by Billy Wynne and Alyssa Llamas - Health Affairs - February 28, 2019
While Democratic presidential candidates and the newspaper headlines
hash out the ideological nuances of a Medicare-based single payer
coverage scheme, work is underway to consider how coverage can be
expanded to those in need within a realistic timeframe at minimal cost
or disruption to the existing system.
Even if we stretch to assume that Democrats, much less the broader
public and any Republicans, can coalesce around a unified vision of what
“true” Medicare for All would look like, history and political demands
suggest that other priorities will capture their attention and
expenditure of political capital should the party gain control of the
White House and Senate in 2021. After all, they spent the first year and
a half of President Obama’s first term drafting and passing the
Affordable Care Act (ACA), and eight years hence paying the political
price for it.
Instead, through use of existing authority under section 1332 of the
ACA and the Center for Medicare and Medicaid Innovation (CMMI), states
could begin opting in to a Medicare fallback option that will help
expand coverage and stabilize existing markets. If deemed necessary and
viable, modest statutory changes could be included in a reconciliation
package (oh yes, it’s coming…) to strengthen and broaden the long-term
horizon for such a plan. More importantly, legislation has already been
introduced that points to how the program could be designed and
implemented under current law.
Bills introduced by Senators Michael Bennet (D-CO) and Tim Kaine
(D-VA) as well as Senator Debbie Stabenow (D-MI) provide a roadmap to
how a Medicare fallback plan could be implemented.
In the Medicare-X Choice Act of 2017,
Senators Bennet and Kaine propose allowing individuals to purchase a
Medicare-like plan through the ACA Exchanges if their county has one or
less plan options currently available in that marketplace. A Medicare-X
plan would be available in all Exchange markets, including for small
businesses, shortly after that.
They recognize that some mechanical changes would be necessary to
institute such a program. For example, benefits offered would need to be
expanded to cover essential health benefits required by the respective
participating states. Premiums would need to be set by CMS using local
market factors and ensuring that the actuarial value of the plan and
administrative costs are covered. They would also include enrollees in
the Medicare-X plan in their respective Exchange risk pools to ensure
costs and benefits for existing Medicare beneficiaries are not impacted.
Senators Bennet and Kaine include some policy changes for Medicare-X
however that we believe are unnecessary and, because they will create
new bureaucratic and political burdens, are probably ill-advised at this
point. (Editor's Note 1)
For example, requiring CMS to negotiate drug prices and adopt new
payment models (beyond the numerous approaches already being
implemented) will likely expand the playing field of opposition and
complexity that could jeopardize enactment.
Senator Stabenow’s Medicare at 50 Act
also provides some framework for how a Medicare fallback option could
be implemented. While her bill limits coverage expansion to those
between 50-64 and does not require enrollment via the Exchanges, it
specifically applies premium and cost-sharing subsidies available via
the Exchanges to Medicare buy-in enrollees and allows for enrollment in
Medicare Advantage (MA) plans that include prescription drug coverage.
Here, as elsewhere, to facilitate adoption of this ambitious but
limited program, it will be vital to maintain existing policies whenever
possible. We undermine ourselves when we get jazzed about designing
wholly new coverage systems (and bureaucracies).
So, in sum, we propose the following core components of the plan:
Enrollees in Exchange markets with one or no plans currently
available would be allowed to purchase a traditional Medicare or MA plan
with drug coverage currently available in those areas, with wrap-around
coverage included to ensure compliance with state essential health
benefit requirements. Additional Exchange markets could be added after
initial testing on this more limited basis, a la the Bennet-Kaine bill.
Medicare providers participating in Medicare or in applicable MA
plan networks would be included and paid at existing Medicare or
relevant MA rates.
Premiums would be based on a combination of the actuarial value of
the plan and the local Exchange market, as other Exchange plans are.
Premium and cost-sharing subsidies would be identical to those offered
in the Exchanges today.
That’s about it folks. No fancy bells or whistles, just offering the
current Medicare program in uncompetitive Exchange markets. Pencils
down.
Now the admittedly trickier part: demonstrating that the program can
be implemented via a combination of existing ACA section 1332 waiver and
CMMI authority.
Under the ACA, section 1332 waivers allow states to test innovative
approaches to coverage so long as they insure as many people as the ACA
regime would with the same or more generous coverage and at the same or
less cost (in a nutshell). One way to leverage this authority could be
to suggest that most individuals who elect the Medicare fallback option
would have otherwise enrolled in an Exchange plan and that, by
leveraging Medicare provider rates and reduced administrative costs,
their premiums would be lower, thereby reducing Federal subsidy
expenditures. The Congressional Budget Office took this view in its 2013
analysis of a potential public plan in the Exchange markets.
