket to fight single-payer proposals. Government-run health care “just doesn’t work,” Chamber CEO Thomas Donohue said in his annual “State of American Business” address this month. “We’ll use all our resources to make sure that we’re careful there.”

It’s certainly true there’s an unprecedented level of enthusiasm among Democrats for making publicly backed health insurance more widely available. About half of all Democrats in contested House races backed a Medicare-for-All approach, according to a count by National Nurses United.
Fifteen Senate Democrats and 124 House Democrats have signed onto Medicare-for-All bills. Included among them are all four members of Congress who have so far announced presidential bids: Sens. Elizabeth Warren of Massachusetts, Kirsten Gillibrand of New York, Kamala Harris of California and Rep. Tulsi Gabbard of Hawaii. Aides to Harris, who was the first senator to sign onto Sanders's bill, said Medicare-for-All will be included in her campaign platform, per my colleague Jeff Stein.
And polls have found a majority of voters favor the idea of Medicare-for-All — although support fades somewhat when respondents hear arguments that it could give the government too much control over health-care or require more taxes.
But industry leaders contend that Medicare for All didn’t sell nearly as well on the campaign trail as some have imagined.
They point to the most competitive House districts, where the winning Democrats largely didn’t run on — or even support — the idea. Of the the 35 Democrats who seized Republican-held seats, 23 didn’t support Medicare-for-All, and seven more who did support it nonetheless didn’t run on it, according to an analysis by Forbes Tate Partners, a public affairs and lobbying firm founded by former Democratic administration officials that is managing part of the coalition.
Highly publicized candidates such as freshmen Reps. Alexandria Ocasio-Cortez of New York and Rashida Tlaib of Michigan embraced Medicare for All. But in moderate districts and swing states, Democrats such as Reps. Lauren Underwood of Illinois and Donna Shalala of Florida kept the idea of a single-payer system an arm's length away.
Republicans helped contribute to the narrative that Democrats are overwhelmingly in favor of Medicare-for-All, running ads on the issue against even candidates that hadn’t endorsed it, as my colleague Dave Weigel reported in the fall.

Some backstory here: At the start of the cycle, many Rs thought that D voters would back only the most left-wing candidates in primaries. In nearly every swing race, they didn't. Solution: Pretend they did!

— Dave Weigel (@daveweigel) September 26, 2018

There are a variety of Medicare-for-All ideas being floated by lawmakers, ranging from a dramatic shift to a single-payer system to merely lowering the age for Medicare eligibility. The partnership is opposed to virtually any idea that would result in fewer people getting private coverage — for the obvious reasons that the government would then pay providers and insurers a lot less money.
But they also make this point: Why upend a system in which 92 percent of Americans already have health coverage to expand it to the 8 percent who don’t? Merritt and Cohen said they’re pushing Congress to focus on expanding coverage to the remaining uninsured while advancing measures to improve care and cut costs for everyone else.
“It’s not sexy, it doesn’t fit on a bumper sticker, and perhaps it’s hard to rally around,” Cohen said. “But there are things Congress can do that will begin to chip away at the anxieties people currently have regarding their health care. There are things people will see materially, sitting at home at the kitchen table, I think we shouldn’t discount.”
  https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2019/01/22/the-health-202-health-care-industry-preps-offense-against-medicare-for-all/5c44c7701b326b29c3778c54/?utm_term=.0429ecbdb83f

Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Health

Brian Castrucci and John Auerbach - Health Affairs - January 16, 2019

Until recently, efforts to improve the health of Americans have focused on expanding access to quality medical care. Yet there is a growing recognition that medical care alone cannot address what actually makes us sick. Increasing health care costs and worsening life expectancy are the results of a frayed social safety net, economic and housing instability, racism and other forms of discrimination, educational disparities, inadequate nutrition, and risks within the physical environment. These factors affect our health long before the health care system ever gets involved.
Hospitals and health care systems have started to address these social determinants of health through initiatives that buy food, offer temporary housing, or cover transportation costs for high-risk patients. The prevalence and initial success of these efforts are clear in headlines such as: "What Montefiore’s 300% ROI from Social Determinants Investments Means for the Future of Other Hospitals," "Social Determinants of Health Gain Traction as UnitedHealthcare and Intermountain Build New Programs," and "How Addressing Social Determinants of Health Cuts Healthcare Costs." But when you take a closer look, these articles aren’t about improving the underlying social and economic conditions in communities to foster improved health for all – they’re about mediating patients’ individual social needs. If this is what addressing the social determinants of health has come to mean, not only has the definition changed, but it has changed in ways that may impede efforts to address those conditions that impact the overall health of our country.
In 2008, the World Health Organization’s Commission on the Social Determinants of Health defined those determinants  as the “conditions in which people are born, grow, live, work, and age” and “the fundamental drivers of these conditions.” This term prioritizes a broad, community-wide focus on the underlying social and economic conditions in which people live, rather than the immediate needs of any one individual. While health care leaders have realized that programs to buy food, offer temporary housing, or cover ridesharing programs are less expensive than providing repeat health care services for their highest cost patients, such patient-centered assistance does not improve the underlying social and economic factors that affect the health of everyone in a community.  While targeted, small-scale social interventions provide invaluable assistance for individual patients, we must also remain focused on the social determinants that perpetuate poor health at the community level.
A recent speech by Health and Human Services (HHS) Secretary Alex Azar highlighted the dichotomy between individual-level “social needs” and community-level “social determinants.” Secretary Azar emphasized that factors like housing and transportation have an important effect on Americans’ health. He asked rhetorically, "How can someone manage diabetes if they are constantly worrying about how they’re going to afford their meals each week? How can a mother with an asthmatic son really improve his health if it’s their living environment that’s driving his condition?” And he appropriately noted that we “can’t simply write a prescription for healthy meals, a new home, or clean air.”
In his discussion of how to address health-related community conditions, Secretary Azar, like a growing number in health care, focused on the social needs of individual patients. In his speech, he recounted the success of the Accountable Health Communities model, noting that “participating providers screen high utilizers of healthcare services for food insecurity, domestic violence risk, and transportation, housing, and utility needs. If needed, patients are set up with navigators, who can help determine what resources are available in the community to meet the patient’s needs.” He even went so far as to suggest that Medicaid may allow hospitals to pay for housing, healthy food, and other services. But in order to improve our nation’s health, we must look beyond “superutilizers,” Medicaid recipients, and those who are already sick. Secretary Azar appropriately noted that health care navigators “can help determine what resources are available in [a] community.”  However, while growing in popularity, health care navigators and similar enhancements to health care can’t actually change the availability of resources in the community. They can’t raise the minimum wage, increase the availability of paid sick leave, or improve the quality of our educational system. These are the systemic changes that are necessary to truly address the root causes of poor health.
 Even if they don’t address broader social conditions within patients’ communities, health providers’ efforts to meet individuals’ non-medical needs are praiseworthy and potentially life-saving. In Chicago, Advocate Health Care saved nearly $5 million by screening for malnutrition risk factors and establishing an enhanced nutrition care program.  In Boston, a six-months-or-longer, home-delivered meals benefit for dual Medicare-Medicaid eligible patients was associated with significant reductions in emergency room visits and overall health care cost savings. An initiative to link WellCare Medicaid and Medicare Advantage plan members to social service organizations resulted in an annual savings of $2,400 per person. In Hennepin County, Minnesota, millions of dollars were saved by offering unconventional services to patients with complex health, housing, and social service needs. The University of Illinois at Chicago reduced costs by 18 percent by identifying homeless patients who could benefit from housing support. These are just a few of the studies and reports documenting the health care system’s efforts to go beyond its own walls to improve health outcomes, decrease consumption of medical services, and reduce costs.
While individual-level interventions are beneficial, characterizing them as efforts to address social determinants of health conveys a false sense of progress. These strategies mitigate the acute social and economic challenges of individual patients, but they do so without implementing long-term fixes.  They are often limited to a small segment of the population – those who are in the worst health and have the greatest health care costs. Meanwhile, those patients who do not rank among the “sickest and most expensive” are ignored.
Policy makers have the power to address the social and economic conditions that affect community health. For example, in Kansas City, Missouri, voters recently approved a ballot initiative empowering health inspectors to respond to tenant complaints about a broad range of housing conditions, funded by an annual fee of $20 per unit for landlords. Earlier this year, the City Council of Alexandria, Virginia voted to raise the city’s meal tax to fund affordable housing. These communities and others like them have embraced the need for policy intervention to improve the social determinants of health for their citizens.
National initiatives offer states and local communities a roadmap for identifying and implementing gold-standard strategies to improve public health. In an initiative known as Health Impact in 5 Years (or HI-5), the Centers for Disease Control and Prevention (CDC) developed a list of 14 evidence-based policies to improve population health. CityHealth, an initiative of the de Beaumont Foundation and Kaiser Permanente, provides city leaders with a package of nine policy solutions that can help millions of people live longer and better lives.
Hospitals and health systems may be stepping up by referring a patient with mold in his or her apartment to a tenant’s right advocate, feeding a patient who needs food, or providing an on-site exercise program. But these interventions do not address the mold in that patient’s next-door neighbor’s apartment, community access to healthy food, or the availability of low-cost exercise options.  These community-level changes can only be made through policy action. While they work to address their patients’ immediate needs, hospitals and health systems would do well to recognize and support community-level policy actions.
This isn’t about picking one approach over another – we need social and economic interventions at both the community and individual levels. We often discuss health using the metaphor of a stream, with upstream factors bringing downstream effects. Social needs interventions create a middle stream (Exhibit 1). They are further upstream than medical interventions, but not yet far enough. Social needs are the downstream manifestations of the impact of the social determinants of health on the community.  Improvements in our nation’s health can be achieved only when we have the commitment to move even further upstream to change the community conditions that make people sick. The demand for social needs interventions won’t stop until the true root causes are addressed. This should ring especially true as the movement to Accountable Health Communities and value-based care gains momentum. Any success these new payment structures enjoy will be short-lived if the underlying social conditions in the communities where they work remain unchanged. While the allure of short-term economic gains from mediating patients’ social needs nearly ensures media and stakeholder attention, the incentives to advance policy, legislation, and regulation to improve health more broadly are often less clear. Redefining the meaning of “social determinants” to be mostly or only about the immediate social needs of expensive patients makes it harder to focus on the systemic changes necessary to address root causes of poor health. 

In 2003, David Kindig and Greg Stoddart offered a comprehensive definition of population health. Twelve years later, Kindig expressed concern that the use of the term had grown too broad, writing that it’s “growing use, most notable in the Triple Aim and in clinical settings, has resulted in a conflicting understanding of the term today.” Is the term “social determinants” heading for a similar fate? If we, even inadvertently, imply that the social determinants of health can be solved by offering Uber rides to individual patients or by deploying community health navigators, it will be challenging, if not impossible, for public health advocates to make the case for proven policies like alcohol sales control, complete streets, and healthy food procurement.
Words matter.  Common definitions ensure that we understand each other. When health care leaders and public health officials use “social determinants of health” to mean different things, it becomes more difficult for us to engage meaningfully with community partners, who will struggle to differentiate between these complementary but different approaches. This may seem like semantics, but when we use this term too broadly, we risk losing the specificity needed when calling on partners to make far-reaching social change, and we weaken our ability to implement the community-level efforts necessary to improve community health. And, ultimately, that doesn’t help any of us get healthier.
https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/?

Donald Trump Did Something Right

His administration has ordered hospitals to reveal their prices. If patients and politicians pay attention, this could be a big deal.

By Elisabeth Rosenthal - NYT - January 21, 2019

As Donald Trump was fighting with Congress over the shutdown and funding for a border wall, his administration implemented a new rule that could be a game-changer for health care.
Starting this month, hospitals must publicly reveal the contents of their master price lists — called “chargemasters” — online. These are the prices that most patients never notice because their insurers negotiate them down or they appear buried as line items on hospital bills. What has long been shrouded in darkness is now being thrown into the light.
For the moment, these lists won’t seem very useful to the average patient — and they have been criticized for that reason. They are often hundreds of pages long, filled with medical codes and abbreviations. Each document is an overwhelming compendium listing a rack rate for every little item a hospital dispenses and every service it performs: A blood test for anemia. The price of lying in the operating suite and recovery room (billed in 15-minute intervals). The scalpel. The drill bit. The bag of IV salt water. The Tylenol pill. No item is too small to be bar coded and charged.
But don’t dismiss the lists as useless. Think of them as raw material to be mined for billing transparency and patient rights. For years, these prices have been a tightly guarded industrial secret. When advocates have tried to wrest them free, hospitals have argued that they are proprietary information. And, hospitals claim, these rates are irrelevant, since — after insurers whittle them down — no one actually pays them.

Of course, the argument is false, and our wallets know it.
First of all, hospitals routinely go after patients without insurance or whose insurer is not in their network. When Wanda Wickizer had a brain hemorrhage in 2013, a Virginia hospital billed her $286,000 after a 20 percent “uninsured” discount on a hospital bill of $357,000 — the list price, according to chargemaster charges. Medicare would have paid less than $100,000 for her treatment.
Second, those list prices form the starting point for negotiations, allowing hospitals and insurers to take credit for beneficence, when there is none.
I recently received an insurance statement for blood tests that were priced at $788.04; my insurer negotiated a “discount” of $725.35, for an agreed-upon price of $62.69 “to help save you money.” My insurer’s price was around 8 percent of the charge. Since my 10 percent co-payment amounted to $6.27, my insurer happily informed me, “you saved 99 percent.”
Not!
If a supposedly $1,000 TV is “on sale” for $80, it’s not really a discount. It’s an absurd list price.
Just as airlines have been shown to exaggerate flight times so they can boast about on-time arrivals, hospitals set prices crazy high so they can tout their generous discounts (while insurers tout their negotiating prowess).

Another rationale for those prices is just plain greed. Dr. Warren Browner, the chief executive of California Pacific Medicine, describes this as the “Saudi Sheikh problem”: “You don’t really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who’s going to pay full charges,” he said.
But in an era when American patients are expected to be good consumers and are paying more of their bills in the form of co-pays and deductibles, they have a right to the information on list prices. They have a right to make sure they are reasonable.
Although making chargemaster pricing public will not, by itself, reform our high-priced medical system, it is an important first step. Maybe, just maybe, a hospital will think twice before charging a $6,000 “operating room fee” for a routine colonoscopy if its competitor down the street is listing its price at $1,000. Making this information public should bring list prices more in line with what is actually paid by an insurer, a far better measure of value.
And while the lists are far from user-friendly, researchers and entrepreneurs can now create apps to make it easier for patients to match procedures to their codes and crunch the numbers. With access to list prices on your phone, you could reject the $300 sling in the emergency room and instead order one for one-tenth of the price on Amazon. You could see in advance the $399 rate your hospital charges for each allergen it applies in a skin test and avoid the $48,000 allergy test — with an $8,000 deductible.
As a next step, regulators should insist that these prices be easily accessible on hospitals’ home pages — perhaps in the place of “PAY YOUR BILL NOW” — and translated into plain English. Seema Verma, the head of the Centers for Medicare and Medicaid Services, has suggested that she may well do so.
Patients can help, too: Check out your hospital’s price list. If it’s not detailed or complete enough, demand more. For discrete items, like an M.R.I. of the brain or a vitamin D blood test, take the trouble to scan the chargemaster for the item. Reject an overpriced procedure (even if your insurer is paying the bulk of the bill) and take your business elsewhere.
Justice Louis Brandeis famously said, “Sunlight is said to be the best of disinfectants; electric light the most efficient policeman.” But, in this case, the reform will work only if people take the trouble to look — and to act — now that the lights are turned on.
https://www.nytimes.com/2019/01/21/opinion/trump-hospital-prices.html

Trump Proposals Could Increase Health Costs for Consumers

by Robert Pear - NYT - January 21, 2019

WASHINGTON — Consumers who use expensive brand-name prescription drugs when cheaper alternatives are available could face higher costs under a new policy being proposed by the Trump administration.
The proposal, to be published this week in the Federal Register, would apply to health insurance plans sold under the Affordable Care Act.
Health plans have annual limits on consumers’ out-of-pocket costs. Under the proposal, insurers would not have to count the full amount of a consumer’s co-payment for a brand-name drug toward the annual limit on cost-sharing. Insurers would have to count only the smaller amount that would be charged for a generic version of the drug.
For example, if a consumer filled a doctor’s prescription for a brand-name drug with a $25 co-payment, rather than using a generic medicine with a $5 co-payment, the consumer might get credit for only $5 in out-of-pocket spending. Consumers would have to spend more of their own money before reaching the annual limit on out-of-pocket costs.

In addition, insurers would not have to count the value of coupons and other financial assistance provided to consumers by drug manufacturers if generic alternatives were available. This change could significantly increase consumers’ out-of-pocket costs for some of the more expensive prescription drugs and has prompted protests from groups representing patients.
President Trump has repeatedly vowed to reduce drug prices and to lower out-of-pocket drug costs. But for some consumers, the latest proposal could have the opposite effect.
The proposal highlights a potential conflict between patients with a particular disease, who may benefit from the use of coupons, and other consumers more generally. Economists say that coupons can raise health care costs by encouraging people to use more expensive drugs.
“The availability of a coupon may cause physicians and beneficiaries to choose an expensive brand-name drug when a less expensive and equally effective generic or other alternative is available,” the Trump administration said in explaining its proposal. “When consumers are relieved of co-payment obligations, manufacturers are relieved of a market constraint on drug prices.”
Moreover, it said, “coupons can add significant long-term costs to the health care system that may outweigh the short-term benefits.”

But Bari Talente, an executive vice president of the National Multiple Sclerosis Society, said, “Many people with M.S. rely on co-pay assistance, even for generic medications.”
In the last few years, she said, generic versions of the drug Copaxone have become available, but even they have high prices. One of the generic medicines costs $60,000 to $65,000 a year, she said.
Carl E. Schmid II, the deputy executive director of the AIDS Institute, a public policy and advocacy organization, said the administration’s proposal could sharply increase out-of-pocket costs, so that a consumer who now pays virtually nothing might have to pay $3,500 a year or more for a drug to treat H.I.V.
“That increases the likelihood that people won’t pick up their drugs, won’t take their drugs,” Mr. Schmid said.
Leyla Mansour-Cole, the policy director of the Diabetes Patient Advocacy Coalition, a nonprofit group, said the Trump administration proposal “caused trepidation” for some patients.
“In theory, co-pay coupons could encourage people to take higher-priced drugs,” Ms. Mansour-Cole said. “In reality, people use them to get the medicines that their doctors prescribe, despite astronomically high deductibles.”
The administration is proposing several other changes that could increase costs for consumers.
Under the proposal, fewer people would qualify for federal subsidies, and those who qualify could be required to spend a larger share of their income on insurance premiums.

In addition, the proposal could lead to a small increase in out-of-pocket costs, which include co-payments and deductibles for doctors’ services and hospital care.
The changes would result from a new method of calculating inflation in health insurance prices — a factor used in computing the amount of premium subsidies and the annual limit on consumers’ out-of-pocket costs.
The Trump administration estimated that the changes would save the government $900 million annually in subsidies in 2020 and 2021 and $1 billion a year in 2022 and 2023. In addition, it predicted that 100,000 fewer people would have coverage through the insurance exchanges created under the Affordable Care Act.
The administration said that some of the 100,000 people might buy short-term insurance policies, which do not have to cover pre-existing conditions or provide all the benefits required by the health law. But, it said, most are “likely to become uninsured.”
Either way, the administration said, “these individuals will be bearing a larger share of the costs of their own health care consumption.”
The proposed rule may reduce federal spending and the need to collect taxes in the future, the administration said. “However,” it added, “the increased number of uninsured may increase federal and state uncompensated care costs.”
The administration estimated that premiums — after subsidies, in the form of tax credits — would be 1 percent higher as a result of its proposal.

The limit on out-of-pocket costs is already high; a consumer can be required to spend as much as $7,900 a year. Under the formula now in use, the limit would rise to $8,000 next year. Under the Trump administration proposal, it would increase to $8,200.
Administration officials said their proposal would more accurately measure insurance price inflation. But Democrats refused to accept that explanation, noting that Mr. Trump had tried to repeal the Affordable Care Act during his entire first year in office.
Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, described the new proposed rule as “Trump’s latest attempt to sabotage health care.”
The Trump administration is also proposing a new requirement to increase the number of health insurance plans that omit coverage of abortion services.
Under the proposal, insurers that provide coverage of abortions would also have to offer at least one plan providing the same benefits but excluding coverage of abortions.
The administration said it was concerned that some people who wanted to buy insurance under the Affordable Care act refrained from doing so because they had religious or moral objections to abortion coverage. The administration acknowledged that some states like California, New York and Oregon generally required insurers to offer abortion coverage on the exchange, and it appears that the proposed federal requirement would not override such state laws.
https://www.nytimes.com/2019/01/21/us/politics/trump-obamacare-drug-costs.html

Can a Nice Doctor Make Treatments More Effective?

By Lauren Howe and Kari Liebowitz - NYT - January 22, 2019

 

In the age of the internet, it’s easier than ever to pull together lots of information to find the best doctor. And if you’re like most patients, the metric you probably rely on most is the doctor’s credentials. Where did she go to school? How many patients has he treated with this condition?
You might also read some Yelp reviews about how nice this doctor is; how friendly and how caring. But all that probably seems secondary to the doctor’s skills; sure, it would be great to have a doctor whom you actually like, but that’s not going to influence your health the way the doctor’s competence will.
But our research in the psychology department at Stanford University suggests that this view is mistaken. We found that having a doctor who is warm and reassuring actually improves your health.
The simple things a doctor says and does to connect with patients can make a difference for health outcomes.