Luckily, however, Mr. Trump and his Administration have set such a
strong precedent for “creative” reinterpretation of these waivers that
such economic gymnastics won’t be necessary. In this age of tit-for-tat
politics, we are happy to take their ball and run with it to expand
quality coverage at relatively low cost.
Naturally, the Trump Administration’s interpretation
of section 1332 waivers flexes them in the opposite direction of what
we’re suggesting here, i.e., they are allowing states to reduce coverage
and limit benefits. For example, under their guidelines, states need
only make available coverage options that are as comprehensive as those under the ACA and need not demonstrate that those comparable plans will actually be purchased.
The essential health benefits requirements for such waivers don’t
even have to be the actual requirements already elected by that state.
They just need to be any benefit package the state could theoretically
design. States are then free to offer alongside that token coverage
other options that do not meet ACA standards for benefits, preexisting
condition protections, etc. Swell deal.
In assessing cost, the new 1332 wavier standard
looks at the “aggregate effects of the waiver” and that deficit
neutrality take into account “all changes in income, payroll, or excise
tax revenue” as a result of the plan. Waivers that include access to
noncompliant ACA plans like association health plans and short-term
limited duration plans will be viewed “favorably.”
We think you get the point. Section 1332 waivers today are a long way
from home. By applying a lesser degree of deviation from the underlying
law than the current Administration, new Medicare fallback option
waivers could comfortably be approved in 2021.
While less pivotal, ACA authority afforded to CMMI would permit CMS
staff to expend the time and energy necessary to facilitate modification
of existing Medicare and MA plan options to meet the new fallback plan
requirements. Federal regulation of these plan options would be loosely
comparable to those applied to employer group waiver plans (EGWPs),
which are essentially MA plans with modest modifications to meet the
needs of that market.
CMMI authority allows for pilot programs that maintain or reduce
expenditures under the applicable program while maintaining or enhancing
the quality of care delivered. It is focused primarily on Medicare,
though participation by other payors is encouraged. The Medicare
fallback option is consistent with this goal by improving the quality of
care delivered to the un- and underinsured, and progress toward that
end would be assessed via the same metrics currently deployed for
Medicare and MA plans. Deficit neutrality requirements would be met by
accurately embedding administrative costs into the fallback plan
premiums. No other Medicare-related costs would be incurred because the
fallback option would be funded by a combination of premiums and
Exchange subsidies.
CMMI also has the authority to extend permanently and expand the
geographic area encompassed by such pilot programs if they prove
effective in meeting their quality and cost goals. Section 1332 waivers
assume the programs would be permanent.
To demonstrate how this plan could work immediately, we suggest
examining the market in Colorado, which happens to be home to one of us
as well as one of the Medicare-X plan’s lead sponsors, Senator Michael
Bennet. It also has a newly elected governor, former Congressman Jared
Polis, who won handily on a platform that included implementing Medicare
for All in the state. Both chambers of the legislature are controlled,
with some room to spare, by Democrats.
According to the Colorado Department of Regulatory Agencies, for 2019, consumers in 14 of the state’s 64 counties only have access to a single insurer. Essential health benefits
the state has adopted that are not currently covered by Medicare
include routine eye exams, vision care, maternity care, well baby
visits, dental care, and a few other services. It is not hard to see how
this program could be implemented in Colorado with relatively
streamlined administrative burden, so long as the state and federal
government stay disciplined in adhering to the core, necessary
components.
In addition to the traditional Medicare benefit being offered statewide, 51 MA plans are available from ten insurers in Colorado, with 95 percent of Medicare beneficiaries in the state having access to MA. On average, a beneficiary can choose from 19 plans offered by five insurers. In other words, there is ample competition in the vast majority of areas. In 2018, 36 percent
of Medicare beneficiaries in Colorado were enrolled in an MA plan, a
portion and trend that reflects the programs rising popularity
nationwide.
Consistent with Billy Wynne’s five-part series,
we believe it is a serious mistake, from coverage expansion, consumer
satisfaction, and political viability perspectives, for Democrats to
deny the full range of Medicare coverage options to any new program
claiming the Medicare for All mantle, as the single payer bill
recently introduced by Congresswoman Pramila Jayapal (D-WA) and over
100 other House Democrats would do. We want to actually get this done,
right?
While it’s imperative to be honest about legal and regulatory
requirements, not to mention political and other practical barriers,
it’s also necessary to be aggressive and perhaps a bit shameless in
utilizing all existing pathways to expanding coverage and bringing down
health care costs. Enough is enough and, in this case, it starts with
Democrats.
Let’s not cannibalize each other over relatively minor ideological
differences that won’t actually have much impact on coverage, quality,
or cost. Let’s look at the policy and political reality before us, such
as it is in this relatively conservative of developed nations, and
initiate a Medicare fallback option that will bring coverage and cost
relief to millions immediately without sabotaging equally important
efforts to address the manifold challenges we face. https://www.healthaffairs.org/do/10.1377/hblog20190228.968246/full/?