Even a brief reassurance to a patient from a doctor might relieve the patient’s symptoms faster. In a recent study that one of us conducted, our research group recruited 76 participants to receive a skin prick test, a common procedure used in assessing allergies. The provider in this study pricked participants’ forearms with histamine, which makes skin itchy and red.
Then, the doctor examined the allergic reactions. For some patients, the doctor examined them without saying much. But for other patients, the doctor had some words of encouragement. He told them: “From this point forward, your allergic reaction will start to diminish, and your rash and irritation will go away.” It turns out that this one sentence of assurance from a provider led patients to report that their reactions were less itchy — even though the doctor didn’t give any medication or treatment along with his words. Words alone from the provider relieved patients’ symptoms.
This tells us that a physician’s words might be more powerful than we normally realize. And research shows that it is not only when patients are taking placebos that demeanor matters. In fact, provider words influence the efficacy of even our most powerful drugs and treatments.
But as anyone who has been on the receiving end of a terse “You’re fine” knows, it’s not just what you say, it’s how you say it.
In another study one of us worked on, we assessed whether the same words from a doctor influence patients differently depending on how warm or competent the doctor seemed. Again, patients received a histamine skin prick. Depending on what experimental group they were assigned to, patients met a provider trained to act in one of two very different ways. One group met the provider many of us dream of: she acted both warm and competent, calling patients by name, smiling, chatting and making eye contact. Her office was spotless, she spoke clearly and confidently, and she pulled off the medical procedures without a hitch.

The other group, however, met the kind of doctor all too many of us have encountered: glued to the computer screen throughout the exam, the provider didn’t bother introducing herself and asked questions only to gather practical information. She also stumbled through some of the procedures in the messy exam room and sounded rather unsure of herself.
In both groups, the provider gave patients a cream that she said was an antihistamine to reduce the allergic reaction and decrease itching. The cream was merely unscented hand lotion: a placebo. (A benefit of doing this research in the lab is that for the purposes of the study, we can temporarily lead patients to believe something that is untrue, something doctors could never do in a real clinic visit.)
Decades of robust literature on placebo effects demonstrate that, even without any active ingredients, this cream should reduce the allergic reaction. But no one had examined how the doctor’s demeanor might influence the effects of a placebo treatment.
Our study revealed that the placebo cream reduced participants’ allergic reactions only when the provider projected warmth and competence. When the provider acted colder and less competent, the placebo cream had no effect. It seems that it’s not just what the doctor says about a treatment that matters. It matters how the doctor who says it engages with patients. Doctors who are warmer and more competent are able to set more powerful expectations about medical treatments. Those positive expectations, in turn, have a measurable impact on health.
So, we saw that when the provider projected both desirable qualities of warmth and competence, her words had an effect. When she projected neither, they did not.
What about a provider who seems competent, but not warm? One other group of patients met a provider who seemed highly competent but remained businesslike and distant throughout the interaction, and they did not respond to the placebo cream as much as when the provider acted warm and competent.
Patients of even the most accomplished and skillful doctors may benefit more when that doctor also connects with them.

All of this research suggests that doctors who don’t connect with their patients may risk undermining a treatment’s success. Doctor-patient rapport is not just a fluffy, feel-good bonus that boosts Yelp reviews, but a component of medical care that has important effects on a patient’s physical health. Particularly as artificial intelligence promises a world where we don’t need to go to the doctor for minor questions, we should not overlook the value of interacting with a human doctor and hearing words of encouragement.
And while physicians may worry that building rapport with patients requires too much time in a health care setting with visits that are already too short, there are simple ways to build warmth and competence — such as smiling, looking patients in the eye and asking their names — that don’t tax doctors beyond their limits.
We often think the only parts of medical care that really matter are the “active” ingredients of medicine: the diagnosis, prognosis and treatment. But focusing only on these ingredients leaves important components of care underappreciated and underutilized. To really help people flourish, health care works better when it includes caring.
https://www.nytimes.com/2019/01/22/well/live/can-a-nice-doctor-make-treatments-more-effective.html

 Removing investor-owned hospitals is not a bail out-- it’s the right thing to do.
by Kay Tillow - Daily Kos - January 25, 2019
Rep. Pramila Jayapal has been re-writing HR 676, the model improved Medicare for all legislation that has united and advanced a growing single payer movement since it was introduced into Congress in 2003.  HR 676 is evidence-based and written to enact the Physicians Proposal for a National Health Program.
Unless the movement acts quickly to assure HR 676’s ban on for-profit institutions is maintained, Jayapal’s new bill will remove this vital section of HR 676.
It’s a compromise that there is no need to make.  We are getting hearings in this Congress.  Why should we take the impact of the for-profits out of the discussion before the debate starts?  We gain nothing.  The ban on for-profits has been in HR 676 since the beginning.  It did not stop 124 congresspersons from signing on to it.  It did not stop unions, organizations, cities, counties, and many others from endorsing it.  It was one of the popular provisions that all of those who have dealt with these for-profit hustlers welcomed.
HR 676 included in Section 103 the following:
“No institution may be a participating provider unless it is a public or not-for-profit institution.  Private physicians, private clinics, and private health care providers shall continue to operate as private entities, but are prohibited from being investor owned.”
And
“For-profit providers of care opting to participate shall be required to convert to not-for-profit status.”¹
That was placed in HR 676 for good reason.  Physicians for a National Health Program states in their proposal that “…because investor ownership of health care providers is known to compromise quality and divert funds from clinical care to overhead and profits the NHP (National Health Program) would not include such providers.”²
The consequences of for-profit institutions in health care are stark—even deadly.  In a review by researchers involving 15 observational studies of 26,000 hospitals and 38 million patients by Devereaux et al, the writers stated:  “Our pooled analysis of the adult population studies demonstrated that private for-profit hospitals were associated with a statistically significant increase in the risk of death.”³
In the United States, said co-author Dr. Holger Schönemann, assistant professor at the University of Buffalo, a 2% increased risk means that 14,000 people die each year at for-profit hospitals who would have lived if treated at non-profit hospitals.⁴
Preventing the deaths of 14,000 people a year is a pretty good reason to take a stand on this rather than write it off as a minor detail.
“According to CMS, for-profit nursing homes are cited for quality deficiencies 28 percent more often than non-profits, and for deficiencies that place residents in immediate jeopardy 53 percent more frequently,”⁵ say health policy experts Drs. Steffie Woolhandler and David Himmelstein.
“For-profit hospitals spend less on nurses and other clinical aspects of care, but more on administration and financial management; for-profit chains have often been cited for questionable business practices and have been repeatedly implicated in large scale fraud,”⁶ assert Woolhandler and Himmelstein.
The evidence is overwhelming.  So why would the ban on for-profit institutions in HR 676 be removed in the rewriting?
Some mistakenly say they don’t want to remove the for-profits because they don’t want to “bail out” those giant corporations.  But this is not a bail out.  A bail out is a situation in which the government uses public money to save a corporation or industry from failing.⁷
Hospital Corporation of America (HCA) and Tenet are far from failing.  In the first quarter of 2018 HCA saw their profits double to $1.1 billion.⁸
In the same quarter, Tenet reported a surprise $99 million profit after expanding a cost-cutting plan.⁹
Florida’s new Senator Rick Scott walked away (scot free) from the charges that his Columbia/HCA hospital corporation defrauded Medicare by paying only $1.7 billion dollars in fines and using the rest of the ill-gotten gains to promote his successful political career.¹⁰ 
These giants don’t want to be bought out.  They want to stay in the system for the massive profits they make.  It is not a bail out when HR 676 converts them to non-profit so that their facilities can be used for the benefit of patients.¹¹
Some assert that paying compensation for the hospitals will cost too much.  It will save lives and even money in the long run and is totally affordable by the use of 15 year bonds as set forth in HR 676.¹²
Taking out the ban on for-profit hospitals will not make our single payer legislation any easier to pass, yet it removes from the discussion the extremely important issue of what profits do to a health care system, to patients, to the costs.  Taking the discussion of profits in health care off the table will deprive the nation of the ability to debate the issue in the upcoming fight.
Some assert that Rep. Jayapal is going to leave the for-profits in the system but somehow regulate them.  Our system would then be burdened by the massive administrative task of trying to rein in the giants.  And it won’t work.  Single payer is supposed to simplify administration so that we can use those wasted funds for expansion of care.
If the for-profits are in, they will make profits and they will harm patients, and they will cost all of us.
Don’t weaken the bill before we get started.  Call Rep. Jayapal and ask her to put patients before profits and keep the ban on for-profit institutions in her Medicare for All bill.
Her number is Phone: 202-225-3106.
https://www.dailykos.com/stories/2019/1/20/1828017/-Removing-investor-owned-hospitals-is-not-a-bail-out-it-s-the-right-thing-to-do?_=2019-01-20T17:38:49.574-08:00

Progressives Warn Against Democrats Pushing 'Diluted' Half-Measures as Alternative to Medicare for All

by Jake Johnson - Common Dreams - January 22, 2019

With Medicare for All polling at an unprecedented 70 percent support among the American public and headed toward its first-ever congressional hearing, Politico on Tuesday reported that there is a growing effort among congressional Democrats—including some 2020 presidential hopefuls—to "water down" the grassroots push for a transformative single-payer program by offering up more incremental approaches to solving America's for-profit healthcare crisis.
"Only improved Medicare for All, aka single-payer, could accomplish those goals, reining in costs while achieving first-dollar universal coverage for everyone in the nation."
—Dr. Adam Gaffney, Physicians for a National Health Program
The proposals listed above, which Politico encapsulated with the term "Medicare for More," are just a handful of ideas Democratic lawmakers have put forth as ostensibly more "pragmatic" paths to achieving a humane healthcare system.
But grassroots Medicare for All advocates and campaigners—whose voices were absent from Politico's report—strongly objected to any plan that leaves intact central elements of a status quo that has produced enormous profits for the insurance and pharmaceutical industries, while leaving millions of Americans with soaring costs or entirely uninsured.
"Improved Medicare for All has support from an overwhelming majority of Democratic voters, so why the sudden proliferation of public option proposals? We should be very skeptical of these sorts of bills," Dr. Adam Gaffney, president of Physicians for a National Health Program (PNHP), told Common Dreams.
"They would not solve the fundamental problems of the American healthcare system, such as uninsurance, underinsurance, enormous administrative waste, or sky-high drug prices," Gaffney added. "Only improved Medicare for All, aka single-payer, could accomplish those goals, reining in costs while achieving first-dollar universal coverage for everyone in the nation. This should be the moment that lawmakers coalesce behind the single-payer bills in the House and the Senate."
According to Politico, Democratic leaders as well as rank-and-file lawmakers like Sens. Sherrod Brown, Tim Kaine, and others are refusing to throw their support behind Medicare for All, instead backing plans that "range from modest Medicare reforms to more ambitious restructurings that would extend government-run care to millions of new patients—an array of options that fall short of campaign trail promises for full Medicare for All."
Michael Lighty, a founding fellow of the Sanders Institute, told Common Dreams that such incremental approaches completely fail to address the fundamental crises at the heart of the U.S. healthcare system, which is the most inefficient and ineffective in the industrialized world.
"The dilution of improved Medicare for All remains the greatest threat to guaranteeing healthcare for all," Lighty said. "Without eliminating all barriers to care—starting with the huge out-of-pocket costs workers must pay—we cannot create a just healthcare system. We cannot reduce the huge administrative costs if we continue a fragmented system dominated by commercial insurance companies. This diluted approach would institutionalize big profits, high executive salaries, and political clout for the healthcare industry."
Lighty concluded that Democrats should stop pushing half-measures and work to "improve Medicare for everybody."
In addition to efforts by some Democrats to undercut Medicare for All with non-universal plans that critics say would fail to deliver badly needed results, the insurance industry and major business lobbying groups like the Chamber of Commerce are ramping up their own campaigns to crush single-payer before it gets off the ground.
"What will the Democratic Party (in the aggregate) do in response? Will it support the health and welfare of the American people, or continue the abuse of the American people by supporting those who extract wealth from suffering?"
—Thomas Neuburger
Thomas Donohue, the president and CEO of the Chamber of Commerce, vowed earlier this month to use all of the resources at his disposal to "combat" Medicare for All.
As part of the effort to overcome this deep-pocketed opposition, National Nurses United (NNU) is holding nationwide Medicare for All "barnstorms" next month to help "build the mass collective action we know we'll need to win."
In a Tuesday op-ed on Common Dreams, essayist Thomas Neuburger wrote that Democrats will soon be forced to pick a side in the immensely consequential fight over the future of the American healthcare system.
"When Medicare for All becomes a bill, the fight will be a cage match with the bright lights on," Neuburger noted. "What will the Democratic Party (in the aggregate) do in response? Will it support, whole-heartedly and by its actions, the health and welfare of the American people, or continue the abuse of the American people by supporting those who extract wealth from suffering?"
https://www.commondreams.org/news/2019/01/22/progressives-warn-against-democrats-pushing-diluted-half-measures-alternative

Mass. General Hospital plans large addition

Priyanka Dayal McCluskey - Boston Globe - January 22, 2019

Massachusetts General Hospital, the busiest medical center in the state, plans to spend more than $1 billion to build a large addition to its crowded campus to keep up with the demand for high-end medical care and compete for patients from around the globe.
The project is likely the largest ever proposed by a hospital in the state, and promises to reshape a busy stretch of downtown Boston between Government Center and the Longfellow Bridge.
It would include two connected 12-story towers on Cambridge Street, with hundreds of private patient rooms, a heart center, a cancer center, operating rooms, and other clinical areas. Mass. General expects to be able to treat at least 100 to 200 additional patients when the building — spanning 1 million square feet — is complete in about seven years.

The project comes as other hospitals in the city are expanding as well. It is expected to be bigger than the more than $1 billion expansion now underway at Boston Children’s Hospital. Beth Israel Deaconess Medical Center is also planning a smaller 10-story tower in the Longwood Medical Area.

Mass. General’s addition, with a completion date of 2026, would be built on property the hospital already owns. Hospital officials would demolish the existing Parkman Street parking garage and construct underground parking below the new building. They expect the project will involve 4,500 construction jobs and allow them to hire new hospital employees.
Mass. General will file its preliminary plans with the city Wednesday. The project requires city and state approvals and is likely to face scrutiny because of its significant cost — and the worry that the costs could trickle down to local patients and consumers. Mass. General, owned by Partners HealthCare, is widely renowned and among the state’s most expensive hospitals.
In interviews, hospital officials described the expansion plan as critical to supporting the growing numbers of patients who need cancer treatment, cardiac care, transplant surgeries, and other services.
The hospital’s facilities are largely outdated, they said. Most Mass. General patients have to share rooms. Only 38 percent of rooms are private, among the lowest percentages in the city, said Dr. Peter Slavin, president of Mass. General.
“If this region wants a world-class academic medical center like MGH, we have to renew our campus and keep it modern and terrific for our patients and competitive not only with local competition but the national competition as well,” Slavin said.
Mass. General currently has more than 1,000 beds and is usually filled almost to capacity, officials said. On any given day, dozens of beds may have to go unused because of infection control and other reasons.
During a tour one recent afternoon, the emergency department was full, as patients spilled into the hallways. More than 30 were waiting to be admitted, but no beds were immediately available.
“We always have patients down here waiting to be admitted,” said Dr. David Brown, chief of emergency medicine. “More beds will help to relieve that pressure.”
While most of Mass. General’s patients are from Massachusetts or New England, the hospital also competes for patients with complex medical needs from all over the world. About 3 percent of its patients are from states outside the region, and 1 percent are from other countries, hospital officials told the Globe.
Patient numbers have been growing, as have profits: Mass. General earned $252.4 million in income from operations last fiscal year, on revenue of almost $4.1 billion.
Founded more than two centuries ago, Mass. General’s campus is a mix of old and new. Some patient floors still in use today were constructed around the time of World War II. Patients in those areas are paired up, separated by just a curtain.
By comparison, the hospital’s last big addition, the Lunder building, has spacious single rooms, giving patients and families more privacy, and a quieter place to recover.
The proposed new building, which has yet to be named, would be twice as large as Lunder, which opened in 2011. It would include 450 single patient rooms, but hospital officials also plan to close and repurpose older patient areas, so they ultimately expect to gain about 100 to 200 new patient beds, they said.
Mass. General, which is structured as a nonprofit, recently began a campaign to raise $3 billion from private donors for the hospital’s programs over seven years. Hospital officials expect that about 20 percent to 30 percent of the cost of the new building would be paid for by donations.
The project still needs approval from several agencies including the Boston Planning & Development Agency and the state Department of Public Health. It also could be reviewed by the Health Policy Commission, which studies issues that affect the cost of health care.
In 2016, the commission warned that Boston Children’s Hospital’s expansion was likely to raise medical costs by drawing patients from other lower-priced hospitals. The Department of Public Health later approved that project with conditions. Mass. General’s project could face similar scrutiny.
Mayor Martin J. Walsh, in a statement Tuesday, voiced initial support for Mass. General’s plans.
“It’s important that our hospitals are making the improvements needed to keep Boston at the global forefront of health care,” Walsh said. “We look forward to closely reviewing Mass. General Hospital’s proposal once it is filed and beginning the comprehensive public process with input from the community.”
City Councilor Josh Zakim, whose district includes Mass. General, noted the hospital is not trying to acquire new land but is staying within its existing footprint.
“It’s certainly a significant project, but it’s not encroaching on the neighborhood,” Zakim said. “We do need to make sure we have modern facilities, enough beds for people from around the world to get treatment here.”
Zakim added that he’d like to see the hospital contribute to traffic improvements on Cambridge Street, which is often congested.
“They’ve generally been a good neighbor,” he said. “I’m looking forward to seeing where this goes.”
https://www.bostonglobe.com/business/2019/01/22/mass-general-hospital-plans-large-addition/bGugz9Fr5E7HoZ88IHFTdM/story.html?camp=breakingnews:newsletter

Mills right to reject failed GOP policy on health care

by David Farmer - Bangor Daily News - January 23, 2019

In a major victory for sound public policy over naked politics, Gov. Janet Mills continued her efforts to expand access to health care to Maine people.
This time, she bucked the Trump administration and former Gov. Paul LePage by rejecting a change to the state’s Medicaid program, which would have erected unnecessary barriers to health insurance for low-income families.
The policy changes, which LePage sought and the Trump administration granted, are often referred to as “work requirements,” meaning that a person receiving health care through Medicaid has to work or volunteer to get coverage.
In reality, the focus-group tested, polling-approved moves are all about denying health care to people. The idea is driven by the misguided idea that people who are poor are lazy and don’t want to work.
In truth, there are real barriers to work for many of the people for whom the requirements would have applied, including a lack of training or education, lack of transportation or the need to care for a sick or disabled child or relative.
Last summer, the Kaiser Family Foundation examined four states that had implemented waivers similar to the one sought by LePage and rejected by Mills. It’s not a pretty picture.
The research found that most people who receive Medicaid and can work, already are, but the jobs they have don’t pay enough to lift them out of poverty. There’s no incentive to find work – because most folks are already punching the clock.
Instead, the requirements set up a difficult-to-navigate bureaucracy that makes it hard for some with steady, long-term employment to comply, putting their health care at risk.
Simple fact: Sick people – and those without access to health care tend to be sicker – have a hard time holding down a job.
Arkansas is one of the first states in the country to put in place these new restrictions, and the results have been terrible. Nearly 17,000 people lost access to health care.
The Indianapolis Star took a look at the horrible consequences in Arkansas and asked if Indiana might suffer the same fate: “If the experience of Arkansas is any guide, Indiana’s plan to require people on Medicaid to work could wind up creating more problems than it solves.”
The Des Moines Register also weighed in on Iowa’s exploration of so-called work requirements: “The GOP idea to add a work requirement to Medicaid is a lame justification for pursuing bad policy. It would erect a barrier for Iowans seeking health insurance, not solve the state’s labor shortage.”
And the left-leaning Center on Budget and Policy Priorities put it this way: “Medicaid work requirements can’t be fixed. Unintended consequences are inevitable result.”
Most of those losing coverage, the center found, are people who are already working or should be exempt but lose coverage because of increased red tape, bureaucracy and paperwork.
Work requirements might sound good, especially to some of the state’s more conservative voters, but Mills made the right decision to put sound policy ahead of sloganeering.
In fact, she’s taking a proactive approach to helping knock down the barriers that prevent some people on Medicaid from working. She’s directed the Maine departments of Labor and Health and Human Services to help Maine people develop the skills they need and help them to find a job.
“Ensuring that Maine people have access to health care and are healthy is the first step to getting them back into the workforce,” acting DHHS Commissioner Jeanne Lambrew said.
As can be expected, LePage – tanned, rested, ready and always eager for the microphone – weighed in on Twitter. Needless to say, he’s not a fan of Mills and her commitment to expanding access to health care.
Beyond that, it was just more blah, blah, blah from a former governor desperate to stay in the spotlight.
Once again, Mills – an accomplished political brawler in her own right – is showing that she won’t let GOP talking points or the ghost of a governor past haunt her into doing the wrong thing.
Just three weeks in, Mills is setting a high bar and showing that she heard voters when they said they wanted more health care, not less. And on that, she’s delivering.
http://davidfarmer.bangordailynews.com/2019/01/23/republicans/mills-right-to-reject-failed-gop-policy-on-health-care/

 

 

 

 

Health Care Reform Articles - January 19, 2019

The Insulin Wars

by Danielle Ofri - NYT - January 18, 2019

“Doctor, could you please redo my insulin prescription? The one you gave me is wrong.” My patient’s frustration was obvious over the phone. She was standing at the pharmacy, unable to get her diabetes medication.
We had gone through this just the week before. I’d prescribed her the insulin she’d been on, at the correct dosage, but when she showed up at her pharmacy she learned that her insurance company no longer covered that brand. After a series of phone messages back and forth, I’d redone the prescription with what I’d thought was the correct insulin, but I was apparently wrong. Again.
Between 2002 and 2013, prices tripled for some insulins. Many cost around $300 a vial, without any viable generic alternative. Most patients use two or three vials a month, but others need the equivalent of four. Self-rationing has become common as patients struggle to keep up. In the short term, fluctuating blood sugar levels can lead to confusion, dehydration, coma, even death. In the long term, poorly controlled diabetes is associated with heart attacks, strokes, blindness, amputation and the need for dialysis.
The exorbitant prices confound patients and doctors alike since insulin is nearly a century old now. The pricing is all the more infuriating when one considers that the discoverers of insulin sold the patent for $1 each to ensure that the medication would be affordable. Today the three main manufacturers of insulin are facing a lawsuit accusing them of deceptive pricing schemes, but it could be years before this yields any changes.