Editor's Note:
Here is a link to an "interview" of PNHP President Adam Gaffney by a gang of five Fox Business "News" talking heads. Apparently they thought it would take five of them to take on Dr. Gaffney.
Very informative:
US should transition to single-payer health care system: Dr. Adam Gaffney
The following clipping from Don McCanne's "Quote of the Day" is a worthwhile and thought provoking essay. The authors, from the Hasting Center (a bioethics research center) points out the differences between "patients" and "consumers", and the misguided efforts to conflate the two, part of the concerted effort to portray a professionally managed public service as a business.
Well worth the time it will take to read it.
-SPC
Patient-Centered Care, Yes; Patients As Consumers, No
1Michael K. Gusmano, Karen J. Maschke and Mildred Z. Soloman - Health Affairs - March, 2019
Abstract
There are numerous calls for building health care delivery systems that are more patient centered. The focus on patient-centered care has increasingly begun to rely upon, and even merge with, the concept of patients as consumers. Early references to patients as consumers were made by patient advocates who were attempting to challenge professional and corporate dominance in health care. Today, “consumer-driven” health care has become associated with neoliberal efforts to emphasize market factors in health reform and deemphasize government regulation and financing. In our view, a narrow focus on consumerism is conceptually confused and potentially harmful. The consumer metaphor wrongly assumes that health care is a market in the usual understanding of that term, that the high cost of US health care is a function of excessive consumer demand, and that price transparency and competition can deliver on the promise of reducing costs or ensuring quality. Furthermore, a consumer metaphor places disproportionate burdens on patients to reduce health care costs, and it could erode professional obligations to provide appropriate and effective care.
Introduction
Building a health care delivery system that is more patient centered has a lengthy history, including powerful grassroots efforts beginning in the 1960s. These initiatives see patient-centered care as an important means of improving health outcomes and a morally worthy good in itself. As a means to an end, patient-centered care includes efforts to make the care delivery system more efficient and easier for patients to navigate. Patient engagement—a particular form of patient-centered care—yields better, well-documented outcomes by stimulating patients to take on more active roles in promoting and maintaining their health. As a moral end in itself, patient-centered care emphasizes the importance of honoring patients’ values and preferences, and it is less paternalistic and more respectful. Although there are concerns about how the concept might be misapplied, there is broad support for it, evidenced by federal investment in studying how best to ensure patient-centered outcomes and patient-centered outcomes research.
Increasingly, however, the focus on patient-centered care has begun to rely upon, and even merge with, the concept of patients as consumers. In this article we call for greater vigilance in distinguishing patient-centered care from the concept of consumer-driven health care. Too often consumer-driven health care is used as if it were a synonym for patient-centered care. We argue that consumer-driven care is based on critical myths about what creates, and what can rein in, high-cost care. Moreover, the consumer-driven concept can easily place the burden for systemwide cost containment on the shoulders of individual patients. In this article we offer a brief history of the patient-centered care movement, demonstrate how the language of patient-centeredness is becoming appropriated by those advocating market reforms, and then articulate why the consumer metaphor is misguided and potentially harmful.
Origins of the Patient-Centered Care Movement
In contrast to the early use of these terms to connote ways of empowering patients, consumer driven and consumerism are now associated with market-oriented health reforms that place a burden on patients to solve cost and quality problems. These consumer terms function as metaphors that represent conceptual confusion and are potentially harmful. The terms wrongly assume that health care is a competitive market and that the high cost of US health care is a function of excessive consumer demand. Because these requisite assumptions are not met, the metaphor’s remedy—price transparency and competition—cannot deliver on the promise of reducing costs or ensuring quality. Moreover, it is misleading to use consumer driven, defined in this narrow sense, as a synonym for patient centered. A consumer metaphor could also erode obligations by policy makers and health care systems to build a truly patient-centered care system.
Health Care Is Not a Market
Patients can be construed as consumers only if they are operating within a market. But health care is not a market in the usual way that markets are defined, and thus patients do not have the power that consumers have to shape that market. Patients are not as well informed as physicians are about medical care. Often patients do not have well-formed preferences, and they seek care under circumstances in which they do not have the time or emotional stamina to shop around on the basis of quality and price. And if policy makers treat health care like any other market, there will likely be very limited cost savings, if any, and huge inequities will continue and likely increase. As Nancy Tomes puts it, “this linguistic transformation has come to represent the worst consequences of American medicine’s growing market orientation.
The High Cost of US Health Care Is Not Due To Excessive Consumer Demand
Policy makers in the US frequently act as if the main problem is excess volume, which in turn arises from excess patient demand. Because most patients in the US have some form of health insurance, they are insulated from the full cost of health care. Some commentators are concerned that there is a potential moral hazard, because insurance provides patients with an incentive to consume health care beyond the point at which marginal benefit equals marginal cost.