There are several reasons that insulin is so expensive. It is a biologic drug, meaning that it’s produced in living cells, which is a difficult manufacturing process. The bigger issue, however, is that companies tweak their formulations so they can get new patents, instead of working to create cheaper generic versions. This keeps insulin firmly in brand-name territory, with prices to match.
But the real ignominy (and the meat of the lawsuit) is the dealings between the drug manufacturers and the insurance companies. Insurers use pharmacy benefit managers, called P.B.M.s, to negotiate prices with manufacturers. Insurance programs represent huge markets, so manufacturers compete to offer good deals. How to offer a good deal? Jack up the list price, and then offer the P.B.M.s a “discount.”
This pricing is, of course, hidden from most patients, except those without insurance, who have to pay full freight. Patients with insurance live with the repercussions of constantly changing coverage as P.B.M.s chase better discounts from different manufacturers.
All insurance companies periodically change which medications they cover, but insulin is in a whirlwind class by itself because of the staggering sums of money involved. “Short-acting” is supposed to be a category of insulin, but now it appears to be its category of insurance coverage. My patient’s “preferred insulin” changed three times in a year, so each time she went to the pharmacy, her prescription was rejected.
On the doctor's end, it’s an endless game of catch-up. Lantus was covered, but now it’s Basaglar: rewrite all the prescriptions for all your patients. Oops, now it’s Levemir: rewrite them all again. NovoLog was covered, then it was Humalog, but now it’s Admelog. If it’s Tuesday, it must be Tresiba.

It’s a colossal time-waster, as patients, pharmacists and doctors log hours upon hours calling, faxing, texting and emailing to keep up with whichever insulin is trending. It’s also dangerous, as patients can end up without a critical medication for days, sometimes weeks, waiting for these bureaucratic kinks to get ironed out.
Lost in this communal migraine is that this whole process is corrosive to the doctor-patient relationship. I knew that my patient wasn’t angry at me personally, but her ire came readily through the phone. No doubt this reflected desperation — she’d run out of insulin before and didn’t want to end in the emergency room on IV fluids, as she had the last time. Frankly, I was pretty peeved myself. By this point I’d already written enough insulin prescriptions on her account to fill a sixth Book of Moses. I’d already called her insurance company and gotten tangled in phone trees of biblical proportions.
This time I called her pharmacy. A sympathetic pharmacist was willing to work with me, and I stayed on the phone with her as we painstakingly submitted one insulin prescription after another. The first wasn’t covered. The second wasn’t covered. The third was. But before we could sing the requisite hosannas, the pharmacist informed me that while the insulin was indeed covered, it was not a “preferred” medication. That meant there was a $72-per-month co-payment, something that my patient would struggle to afford on her fixed income.
“So just tell me which is the preferred insulin,” I told the pharmacist briskly.
There was a pause before she replied. “There isn’t one.”
This was a new low — an insurance company now had no insulins on its top tier. Breaking the news to my patient was devastating. We had a painful conversation about how she would have to reconfigure her life in order to afford this critical medication.
It suddenly struck me that insurance companies and drug manufacturers had come upon an ingenious business plan: They could farm out their dirty work to the doctors and the patients. Let the doctors be the ones to navigate the bureaucratic hoops and then deliver the disappointing news to our patients. Let patients be the ones to figure out how to ration their medications or do without.
Congress and the Food and Drug Administration need to tame the Wild West of drug pricing. When there’s an E. coli outbreak that causes illness and death, we rightly expect our regulatory bodies to step in. The outbreak of insulin greed is no different.

It is hard to know where to direct my rage. Should I be furious at the drug manufacturers that refuse to develop generics? Should I be angry at the P.B.M.s and insurance companies that juggle prices and formularies to maximize profits, passing along huge co-payments if they don’t get a good enough deal? Should I be indignant at our elected officials who seem content to let our health care system be run by for-profit entities that will always put money before patients?
The answer is all of the above. But what’s most enraging is that drug manufacturers, P.B.M.s and insurance companies don’t have to pick up the pieces from the real-world consequences of their policies. That falls to the patients.
https://www.nytimes.com/2019/01/18/opinion/cost-insurance-diabetes-insulin.html?login=email&auth=login-email

The Strange Marketplace for Diabetes Test Strips

by Ted Alcorn - NYT - January 14, 2019

On most afternoons, people arrive from across New York City with backpacks and plastic bags filled with boxes of small plastic strips, forming a line on the sidewalk outside a Harlem storefront.
Hanging from the awning, a banner reads: “Get cash with your extra diabetic test strips.”
Each strip is a laminate of plastic and chemicals little bigger than a fingernail, a single-use diagnostic test for measuring blood sugar. More than 30 million Americans have Type 1 and Type 2 diabetes, and most use several test strips daily to monitor their condition.
But at this store on W. 116th Street, each strip is also a lucrative commodity, part of an informal economy in unused strips nationwide. Often the sellers are insured and paid little out of pocket for the strips; the buyers may be underinsured or uninsured, and unable to pay retail prices, which can run well over $100 for a box of 100 strips.
Some clinicians are surprised to learn of this vast resale market, but it has existed for decades, an unusual example of the vagaries of American health care. Unlike the resale of prescription drugs, which is prohibited by law, it is generally legal to resell unused test strips.

And this store is far from the only place buying. Mobile phones light up with robo-texts: “We buy diabetic test strips!” Online, scores of companies thrive with names like TestStripSearch.com and QuickCash4TestStrips.com.
“I’m taking advantage, as are my peers, of a loophole,” said the owner of one popular site, who asked that his name not be used. “We’re allowed to do that. I don’t even think we should be, frankly.”
Test strips were first developed in 1965 to provide an immediate reading of blood sugar, or glucose, levels. The user pricks a finger, places a drop of blood on the strip, and inserts it into a meter that provides a reading.
The test strips were created for use in doctors’ offices, but by 1980 medical-device manufacturers had designed meters for home use. They became the standard of care for many people with diabetes, who test their blood as often as ten times a day.

Test strips are a multi-billion-dollar industry. A 2012 study found that among insulin-dependent patients who monitor their blood sugar, strips accounted for nearly one-quarter of pharmacy costs. Today, four manufacturers account for half of global sales.

In a retail pharmacy, name-brand strips command high prices. But like most goods and services in American health care, that number doesn’t reflect what most people pay.
The sticker price is the result of behind-the-scenes negotiations between the strips’ manufacturer and insurers. Manufacturers set a high list price and then negotiate to become an insurer’s preferred supplier by offering a hefty rebate.
These transactions are invisible to the insured consumer, who might cover a copay, at most. But the arrangement leaves the uninsured — those least able to pay — paying sky-high sticker prices out of pocket. Also left out are the underinsured, who may need to first satisfy a high deductible.
For a patient testing their blood many times a day, paying for strips out-of-pocket could add up to thousands of dollars a year. Small wonder, then, that a gray market thrives. The middlemen buy extras from people who obtained strips through insurance, at little cost to themselves, and then resell to the less fortunate.
That was the opportunity that caught Chad Langley’s eye. He and his twin brother launched the website Teststripz.com to solicit test strips from the public for resale. Today they buy strips from roughly 8,000 people; their third-floor office in Redding, Mass., receives around 100 deliveries a day.
The amount the Langleys pay depends on the brand, expiration date and condition, but the profit margins are reliably high. For example, the brothers will pay $35 plus shipping for a 100-count box of the popular brand Freestyle Lite in mint condition.
The Langleys sell the box for $60. CVS, by contrast, retails the strips for $164.
The Langleys are mainly buying up excess strips from insured patients who have been flooded with them, sometimes even when not medically necessary.

Although patients who manage their diabetes with non-insulin medications or with diet and exercise needn’t test their blood sugar daily, a recent analysis of insurance claims found that nearly one in seven patients still used test strips regularly.

---

‘It’s a tiny little piece of plastic that’s super cheap to manufacture, and they’ve managed to make a cash cow out of it.’

Gretchen Obrist

---

The market glut is also a consequence of a strategy adopted by manufacturers to sell patients proprietary meters designed to read only their brand of strips. If a patient’s insurer shifts her to a new brand, she must get a new meter, often leaving behind a supply of useless strips.
While some resellers use websites like Amazon or eBay to market strips directly to consumers, the biggest profits are in returning them to retail pharmacies, which sell them as new and bill the customer’s insurance the full price.
The insurer reimburses the pharmacy the retail price and then demands a partial rebate from the manufacturer — but it’s a rebate the manufacturer has paid already for this box of strips.

Glenn Johnson, general manager for market access at Abbott Diabetes Care, which makes about one in five strips purchased in the United States, said manufacturers lose more than $100 million in profits a year this way, much of it in New York, California and Florida.
The company supported a new California law that prohibits pharmacies from acquiring test strips from any but an authorized list of distributors. Mr. Johnson said he has spoken with lawmakers about similar efforts in Florida, New Jersey, New York and Ohio.
Such measures leave intact the inflated retail prices that make the gray market possible and which critics say benefit manufacturers and their retail intermediaries, pharmacy benefit managers.

In a lawsuit against P.B.M.’s and the dominant test strip manufacturers filed in New Jersey, consumer advocates presented data showing that the average wholesale price for test strips has risen as much as 70 percent over the last decade.
They alleged that this has allowed the defendants to pocket an unfair portion of the rebates. The price of a strip would be much lower if it wasn’t fattened by profiteering, said Gretchen Obrist, one of the lawyers who brought the case.
“It’s a tiny little piece of plastic that’s super cheap to manufacture, and they’ve managed to make a cash cow out of it,” she said.
To justify the rising price of strips, manufacturers point to advances in engineering that have made the strips smaller and more convenient to use. But there is little evidence those features have improved health outcomes for people with diabetes — and with increasingly unaffordable prices, the newfangled test strips may be even less accessible.
The markups on strips look particularly stark when compared to the cost of producing them.
“Test strips are basically printed, like in a printing press,” said David Kliff, who publishes a newsletter on diabetes. “It’s not brain surgery.”
He estimated the typical test strip costs less than a dime to make.
https://www.nytimes.com/2019/01/14/health/diabetes-test-strips-resale.html

 

Seven in 10 Maintain Negative View of U.S. Healthcare System

by Justin McCarthy - Gallup - January 14, 2019

 

• 70% say U.S. healthcare has major problems/is in state of crisis
• Overall perceptions stable, but party views have changed
• About six in seven Democrats now have negative assessments of the system

WASHINGTON, D.C. -- Seventy percent of Americans describe the current U.S. healthcare system as being "in a state of crisis" or having "major problems." This is consistent with the 65% to 73% range for this figure in all but one poll since Gallup first asked the question in 1994.

In that one poll -- conducted right after the 9/11 attacks in 2001 -- just 49% of Americans said the U.S. healthcare system had major problems or was in crisis. This was because of Americans' heightened concerns about terrorism after the attacks, which temporarily altered their views and behaviors on a variety of issues.
The latest data are from Gallup's annual Healthcare poll, conducted Nov. 1-11.

About Six in Seven Democrats Rate the Healthcare System Negatively

Although the percentage of Americans saying U.S. healthcare has major problems or is in crisis has been fairly flat over the past two decades, Democrats' and Republicans' views have changed within that time frame.

From 2001 to 2009, Democrats and Democratic-leaning independents were considerably more likely than Republicans and Republican-leaning independents to say healthcare had major problems or was in crisis. Democrats' negative assessments then decreased in the rest of President Barack Obama's first term, after passage of the Affordable Care Act (ACA) in 2010, at the same time that Republicans' concerns mounted. By 2012, the lines crossed, so that during most of Obama's second term, Republicans were significantly more likely than Democrats to perceive significant or critical problems in the healthcare system.
Now, with Republican President Donald Trump in office, partisan views have flipped again, with Democrats more likely to be concerned.
The difference between the two major parties on this measure was just five percentage points in 2017, Trump's first year, when 76% of Democrats and 71% of Republicans said healthcare had major problems or was in crisis. This expanded to a 28-point gap in 2018, when 84% of Democrats and 56% of Republicans expressed these views -- the largest partisan gap on this measure in Gallup's trend since 2001.
The 2018 poll was conducted on the heels of last year's midterm elections, in which Democratic candidates highlighted key problems with the healthcare system -- especially coverage.
Although most Americans, including majorities of Republicans and Democrats, give the healthcare system a pessimistic diagnosis, when asked specifically about the quality of U.S. healthcare, 55% rate it positively. Smaller percentages have positive reviews of U.S. healthcare coverage (34%) and costs (20%). Americans rate cost and access as the greatest health problems facing the country.
More broadly, Gallup has found that Americans are much more positive in their assessments of their personal healthcare than they are about the healthcare system nationally.

Bottom Line

Barring any major breakthroughs in healthcare reform, it's difficult to imagine Americans' dim assessments of the state of U.S. healthcare changing anytime soon, given the mostly stable trend Gallup has recorded over nearly a quarter of a century.
The last major feat in healthcare policy reform was met by more disapproval than approval from Americans for many years, and the public's preferences for next steps on the ACA provide an unclear path for policymakers to follow to improve perceptions of the system.
Democratic efforts in the House of Representatives to protect the ACA will likely hit roadblocks with a GOP-controlled Senate and White House, and even some Democratic approaches to lowering drug prices are unlikely to receive Republicans' support. 2018 GOP congressional candidates campaigned on protection for those with pre-existing conditions, which more than a quarter of Americans report having, but there is already disagreement between the two major parties on how to provide that.
View complete question responses and trends.

https://news.gallup.com/poll/245873/seven-maintain-negative-view-healthcare-system.aspx 

Report raises alarm about physician burnout - The Boston Globe

By Priyanka Dayal McCluskey - The Boston Glober - January 17, 2019

Physician burnout has reached alarming levels and now amounts to a public health crisis that threatens to undermine the doctor-patient relationship and the delivery of health care nationwide, according to a report from Massachusetts doctors to be released Thursday.
The report — from the Massachusetts Medical Society, the Massachusetts Health & Hospital Association, and the Harvard T.H. Chan School of Public Health — portrays a profession struggling with the unyielding demands of electronic health record systems and ever-growing regulatory burdens.
It urges hospitals and medical practices to take immediate action by putting senior executives in charge of physician well-being and by giving doctors better access to mental health services. The report also calls for significant changes to make health record systems more user-friendly.
While burnout has long been a worry in the profession, the report reflects a newer phenomenon — the draining documentation and data entry now required of doctors. Today’s electronic record systems are so complex that a simple task, such as ordering a prescription, can take many clicks.
Doctors typically spend two hours on computer work for every hour they spend with patients, the report said. Much of this happens after they leave the office; they call it “pajama time.”
Medicine has become more regulated and complex over the past several years, generating what doctors often consider to be meaningless busywork detached from direct patient care. That’s when they start to feel disheartened, authors of the report said.
“A lot of physicians feel they are on a treadmill, on a conveyor belt,” said Dr. Alain A. Chaoui, president of the Massachusetts Medical Society and a family doctor in Peabody. “They’re not afraid of work — it’s the work that has nothing to do with the patients that makes physicians unhappy. And it makes the patients unhappy, because they feel the system is failing them.”
Chaoui and the report’s other authors reviewed dozens of studies to develop their paper, which they described as “a call to action” for providers, insurers, government agencies, and health technology companies. The report does not specifically address burnout of nurses or other health care workers — only doctors.
Surveys indicate that 50 percent to as many as 78 percent of doctors have at some point experienced burnout — described as emotional exhaustion and disengagement from their work — as they contend with the realities of modern medicine.
Doctors must comply with a host of federal reporting requirements and insurance company rules. As insurers set tighter restrictions aimed at controlling costs, for example, doctors spend more time on the phone to persuade insurers to reimburse them for certain tests and services, they say.
And much of the day is spent typing, pointing, and clicking in electronic health records, which are notoriously time-consuming and difficult to use. While doctors acknowledge that electronic records hold many advantages over paper charts, they say computers have become an obstacle — literally — that can hinder conversation with patients.
Studies show that burnout has costly consequences for doctors as well as patients, and for the health care system as a whole.
When doctors are less engaged, patients are less satisfied. Burned-out physicians are more likely to make mistakes. They’re also more likely to reduce their hours or retire early. This affects their employer’s bottom line: Each departing doctor costs as much as $500,000 to $1 million to replace, according to one study.
In a national survey of doctors published last year, 10.5 percent reported a major medical error in the prior three months. Those who reported errors were more likely to experience burnout, fatigue, and suicidal thoughts.
To tackle the problem, the report says, physicians need access to mental health care without stigma or fear of losing their right to practice. The authors argue that state licensing boards should not ask probing questions about a physician’s mental health but focus instead on his or her ability to practice medicine safely.
“We want to normalize it. We want to encourage people to ask for help when they need it,” said Dr. Steven Defossez, vice president of clinical integration at the Massachusetts Health & Hospital Association. “There is certainly a fear that keeps people from accessing services today.”
Asking doctors to manage their feelings on their own is not enough, the report says; it demands that major health care organizations take burnout seriously by hiring a chief wellness officer — a senior executive in charge of tracking burnout and helping to improve physician wellness.
“This is not about more yoga classes in the hospital,” said Dr. Ashish K. Jha, a Harvard professor who worked on the report. “This is about someone at the highest level of the organization who is responsible for making sure that the workforce is healthy and thriving.”
“We think the responsibility lies with the system that has created these problems,” not with individual doctors, Jha added.
In response to the burnout “epidemic,” officials at Stanford Medicine in California hired Dr. Tait Shanafelt from the Mayo Clinic as their first chief wellness officer in 2017. Stanford also trains doctors from around the country in physician wellness.
Shanafelt said his job is to identify “problem areas” and develop a coordinated approach to address the problems.
“Part of our role is, when other key strategies or initiatives are being discussed, [to think about] the concept of how they’re going to impact our people,” he said.
Physician burnout has spawned numerous studies that have raised awareness of the issue in recent years, and several Massachusetts health systems have begun working to address it. Last January, Boston Medical Center named Dr. Susannah Rowe, an ophthalmologist, to the new role of associate chief medical officer for wellness and professional vitality. Hospital officials said they are working on initiatives to reduce administrative burdens for doctors and implement flexible work schedules.
Brigham and Women’s Hospital asked its physicians how they felt about their work in 2017 and plans to repeat the survey this year, though it has not published the results.
“We’re really in this to make our physicians professionally fulfilled — not just stop burnout,” said Dr. Jessica C. Dudley, chief medical officer of the Brigham and Women’s Physicians Organization.
Based on physicians’ feedback, the Brigham decided to provide individualized training on the hospital’s complicated health record software. The training was held at the clinics where doctors practice, Dudley said.
Thursday’s report from the medical society, hospital association, and Harvard also urges medical software companies to design more efficient systems, including by developing apps that doctors can download to help with certain tasks, such as documenting patient visits.
The report concludes with a warning: “If left unaddressed, the worsening crisis threatens to undermine the very provision of care, as well as eroding the mental health of physicians across the country.”
https://www.bostonglobe.com/metro/2019/01/17/report-raises-alarm-about-physician-burnout/9CGdUc0eEOnobtSUiX5EIK/story.html?

Doctor burnout is real. And it’s dangerous

by Alan Chaoui, Steven Defossez and Michelle Williams - Boston Globe - January 17, 2019

Burnout — a condition characterized by emotional exhaustion, cynicism, and feelings of reduced effectiveness in the workforce — impacts all caregivers and, in particular, threatens to undermine the physician workforce, endangering our health care system.

So profound it has been described as “moral injury,” burnout results from a collision of norms between the physician’s mission to provide care and increasing bureaucratic demands of a new era.

Evidence shows the worsening scope, severity, and impact of this public health crisis: Frustrating computer interfaces have crowded out engagement with patients, extending already long work days as physicians and all caregivers struggle to keep up with a soaring burden of administrative tasks. Nearly half of all physicians experience burnout in some form, and the number will continue to grow. The consequences of this epidemic on patients and physicians are clear, and physicians have affirmed a necessary and unwavering commitment to spearhead changes that will lead to solutions.

Burned-out physicians who choose not to leave the profession are more likely to reduce their work hours. This reduction is already equivalent to losing the graduates of seven medical schools every year. Recruiting and replacing one physician can cost employers as much as $1 million. Burned-out physicians are also unable to provide the best care, with evidence suggesting that burnout is associated with increased medical errors. 

We cannot improve patient experience and population health while reducing health care costs without a strong and engaged physician workforce.

What can we do? A lot. A new white paper produced by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Health and Hospital Association, and the Massachusetts Medical Society, proposes three key recommendations.

First, we must support proactive and confidential mental health treatment for burned-out physicians and expand outreach, particularly for trainees, who are at a vulnerable stage of their careers. Physicians seeking care face stigma and professional obstacles, including probing questions about mental health in their medical license process. We recommend such questions be limited or eliminated. If they are included, these questions should focus on impairments impacting the physician’s current practice and competence, in the same way questions about physical health do.

Second, we must improve the usability of electronic health records, or EHRs. Physicians must now spend much of an appointment clicking and typing, eyes glued to a computer monitor rather than engaged with the patient. The ever-increasing array of reporting systems and unhelpful alerts not only interfere with patient interaction, but also force physicians to spend additional hours completing administrative tasks that limit patient interaction and can harm patient experience and care.

Fortunately, there are opportunities for improvements that involve more user-friendly mobile apps. We are also seeing the first results of a drive to make it easier for EHRs from one office or hospital to share critical patient information with another system (interoperability). Further, there is technical innovation under development around streamlining some of the most burdensome, time-consuming, and demoralizing processes for obtaining insurance company approvals for services and patient referrals.