More than just a technical term, moral hazard is a concept that is normatively loaded. It suggests that health care spending is the result of policies that offer an incentive for bad behavior.
Moral hazard concerns suggest that the use of expensive hospitalizations, surgeries, and other interventions are shaped primarily by ability to pay. This perspective fails to recognize that most people consume such services only reluctantly. The use of these services is often driven by providers, not by patients. Indeed, academics and policy makers have expressed concern for decades about the reliance of the health insurance system on fee-for-service payments to physicians, hospitals, and other health care providers. Fee-for-service provides an incentive for physicians to deliver additional and more complex services than patients need (or more care than economists would view as efficient) because health care providers receive an additional payment for every additional service—and services that are viewed as more technically complex generate higher fees. In most countries outside the US, however, “provider-driven” demand is not countered by shifting costs to individual patients and asking them to control costs by acting as informed consumers in a marketplace. Instead, most countries rely on a combination of overall budget targets for health care services and systems of all-payer rate regulation in which national health insurance funds negotiate rates for hospital, physician, and other services with representatives from those professions. Because the US does not use the negotiating power of government to confront the power of providers, it pays higher prices for all medical goods and services than other countries do.
Not only is the use of market competition limited when it comes to asking patients to make efficient decisions about health care services and providers, but it also does not work well when it comes to making decisions about health insurance plans. Competition among health plans in the Medicare program was promoted as a method for reducing the costs of the program, but Medicare Advantage has not produced the intended savings. In fact, there has been some examination of choices made in Medicare Part D, suggesting that consumers do not necessarily make choices in their own best interests: Beneficiaries fail to select plans that provide better risk protection at lower cost. These findings are consistent with earlier work on choice overload and Medicare beneficiaries’ selection of health plans. The findings led economist Paul Krugman to exclaim that “‘consumer-based’ medicine has been a bust everywhere it has been tried.
While it is wise to help patients make more informed decisions about the costs of care and to grow in their ability to make quality comparisons across health systems, the main driver of health care costs is not consumer demand, but rather the introduction of new technologies and unwillingness on the part of US political leaders to regulate prices—or at least use government bargaining power as leverage to negotiate lower prices. The US relies on a system of uncoordinated payment by thousands of payers, many of which do not have the bargaining power necessary to drive down prices. This has resulted in high prices for medical services. Technological improvements in health care have driven increases in cost all over the world, but extraordinarily high prices and a refusal by government to regulate them or bargain them lower differentiate the US from other countries.
The Consumer Metaphor Could Erode Health Care Professionalism
Medical professionalism requires independent, discretionary judgment. Professionals do not simply do as they are told or requested but must act on the basis of knowledge, skill, and fiduciary obligations to patients’ well-being.
Hospitals must judge each case to find the right balance between patient and family preference and physician integrity. It seems reasonable to anticipate that as the consumer metaphor grows, physicians’ authority in these kinds of cases could erode to the point where they may become technicians doing what they are asked to do, but doing so against their own consciences.
Professionalism may also erode if physicians are more inclined to offer unproven treatments simply because patients demand them. If the customer is always right, self-restraint on the part of providers could erode.
Conclusion
After four decades of organized patient advocacy, US patients are still struggling to influence the health care decisions and policies that shape their lives. Conflating consumer approaches with authentically patient-centered approaches will exacerbate this gap. In health care delivery and health policy, a patient-centered approach affirms the ethical principles of respect for persons and justice while striving to make the health system more responsive to patients’ values and preferences. There are some patient-centered approaches, such as patient engagement and activation, that yield substantial improvements in health outcomes. Pursuing the sensible goal of creating a patient-centered health system will be undermined if consumer metaphors prevail. It is important for policy makers and health system leaders to be vigilant in distinguishing between these seemingly similar, but different, approaches. Patient-centered approaches aim to ensure clinical care that can meet patients’ preferences and needs. That is different from a consumer orientation calling on patients to be prudent purchasers of medical care services. The former approach empowers patients. The latter expects patients to solve society’s cost-containment challenges.
by Walter Einenkel - Daily Kos - February 28, 2019
One of the many hopes of a Medicare-for-all program is that in giving
our government a larger share of the medical “market” (for lack of a
better term), Americans—collectively—will be able to negotiate down the
skyrocketing costs of medicine. Every day brings tragic stories of
Americans young and old, of all racial backgrounds, dying after rationing their insulin—the
result of explosive increases in the costs of the drug. While some
people’s diabetes treatments have risen from $24 to $80 per vial over
the past decade, others face much more prohibitive prices. As diabetes
patient Alec Raeshawn Smith’s mother told NPR in September,
her son’s monthly bill for insulin and related supplies was around
$1,300 without insurance—something he and his family could not afford.