Improvements by EHR vendors and payers will require action by state and federal agencies. The US Department of Health and Human Services recently acknowledged that the burden of EHRs contributes to burnout, in its draft “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.” We encourage physicians and health care organizations to submit comments on how to make sure EHRs support both patient care and physician workflow.

Third, and most important for the long term, we call for the appointment of executive-level chief wellness officers at every major health care organization. Several major organizations, including Stanford Medicine and Kaiser Permanente, have already done so, recognizing that burnout among physicians and clinical and support staff across every layer of their organization demands action. This is a welcome and necessary development and must be the first step in creating a professional learning community of health care leaders and providers sharing successful burnout remediation strategies. Over time, physician and clinician wellness among all health care providers must become a “dashboard” item for institutional CEOs and boards of directors. We believe strongly that there will be a substantial financial and patient experiential return on investment.

This crisis could not be more urgent. If physician burnout continues to worsen, it will degrade the quality of health care our physicians and hospitals provide, in addition to increasing the profound harm to physician mental health resulting from the serious misalignment between the demands placed on them and their core mission of providing care. Fortunately, we have the tools to make changes. We need to take better care of our physicians and all caregivers so that they can continue to take the best care of us.
https://www.bostonglobe.com/opinion/2019/01/17/doctor-burnout-real-and-dangerous/LpEgCCzyWhHou6qketcGQK/story.html?et_rid=1744895461&s_campaign=todayinopinion:newsletter

 Editor's Note -

The preceding two clippings from the Boston Globe are prime examples of treating the symptoms and ignoring the underlying pathology. While they do a decent job of describing the symptoms of the disease they cover (physician burnout), they totally ignore the underlying pathology that is causing the disease - the excessive complexity of our health insurance system and its excessive focus on the business of medicine rather than on its healing mission. That’s not especially remarkable - clueless “leaders” are a dime a dozen. But the recommendations of the cited report are in fact the product of two Harvard-affiliated institutions and two powerful trade (excuse me - professional) associations. 

The disease afflicting American medicine is widespread and deep rooted indeed..

-SPC

GoFundMe CEO: ‘Gigantic Gaps’ In Health System Showing Up In Crowdfunding

by Rachel Bluth - Kaiser Health News - January 16, 2019

 

Scrolling through the GoFundMe website reveals seemingly an endless number of people who need help or community support. A common theme: the cost of health care.
It didn’t start out this way. Back in 2010, when the crowdfunding website began, it suggested fundraisers for “ideas and dreams,” “wedding donations and honeymoon registry” or “special occasions.” A spokeswoman said the bulk of collection efforts from the first year were “related to charities and foundations.” A category for medical needs existed, but it was farther down the list.
In the nine years since, campaigns to pay for health care have reaped the most cash. Of the $5 billion the company says it has raised, about a third has been for medical expenses from more than 250,000 medical campaigns conducted annually.
Take, for instance, the 25-year-old California woman who had a stroke and “needs financial support for rehabilitation, home nursing, medical equipment and uncovered medical expenses.” Or the Tennessee couple who want to get pregnant, but whose insurance doesn’t cover the $20,000 worth of “medications, surgeries, scans, lab monitoring, and appointments [that] will need to be paid for upfront and out-of-pocket” for in vitro fertilization.
The prominence of the medical category is the symptom of a broken system, according to CEO Rob Solomon, 51, who has a long tech résumé as an executive at places like Groupon and Yahoo. He said he never realized how hard it was for some people to pay their bills: “I needed to understand the gigantic gaps in the system.”
This year, Time Magazine named Solomon one of the 50 most influential people in health care.
“We didn’t build the platform to focus on medical expenses,” Solomon said. But it turned out, he said, to be one of those “categories of need” with which many people struggle.
Solomon talked to Kaiser Health News’ Rachel Bluth about his company’s role in financing health care and what it says about the system when so many people rely on the kindness of strangers to get treatment. The conversation has been edited for length and clarity.
Q: KHN and other news outlets have reported that hospitals often advise patients to crowdfund their transplants. It’s become almost institutionalized to use GoFundMe. How do you feel about that?
It saddens me that this is a reality. Every single day on GoFundMe we see the huge challenges people face. Their stories are heartbreaking.
Some progress has been made here and there with the Affordable Care Act, and it’s under fire, but there’s ever-widening gaps in coverage for treatment, for prescriptions, for everything related to health care costs. Even patients who have insurance and supposedly decent insurance [come up short]. We’ve become an indispensable institution, indispensable technology and indispensable platform for anyone who finds themselves needing help because there just isn’t adequate coverage or assistance.
I would love nothing more than for “medical” to not be a category on GoFundMe. The reality is, though, that access to health care is connected to the ability to pay for it. If you can’t do that, people die. People suffer. We feel good that our platform is there when people need it.
Q: Did anyone expect medical funding would become such a big part of GoFundMe?
I don’t think anyone anticipated it. What we realized early on is that medical need is a gigantic category.
A lot of insurance doesn’t cover clinical trials and research and things like that, where people need access to leading-edge potential treatments. We strive to fill these gaps until the institutions that are supposed to handle this handle it properly. There has to be a renaissance, a dramatic change in public policy, in how the government focuses on this and how the health care companies solve this.
This is very interesting. In the places like the United Kingdom, Canada and other European countries that have some form of universal or government-sponsored health coverage, medical [costs] are still the largest category. So it’s not just medical bills for treatment. There’s travel and accommodations for families who have to support people when they fall ill.
Q: What have you learned that you didn’t know before?
I guess what I realized [when I came] to this job is that I had no notion of how severe the problem is. You read about the debate about single-payer health care and all the issues, the partisan politics. What I really learned is the health care system in the United States is really broken. Way too many people fall through the cracks.
The government is supposed to be there and sometimes they are. The health care companies are supposed to be there and sometimes they are. But for literally millions of people they’re not. The only thing you can really do is rely on the kindness of friends and family and community. That’s where GoFundMe comes in.
I was not ready for that at all when I started at the company. When you live and breathe it every day and you see the need that exists, when you realize there are many people with rare diseases but they aren’t diseases a drug company can make money from, they’re just left with nothing.
Q: But what does this say about the system?
The system is terrible. It needs to be rethought and retooled. Politicians are failing us. Health care companies are failing us. Those are realities. I don’t want to mince words here. We are facing a huge potential tragedy. We provide relief for a lot of people. But there are people who are not getting relief from us or from the institutions that are supposed to be there. We shouldn’t be the solution to a complex set of systemic problems. They should be solved by the government working properly, and by health care companies working with their constituents. We firmly believe that access to comprehensive health care is a right and things have to be fixed at the local, state and federal levels of government to make this a reality.
Q: Do you ever worry that medical fundraising on your site is taking away from other causes or other things that need to be funded?
We have billions being raised on our platform on an annual basis. Everything from medical, memorial and emergency, to people funding Little League teams and community projects.
Another thing that’s happened in the last few years is we’ve really become the “take action button.” Whenever there’s a news cycle on something where people want to help, they create GoFundMe campaigns. This government shutdown, for example: We have over a thousand campaigns right now for people who have been affected by it — they’re raising money for people to pay rent, mortgages, car payments while the government isn’t.
https://khn.org/news/gofundme-ceo-gigantic-gaps-in-health-system-showing-up-in-crowdfunding/

Can States Fix the Disaster of American Health Care?

by Elizabeth Rosenthal - NYT - January 17, 2019

Last week, California’s new governor, Gavin Newsom, promised to pursue a smorgasbord of changes to his state’s health care system: state negotiation of drug prices; a requirement that every Californian have health insurance; more assistance to help middle-class Californians afford it; and health care for undocumented immigrants up to age 26.
The proposals fell short of the sweeping government-run single-payer plan Mr. Newsom had supported during his campaign — a system in which the state government would pay all the bills and effectively control the rates paid for services. (Many California politicians before him had flirted with such an idea, before backing off when it was estimated that it could cost $400 billion a year.) But in firing off this opening salvo, Mr. Newsom has challenged the notion that states can’t meaningfully tackle health care on their own. And he’s not alone.
A day later, Gov. Jay Inslee of Washington proposed that his state offer a public plan, with rates tied to those of Medicare, to compete with private offerings.
New Mexico is considering a plan that would allow any resident to buy into the state’s Medicaid program. And this month, Mayor Bill de Blasio of New York announced a plan to expand health care access to uninsured, low-income residents of the city, including undocumented immigrants.

For over a decade, we’ve been waiting for Washington to solve our health care woes, with endless political wrangling and mixed results. Around 70 percent of Americans have said that health care is “in a state of crisis” or has “major problems.” Now, with Washington in total dysfunction, state and local politicians are taking up the baton.
The legalization of gay marriage began in a few states and quickly became national policy. Marijuana legalization seems to be headed in the same direction. Could reforming health care follow the same trajectory?
States have always cared about health care costs, but mostly insofar as they related to Medicaid, since that comes from state budgets. “The interesting new frontier is how states can use state power to change the health care system,” said Joshua Sharfstein, a vice dean at Johns Hopkins Bloomberg School of Public Health and a former secretary of the Maryland Department of Health and Mental Hygiene. He added that the new proposals “open the conversation about using the power of the state to leverage lower prices in health care generally.”
Already states have proved to be a good crucible for experimentation. Massachusetts introduced “Romneycare,” a system credited as the model for the Affordable Care Act, in 2006. It now has the lowest uninsured rate in the nation, under 4 percent. Maryland has successfully regulated hospital prices based on an “all payer” system.
It remains to be seen how far the West Coast governors can take their proposals. Businesses — pharmaceutical companies, hospitals, doctors’ groups — are likely to fight every step of the way to protect their financial interests. These are powerful constituents, with lobbyists and cash to throw around.