He died, having most likely been rationing a lifesaving medication he
could not afford.
These aren’t outliers. According to a study by Yale University researchers, 1 in 4 people with diabetes are rationing their prescriptions. This is not a new phenomenon, but one that is getting worse with the continuing rise in drug costs.
The most severe cost of insulin deprivation is death, but people who
survive with diabetes have to deal with the stresses brought about by
rising and falling blood sugar levels. These can include passing out,
losing one’s ability to control their temper, nausea, and dizziness. A
woman recounted to the New Yorker’sAmanda
Schaffer how she and her sister, who both have Type 1 diabetes, have
shared and rationed their insulin due to its rising costs. It’s
something that has driven her life, leading to her dropping out of
college her first year: “I lost a lot of weight that year, about
twenty pounds. When you don’t have insulin, you can’t eat much because
you can’t correct your blood sugar. So I was barely eating. I was
supposed to take four to five shots of insulin a day, and I was only
taking two to three. I was lethargic all the time. I was rationing just
so I could live. I knew if I ran out I wouldn’t survive more than a few
days. That took a mental toll.”
The solution is cheaper insulin. The problem, as Audrey Farley writes in the Washington Post,
is that many people are hoping that older types of cheaper insulin are
the solution—they just need to go to Walmart! The problem with using
older forms of insulin is that the level of planning for adults and
children can be unrealistic, as the older, slower-acting forms must be
taken well in advance of eating meals. The costs of older, slow-acting
insulins may be less, but the possibility of error on the part of
patients is much higher. When Trump breaks his campaign promises about
lowering drug prices, he’s not simply being a corrupt liar—he’s
complicit in our growing public health crises. https://www.dailykos.com/stories/2019/2/26/1837835/-t-least-25-of-diabetes-patients-rationing-insulin-as-drug-costs-continue-to-skyrocket
Drugmaker will offer half-price insulin in wake of debate over rising drug costs
by Thomas Mulier - Bloomberg - March 4, 2019
Eli Lilly's move is one of the first by a major drugmaker to offer a
cut-price version of a major product, and could put pressure on other
pharmaceutical companies to do the same.
Drugmaker Eli Lilly & Co. will offer a half-priced version of its
blockbuster insulin, becoming one of the first companies to effectively
cut the price of a top-selling drug amid the ongoing U.S. debate over
pharmaceutical costs.
While it will continue selling its brand-name version at the existing
price, Indianapolis-based Lilly will also sell a half-cost “authorized
generic” for $137.35 a vial, or $265.20 for a five-pack of injectable
pens. That will give a better deal to customers who pay cash, or who are
in insurance plans that make them pay a percentage of a drug’s list
price.
Insurers and PBMs don’t typically pay the listed prices for drugs,
and instead negotiate discounts and rebates that can help lower premiums
as a whole, but that can result in large out-of-pocket costs for some
patients on costly medicine or who have chronic conditions that force
them to take treatments year-round.
“The significant rebates we pay on insulins do not directly benefit
all patients. This needs to change,” Lilly Chief Executive Officer David
Ricks said in a statement announcing the move. “We hope our
announcement is a catalyst for positive change across the U.S.
health-care system.”
Lilly’s move is one of the first by a major drugmaker to offer a
cut-price version of a major product, and could put pressure on other
pharmaceutical companies to do the same. Mylan faced a similar outcry
over the price of its EpiPen allergy shot, and in 2016 announced a
lower-cost authorized generic. But such moves have been rare, even as
drug CEOs have been called before Congress and faced frequent criticism
from both political parties.
There are millions of people with diabetes in the U.S., and insulin
has become a particular flashpoint for the debate over the cost of
drugs. Lilly, Novo Nordisk A/S and Sanofi last month were sent letters
by a Senate committee asking how they set insulin prices, and Sanofi CEO
Olivier Brandicourt was among the pharma bosses who headed to
Washington last month to testify on drug costs.
Shares of Novo Nordisk, the world’s biggest maker of insulin, fell as much as 2.8 percent after Lilly’s announcement.
Lilly, Novo and Sanofi all heavily discount the price of many of
their diabetes medications, and there is typically a wide difference in
the list and net prices.
Sanofi’s CEO said in his testimony that the average net price of
Lantus, the company’s most prescribed insulin, has fallen by more than
30 percent since 2012, yet out-of-pocket costs for patients with
commercial insurance and Medicare have increased about 60 percent. In an
emailed statement, Sanofi said it has a competing version of Humalog,
called a biosimilar, that it sells under the name Admelog. The company
said it also offers a variety of discount programs for patients. https://www.pressherald.com/2019/03/04/drugmaker-will-offer-half-price-insulin-in-wake-of-debate-over-rising-drug-costs/?rel=related
Sorry, ER patients. People with elective procedures get the hospital beds first.
ByRichard Klascoand Richard Wolfe - The Washington Post - February 24, 2019
In a medical emergency, you may have a surprisingly
difficult time finding a bed in a hospital. This is because elective
admissions — that is, patients whose hospital stays have been scheduled
in advance — take priority over emergencies.
Such
a preference for elective admissions might be unexpected, as emergency
patients are, by definition, emergencies. But elective patients have
attributes that make them financially attractive. They arrive promptly
in the morning; they are well-insured; and they undergo invasive
procedures that represent a significant revenue stream for hospitals.
An analysis of more than 1 million Medicare cases
indicates that hospitals earn about $700 more on each elective
admission than on each patient admitted through the emergency department
(ED).
Predictability is often touted as a
reason for prioritizing elective admissions. But while predictability is
thought to be in short supply in the ED, the data — and our experience
as ED doctors — argue otherwise. The number of patients admitted through
the ED are about the same every day of the week, whereas elective
admissions peak Mondays through Thursdays and tail off toward the
weekend. This is designed to minimize the need for weekend work by the
doctors who perform procedures.
The weekday peak
in elective admissions creates a bottleneck that results in admitted
patients “boarding” in the ED. Boarded patients have nominally been
admitted to the hospital, yet they physically remain in the ED until
vacancies in the hospital arise. But vacancies may not arise for hours
or, in extreme cases, days.
Boarding increases
the risk for patients whose condition might become unstable: patients
with new-onset diabetes who require intensive monitoring; patients with
metastatic cancer, who require high doses of pain medication; and critically ill patients, who require advanced life support.
A 2007 publication by the national Institute of Medicine
found that “ED overcrowding is a nationwide phenomenon, affecting urban
and rural areas alike” and noted that “on a typical Monday evening, 73
percent of hospitals reporting boarding two or more admitted patients.”
Boarding
is not merely inconvenient. It is also unsafe. As the Institute of
Medicine report put it: “The potential for errors, life-threatening
delays in treatment, and diminished overall quality of care is enormous
in these situations.” In a 2011 study of more than 40,000 ED admissions,
the risk of in-hospital death nearly doubled,
from 2.5 percent to 4.5 percent, in patients who boarded for more than
12 hours compared with those who boarded for less than two hours.
Boarding also tends to exert a disproportionate effect on vulnerable populations. The length of ED stay has been found to be longer for African American and Hispanic patients. The elderly and patients with mental-health issues are more likely to receive their initial inpatient care on gurneys in the ED.
The
problem of boarding can be solved by increasing inpatient hospital bed
capacity, but the cost of increasing capacity can be daunting to many
medical institutions that are already struggling to maintain profitability.
An
alternative is to increase efficiency by a process known as
“smoothing.” Smoothing reorients schedules to distribute surgical cases
uniformly across the workweek, mitigating the bottleneck to emergency
admissions. At the Mayo Clinic, smoothing resulted in “improvement in
operating room operational and financial performance.” At Massachusetts
General Hospital, which performs more than 36,000 operations a year,
smoothing decreased congestion and improved effective operating room
capacity.
But smoothing can be disruptive to the doctors who perform the surgeries and procedures that drive hospital revenues.
It
can require them to work less desirable hours and alter long-standing
practices, such as having a dedicated day of the week in the operating
room. As a result, adoption has been slow, according to research published in 2012 in Health Affairs. Only 6 percent of hospitals with the busiest EDs were found using smoothing for surgical scheduling in a 2015 study.
At
the institutions where we work, the University of Colorado improved
efficiency by decreasing unnecessary admissions by 20 percent, despite a
53 percent increase in ED volume. And, Boston’s Beth Israel Deaconess
Medical Center implemented a number of techniques to speed patient flow
through the system: bedside registration, electronic dashboard that
displays bed status throughout the hospital, physical expansion of the
ED, and a paging protocol to notify senior leadership of impending
capacity issues. When hospital capacity is strained, BIDMC
administrators work with doctors in the community to direct emergency
admissions to other hospitals that have capacity.
Achieving
these gains on a national level will require Medicare and private
insurers to up their reimbursement rates to hospitals for emergency
admissions. Making that change will be costly, but it will help ensure
that, in an emergency, your hospital bed is ready when you need it.
Richard Klasco is an assistant professor of emergency medicine at the
University of Colorado School of Medicine. Richard Wolfe is chair of the
Department of Emergency Medicine, Harvard Medical Faculty Physicians at
Beth Israel Deaconess Medical Center in Boston, and is a member of the
board of directors of the Society for Academic Emergency Medicine.
Mental Health Treatment Denied to Customers by Giant Insurer’s Policies, Judge Rules
by Reed Abelson - NYT - March 5, 2019
In a
scathing decision released Tuesday, a federal judge in Northern
California ruled that a unit of UnitedHealth Group, the giant health
insurer, had created internal policies aimed at effectively
discriminating against patients with mental health and substance abuse
disorders to save money.