The California Hospital Association came out in full support of Mr. Newsom’s proposals to expand insurance (after all, this would be good for hospitals’ bottom lines). It offered a slightly less enthusiastic endorsement for the drug negotiation program (which is less certain to help their budgets), calling it a “welcome” development. It’s notable that his proposals didn’t directly take on hospital pricing, even though many of the state’s medical centers are notoriously expensive.
Giving the state power to negotiate drug prices for the more than 13 million patients either covered by Medicaid or employed by the state is likely to yield better prices for some. But pharma is an agile adversary and may well respond by charging those with private insurance more. The governor’s plan will eventually allow some employers to join in the negotiating bloc. But how that might happen remains unclear.
The proposal by Governor Inslee of Washington to tie payment under the public option plans to Medicare’s rates drew “deep concern” from the Washington State Medical Association, which called those rates “artificially low, arbitrary and subject to the political whims of Washington, D.C.”
On the bright side, if Governor Newsom or Governor Inslee succeeds in making health care more affordable and accessible for all with a new model, it will probably be replicated one by one in other states. That’s why I’m hopeful.
In 2004, the Canadian Broadcasting Corporation conducted an exhaustive nationwide poll to select the greatest Canadian of all time. The top-10 list included Wayne Gretzky, Alexander Graham Bell and Pierre Trudeau. No. 1 is someone most Americans have never heard of: Tommy Douglas.
Tommy Douglas, a Baptist Minister and left-wing politician, was premier of Saskatchewan from 1944 to 1961. Considered the father of Canada’s health system, he arduously built up the components of universal health care in that province, even in the face of an infamous 23-day doctors’ strike.
In 1962, the province implemented a single-payer program of universal, publicly funded health insurance. Within a decade, all of Canada had adopted it.
The United States will presumably, sooner or later, find a model for health care that suits its values and its needs. But 2019 may be a time to look to the states for ideas rather than to the nation’s capital. Whichever state official pioneers such a system will certainly be regarded as a great American.
https://www.nytimes.com/2019/01/16/opinion/california-states-health-care.html

Is the Drug Industry an Existential Threat to the Private Health Insurance Business? 

by Robert Laszewski - Health Care Policy and  Marketplace Review -  January 16, 2019

At a time when many Democrats are calling for a single-payer health insurance system, are the drug companies inadvertently driving the system on a course to that end?
Consider this.
The longtime political firewall against a single-payer system has been the satisfaction consumers have had with their employer-sponsored health insurance. Most voters have had no interest in giving up their affordable and attractive employer health benefits for the uncertainty of a one-size-fits-all government-run plan.
Employer-sponsored health insurance covers 140 million people—by far the largest part of the under-age-65 health insurance system. Most of these people are in the politically all-important middle class.
But in recent years, the employer share of premiums and out-of-pocket costs has been exploding (Willis Towers Watson, November 2018):

• The unemployment rate is 3.7%—the lowest since 2000.
• But, corrected for inflation, wages are up only 2% since January 2015—about one-half of one percent annually.
• For the bottom 60% of workers by income, wage gains have been completely wiped out by contributions for employer-provided health insurance.
• For the bottom 50% of workers, employers’ health insurance contributions averaged 30% to 35% of the total compensation package.
• From 1999 to 2015, worker premiums for a family plan more than doubled in inflation adjusted dollars, from $2,000 annually to $5,000.

In 2008, the average annual share of health insurance costs for employees was $3,354 but by 2018 that was up to $5,547:

Driving these costs has been pharmacy.
I recently polled a number of my clients on their historic and current drug spend.

• Twenty years ago, drug spend as a percentage of overall medical costs for a health insurer regularly ranged from 5% to 7%.
• Today, all drug costs, including specialty drugs and infusion drugs, range from 30% to 35% of all costs.
• Today, employer plan health care cost trend is regularly reported by health plans to be in the 5% to 7% range. 
• When their drug cost trend is subtracted from overall trend, non-drug trend is about 2%—essentially the level of current overall inflation.

To me there is an inescapable set of conclusions here:

• Because of the impact health insurance costs are having on take home income, we are at risk that the historical attractiveness employees and their families have had for employer-based health insurance will be lost.
• If the health insurance industry loses the support of employer-plan participants it will have lost the firewall that has made voters reluctant to support government-run health care.
• The health plan industry is providing health insurance to consumers for physician, hospital, and related costs at an annual level of increase that is close to overall inflation.
• With drug costs exploding from 5% to 7% of total costs to now 30% to 35% of costs, the primary villain in the multi-year erosion of the value of the employer-provided health benefit, and private insurance generally, has been drug costs.

Voters, Donald Trump, the Democrats, and the Republicans have all cited drug costs as a huge economic issue that has to be brought under control.
But for the private health insurance industry, it could be the one major factor that does them in if a solution isn’t found.
I can’t see a more important issue for the health insurance industry than the unfettered ability of drug companies to unilaterally dictate prices.
http://healthpolicyandmarket.blogspot.com/2019/01/is-drug-industry-existential-threat-to.html?

Learning From Cuba’s ‘Medicare for All’

by Nicholas Kristof - NYT - January 18, 2019

HAVANA — Claudia Fernández, 29, is an accountant whose stomach bulges with her first child, a girl, who is due in April.

Fernández lives in a cramped apartment on a potholed street and can’t afford a car. She also gets by without a meaningful vote or the right to speak freely about politics. Yet the paradox of Cuba is this: Her baby appears more likely to survive than if she were born in the United States.

Cuba is poor and repressive with a dysfunctional economy, but in health care it does an impressive job that the United States could learn from. According to official statistics (about which, as we’ll see, there is some debate), the infant mortality rate in Cuba is only 4.0 deaths per 1,000 live births. In the United States, it’s 5.9.

In other words, an American infant is, by official statistics, almost 50 percent more likely to die than a Cuban infant. By my calculations, that means that 7,500 American kids die each year because we don’t have as good an infant mortality rate as Cuba reports.

How is this possible? Well, remember that it may not be. The figures should be taken with a dose of skepticism. Still, there’s no doubt that a major strength of the Cuban system is that it assures universal access. Cuba has the Medicare for All that many Americans dream about.

“Cuba’s example is important since for decades ‘health care for all’ has been more than a slogan there,” said Dr. Paul Farmer, the legendary globe-trotting founder of Partners in Health. “Cuban families aren’t ruined financially by catastrophic illness or injury, as happens so often elsewhere in the neighborhood.”

In Havana, I shadowed a grass-roots doctor, Lisett Rodríguez, as she paid a house call on Fernández — and it was the 20th time Dr. Rodríguez had dropped in on Fernández’s apartment to examine her over the six months of her pregnancy. That’s on top of 14 visits that Fernández made to the doctor’s office, in addition to pregnancy consultations Fernández held with a dentist, a psychologist and a nutritionist.

This was all free, like the rest of the medical and dental system. It’s also notable that Cuba achieves excellent health outcomes even though the American trade and financial embargo badly damages the economy and restricts access to medical equipment.

Fernández has received more attention than normal because she has hypothyroidism, making her pregnancy higher risk than average. Over the course of a more typical Cuban pregnancy, a woman might make 10 office visits and receive eight home visits.

Thirty-four visits, or even 18, may be overkill, but this certainly is preferable to the care common in, say, Texas, where one-third of pregnant women don’t get a single prenatal checkup in the first trimester.

Missing a prenatal checkup is much less likely in Cuba because of a system of front-line clinics called consultorios. These clinics, staffed by a single doctor and nurse, are often run down and poorly equipped, but they make health care readily available: Doctors live upstairs and are on hand after hours in emergencies.

They are also part of the neighborhood. Dr. Rodríguez and her nurse know the 907 people they are responsible for from their consultorio: As I walked with Dr. Rodríguez on the street, neighbors stopped her and asked her about their complaints. This proximity and convenience, and not just the lack of fees, make Cuba’s medical system accessible.

“It helps that the doctor is close, because transportation would be a problem,” Fernández told me.

Home visits are also a chance to reach elderly and disabled people and to coach dysfunctional families, such as those wracked by alcoholism (a common problem), and to work on prevention. During Dr. Rodríguez’s visits to Fernández, for example, they discuss breast-feeding and how to make the home safe for the baby.

“It’s no secret that most health problems can be resolved at the primary-care level by the doctor, nurse or health worker nearest you,” said Gail Reed, the American executive editor of the health journal Medicc Review, which focuses on Cuban health care. “So, there is something to be said for Cuba’s building of a national primary-care network that posts health professionals in neighborhoods nationwide.”

Each consultorio doctor is supposed to see every person in the area at least once a year, if not for a formal physical then at least to take blood pressure.

All this is possible because Cuba overflows with doctors — it has three times as many per capita as the United States — and pays them very little. A new doctor earns $45 a month, and a very experienced one $80.

The opening of Cuba to tourism has created some tensions. A taxi driver who gets tips from foreigners may earn several times as much as a distinguished surgeon. Unless, of course, that surgeon also moonlights as a taxi driver.

Critics inside and outside the country raise various objections to the Cuban system. Corruption and shortages of supplies and medicine are significant problems, and the health system could do more to address smoking and alcoholism.

There are also allegations that Cuba fiddles with its numbers. The country has an unusually high rate of late fetal deaths, and skeptics contend that when a baby is born in distress and dies after a few hours, this is sometimes categorized as a stillbirth to avoid recording an infant death. 

Dr. Roberto Álvarez, a Cuban pediatrician, insisted to me that this does not happen and countered with explanations for why the fetal death rate is high. I’m not in a position to judge who’s right, but any manipulation seems unlikely to make a huge difference to the reported figures.

Outsiders mostly say they admire the Cuban health system. The World Health Organization has praised it, and Ban Ki-moon, the former United Nations secretary general, described it as “a model for many countries.”

In many ways, the Cuban and United States health care systems are mirror opposites. Cuban health care is dilapidated, low-tech and free, and it is very good at ensuring that no one slips through the cracks. American medicine is high-tech and expensive, achieving some extraordinary results while stumbling at the basics: A lower percentage of children are vaccinated in the United States than in Cuba.

The difference can also be seen in treatment of cancer. Cuba regularly screens all women for breast and cervical cancer, so it is excellent at finding cancers — but then it lacks enough machines for radiation treatment. In the United States, on the other hand, many women don’t get regular screenings so cancers may be discovered late — but then there are advanced treatment options.

As Cuba’s population becomes older and heavier (as in the United States, the nutrition problem here is people who are overweight, not underweight), heart disease and cancer are becoming more of a burden. And the lack of resources is a major constraint in treating those ailments.

There’s a Cuban saying: “We live like poor people, but we die like rich people.”

https://www.nytimes.com/2019/01/18/opinion/sunday/cuba-healthcare-medicare.html 

New poll reveals most Democrats are willing to pay Medicare for all tax

by Diane Archer - Just Feed - January 16, 2019

Pundits suggest that one of the biggest challenges to enacting Medicare for All is that the public will object to paying additional public taxes for their health care. But, is that really a challenge? A new Harvard/POLITICO poll shows that more than 80 percent of Democrats are willing to pay the Medicare for all tax.
With Medicare for All, people would stop paying a high private tax–premiums, deductibles and coinsurance for their health care. Indeed, eight in ten Americans would pay less for their health care. Only the wealthiest Americans would pay more.
The poll also shows that:

• More than four in ten Democrats support repealing and replacing the Affordable Care Act. Their goal is to ensure coverage for everyone. The ACA, which relies on the states to administer health exchanges, and commercial insurers to provide coverage, will never deliver the good affordable care we all need. Today, millions of Americans are still uninsured and millions with coverage struggle to afford needed care.
• A solid majority of  Republicans (60 percent) now support letting people under 65 buy into Medicare. The poll did not ask whether they supported Medicare for All to everyone. Curiously, fewer Republicans–51 percent–support a public health insurance option than a Medicare buy-in.  They are one and the same thing, two different ways of describing a Medicare option.
• Republicans and Democrats alike want Congress to lower prescription drug prices. It remains a top priority for Americans. More than nine in ten (92 percent) say it is very important (94 percent of Democrats and 89 percent of Republicans).
• Republicans and Democrats alike want to ensure coverage for people with pre-existing conditions.
• And, people in both parties do not want to see cuts to Medicare (more than nine in ten Democrats (93 percent) and nearly eight in ten Republicans.) Republicans in Congress who are eyeing Medicare cuts as a way to address the deficit should take note.

The mid-December poll surveyed 1,013 adults.
http://justcareusa.org/new-poll-reveals-most-democrats-are-willing-to-pay-medicare-for-all-tax/?