U.S. Chief Magistrate Judge Joseph C.
Spero found that United Behavioral Health, the insurer’s unit that
administers treatments for mental illness and addiction in private
health plans, had violated its fiduciary duty under federal law.
In
his 106-page decision, Judge Spero described the company’s guidelines
as “unreasonable and an abuse of discretion” and having been “infected”
by financial incentives meant to restrict access to care.
“There
is an excessive emphasis on addressing acute symptoms and stabilizing
crises while ignoring the effective treatment of members’ underlying
conditions,” he said. He dismissed much of the testimony by
UnitedHealth’s experts as “evasive — and even deceptive.”
Patients
said they were denied care as soon as they appeared stable. One of the
plaintiffs in the case said in a filing her son, who struggled with
substance abuse, died after he was forced to leave a residential
treatment facility when the insurer denied coverage.
“In our view,
it’s a monumental win for mental health and substance abuse patients,”
said D. Brian Hufford, an attorney with Zuckerman Spaeder, who, along
with Psych-Appeal, a private law firm specializing in insurance coverage
for mental health issues, is representing the plaintiffs. The
plaintiffs are part of a class-action lawsuit against United Behavioral
Health, and say they were covered under the United plans from 2011 to
2017 and denied care.
In the aftermath of the ruling, the company maintained that it had not failed to provide the proper care.
“We
look forward to demonstrating in the next phase of this case how our
members received appropriate care,” said UnitedHealth in an emailed
statement. “We remain committed to providing our members with access to
the right care for the treatment of mental health conditions and
substance use disorders.”
Judge Spero is expected to reach a final judgment in the next few months.
The
case represents the latest development in the contentious debate over
how health insurance companies cover mental health and substance abuse
disorders, as compared to medical conditions like diabetes, multiple
sclerosis and asthma. In spite of the passage of a federal law, the
Mental Health Parity and Addiction Equity Act of 2008, patients have long complained about the difficulty of getting care covered, especially when they are in no immediate danger.
When
the federal parity law prevented insurers from placing sharp limits on
behavioral health coverage, the companies “came up with an even more
insidious approach,” Mr. Hufford said, by developing internal rules that
focused on providing expensive outpatient and residential care only
when patients were acutely ill.
Once the acute condition was
treated, the companies would reduce or deny services, he said. The care
“wasn’t addressing the underlying issue or the chronic condition,” he
said.
Advocates praised the judge’s decision as making clear that
insurers cannot ignore standards that would be applied to other forms of
medical care in determining whether they will cover a mental health or
substance abuse treatment. “This should put health plans on notice that
they simply can’t make up the rules as they go along,” said Angela
Kimball, the national director of public policy and advocacy for NAMI,
the National Alliance on Mental Illness.
Such denials of care are
not limited to UnitedHealth, said Patrick Kennedy, the mental health
advocate and former member of Congress who is pushing for stronger
enforcement of federal and state parity laws. The judge’s ruling that
UnitedHealth had not complied with the law is an “independent validation
of what we have as advocates been saying for 11 years since this law
was passed,” he said. https://www.nytimes.com/2019/03/05/health/unitedhealth-mental-health-parity.html
Glasses can have a markup of 1,000%. Two former LensCrafters executives revealed why.
by Chavie Lieber - VOX - March 6, 2019
For many, they’re a basic necessity, but eyeglasses are expensive.
Designer frames can cost upward of $400, while standard
glasses from a company like Pearle Vision can start at around $80. In
recent years, the eyewear startup Warby Parker has stepped into the
picture, providing an affordable, attractive solution for shoppers, but
glasses from Warby Parker still start at $95.
These prices, it turns out, are marked up. Way up.
This week, the Los Angeles Times
spoke with two former executives of LensCrafters: Charles Dahan and E.
Dean Butler, who founded LensCrafters in 1983. Both admitted that today,
glasses are marked up nearly 1,000 percent.
“You can get amazingly good frames, with a Warby Parker
level of quality, for $4 to $8,” said Butler. “For $15, you can get
designer-quality frames, like what you’d get from Prada.”
Butler added that shoppers could get “absolutely
first-quality lenses for $1.25 apiece.” When hearing that some glasses
sell for $800 in the US, he laughed. “I know. It’s ridiculous. It’s a
complete rip-off.”
Butler and Dahan confirmed what shoppers have already
suspected: There’s price gouging in the optical industry. The main
culprit? The eyewear giant EssilorLuxottica, which essentially controls
the industry.
Luxottica is an Italian glasses company that was founded
in 1961. Its most popular brands are Oakley and Ray-Ban, but over the
years it’s gone through a spree of acquisitions, buying Sunglass Hut, Pearle Vision, and Cole National, which owns both Target and Sears Optical. Luxottica also owns the licensing on designer eyewear
from Prada, Chanel, Coach, Versace, Michael Kors, Tory Burch, and more.
If you buy glasses from a retail store in the US, the odds are pretty
high that they were made by Luxottica.
Essilor is a French optical company that’s been around since the 1800s but has spent the past 20 years acquiring some 250 companies. In 2017, Essilor bought Luxottica
for about $24 billion. Although it got approval by regulators in the US
and the EU, and even passed an antitrust investigation by the Federal Trade Commission, business experts have called the merged EssilorLuxottica a monopoly. (Vox reached out to the company for comment and did not immediately hear back.)
Journalist Sam Knight wrote in the Guardian
last year that “in seven centuries of spectacles, there has never been
anything like it. The new entity will be worth around $50 billion, sell
close to a billion pairs of lenses and frames every year, and have a
workforce of more than 140,000 people.”
Reporting extensively on how both companies have their hands in every aspect of the eyewear industry, Knight wrote:
If Luxottica has spent the last quarter of a
century buying up the most conspicuous elements of the optical business
(the frames, the brands and the high-street chains), then Essilor has
busied itself in the invisible parts, acquiring lens manufacturers,
instrument makers, prescription labs (where glasses are put together)
and the science of sight itself. The company holds more than 8,000
patents and funds university ophthalmology chairs around the world.
With such a grip on the industry, EssilorLuxottica
essentially controls pricing. As one member of England’s Association of
Optometrists told the BBC of the merger, “This now allows the group to control all aspects of supply of product — from manufacturer to the end user.”
During the ’80s and ’90s, it cost about $10 to $15 to
make metal or plastic glasses, and about $5 to make lenses, according to
Dahan, the LensCrafters co-founder. His company would price a product
that cost about $20 to make at $99. Today, though, EssilorLuxottica
marks its products up to several hundred dollars, because it can.
The company’s control hasn’t gone unnoticed. In 2017, former FTC policy director David Balto called on regulators in an op-ed to block the EssilorLuxottica merger, saying shoppers “need real competition to curb the sky-high prices of eyeglasses.” Industry experts
have long said the company’s powers, even when they were separate
entities, made for unfair results, for competing brands as well as
shoppers’ wallets.
“That’s how they gained control of so many brands,” Dahan
said. “If you don’t do what they want, they cut you off. Federal
officials fell asleep at the wheel. They should never have allowed all
these companies to roll into one. It destroyed competition.”
Some companies have been able to compete against
EssilorLuxottica’s high prices, particularly online retailers. There’s
ZenniOptical, a digital-only company that sells glasses for as low as
$8. There’s also the company America’s Best, a giant glasses company
that has more than 400 stores in the US.
Warby Parker, too, has been able to stand on its own
pricing structure. It launched in 2010 and has become a millennial
favorite for its try-on-at-home option and its colorful fleet of over 85
stores. Some have estimated
that Warby Parker, which doesn’t release financial figures, earns about
$340 million a year, compared to EssilorLuxottica’s annual $8.4
billion. But it still proves that a company can sell shoppers eyewear
that doesn’t have a comically egregious markup.
Still, as the former LensCrafters executives revealed,
many glasses really cost about $20 to make. This means even Warby
Parker’s $95 frames could be seen as overpriced. Seems like eyeglasses
will forever be a product we’re spending too much on.
by Katie Thomas and Charles Ornstein - NYT - December 31, 2019
Cancer centers are re-evaluating their relationships with
health care companies, including when, if ever, doctors and researchers
should serve on corporate boards. Here are some hospital executives and
cancer researchers who sit on the boards of publicly traded companies,
in dual roles that may raise questions about conflicts of interest.
Dr. Laurie H. Glimcher
Credit
Image Credit
President and chief executive of the Dana-Farber Cancer Institute, Boston
Company: Dr.
Glimcher sits on the boards of the British drugmaker GlaxoSmithKline
and Waters Corp., a laboratory equipment and software company. Outside Compensation: Dr. Glimcher joined the board of GlaxoSmithKline in September of 2017; she received $101,000 in total compensation from the company that year, plus compensation of $285,440 from Waters that year.
Dr. Gary Gilliland
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Image Credit
President and director of the Fred Hutchinson Cancer Research Center, Seattle
Chief executive of the Huntsman Cancer Institute at the University of Utah, Salt Lake City
Company: Dr.
Beckerle is on the board of the health care giant Johnson & Johnson
and the Huntsman Corporation, a chemical manufacturer. Compensation: Johnson & Johnson paid Dr. Beckerle $324,893 in total compensation in 2017, and the Huntsman Corporation paid her $310,000.
Dr. Craig B. Thompson
Credit
Image Credit
Chief executive of Memorial Sloan Kettering Cancer Center, New York
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