Archive for the ‘Healthcare’ Category
Paul Krugman posts an interesting graph:
Kevin Drum blogs at Mother Jones:
Medicaid funding is shared by the states and the federal government. Between 2000 and 2013—the most recent year reported by the CMS actuaries—the share of Medicaid spending shouldered by the states increased by an average of 6.1 percent per year. This is not total spending. It’s just the portion the states themselves paid for.
In 2015, according to a survey by the Kaiser Foundation, spending by states that refused to expand Medicaid grew by 6.9 percent. That’s pretty close to the historical average. However, spending by states that accepted Medicaid expansion grew by only 3.4 percent.Obamacare may have increased total Medicaid enrollment and spending, but the feds picked up most of the tab. At the state level, it actually reined in the rate of growth.
In other words, the states that have refused the expansion are cutting off their noses to spite their faces. They’re actually willing to shell out money just to demonstrate their implacable hatred of Obamacare. How much money? Well, the expansion-refusing states spent $61 billion of their own money on Medicaid in 2014. If that had grown at 3.4 percent instead of 6.9 percent, they would have saved about $2 billion this year.
Here’s what this means: the states that refuse to expand Medicaid are denying health care to the needy and paying about $2 billion for the privilege. Try to comprehend the kind of people who do this.
POSTSCRIPT: Actually, there’s more. The residents of every state pay taxes to fund Obamacare, whether they like it or not. Residents of the states that refuse to expand Medicaid are paying about $50 billion in Obamacare taxes each year, and about $20 billion of that is for Medicaid expansion. Instead of flowing back into their states, this money is going straight to Washington DC, never to be seen again.
So they’re willing to let $20 billion go down a black hole and pay $2 billion extra in order to prevent Obamacare from helping the needy. It’s hard to fathom, isn’t it?
Very interesting article by Benedict Carey in the NY Times:
More than two million people in the United States have a diagnosis of schizophrenia, and the treatment for most of them mainly involves strong doses of antipsychotic drugs that blunt hallucinations and delusions but can come with unbearable side effects, like severe weight gain or debilitating tremors.
Now, results of a landmark government-funded study call that approach into question. The findings, from by far the most rigorous trial to date conducted in the United States, concluded that schizophrenia patients who received smaller doses of antipsychotic medication and a bigger emphasis on one-on-one talk therapy and family support made greater strides in recovery over the first two years of treatment than patients who got the usual drug-focused care.
The report, to be published on Tuesday in The American Journal of Psychiatry and funded by the National Institute of Mental Health, comes as Congress debates mental health reform and as interest in the effectiveness of treatments grows amid a debate over the possible role of mental illness in mass shootings.
ts findings have already trickled out to government agencies: On Friday, the Centers for Medicare & Medicaid Services published in its influential guidelines a strong endorsement of the combined-therapy approach.Mental health reform bills now being circulated in Congress “mention the study by name,” said Dr. Robert K. Heinssen, the director of services and intervention research at the centers, who oversaw the research.
In 2014, Congress awarded $25 million in block grants to the states to be set aside for early-intervention mental health programs. So far, 32 states have begun using those grants to fund combined-treatment services, Dr. Heinssen said.
Experts said the findings could help set a new standard of care in an area of medicine that many consider woefully inadequate: the management of so-called first episode psychosis, that first break with reality in which patients (usually people in their late teens or early 20s) become afraid and deeply suspicious. The sooner people started the combined treatment after that first episode, the better they did, the study found. The average time between the first episode and receiving medical care — for those who do get it — is currently about a year and half.
The more holistic approach that the study tested is based in part on programs in Australia, Scandinavia and elsewhere [i.e., nations more advanced in medical care than the U.S. – LG] that have improved patients’ lives in those countries for decades. This study is the first test of the approach in this country — in the “real world” as researchers described it, meaning delivered through the existing infrastructure, by community mental health centers.
The drugs used to treat schizophrenia, called antipsychotics, work extremely well for some people, eliminating psychosis with few side effects; but most who take them find that their bad effects, whether weight gain, extreme drowsiness, or emotional numbing, are hard to live with. Nearly three quarters of people prescribed medications for the disorder stop taking them within a year and a half, studies find. . .
THirt has an interesting post on Daily Kos:
Most people are aware of the main provisions of the ACA: elimination of pre-existing conditions, kids allowed to be on their parents’ insurance until age 26, coverage without cost for preventative healthcare, expansion of Medicaid for states willing to accept billions of dollars from the federal government, and of course, http://www.healthcare.gov and its insurance exchanges.
However, there is a smaller part of the ACA that has potentially far-reaching effects on all of primary care, and I’ve hardly heard a thing about it in the media. It is helping primary care physicians transform how we deliver care to our population of patients and it is actually kind of exciting. . .
For a brief piece of background, I am a family practice physician in a multi-specialty group of about 60 doctors, mostly primary care.
I think most people would agree that the American healthcare system has a lot of flaws. One of the biggest flaws is our fee-for-service system in general. It doesn’t make any sense, but I get paid the same to see someone for an ear infection as I do to see someone with high blood pressure, high cholesterol, and diabetes. Someone comes for an appointment, and based on the level of detail I obtain in the history, the level of detail needed in physical examination, and the complexity of medical decision-making, that determines the fee for the visit. So as you can imagine, an ear infection or sore throat requires a LOT less work than managing three or more chronic problems, and the medications, labs, monitoring tests, etc. that go along with them. But again, you are paid the same to see the ear infection patient as you are to see the person with uncontrolled diabetes, high BP, and high cholesterol.
On the surface, that makes no sense at all, but the thinking is that it probably costs too much for the ear infection, too little for the diabetes/BP/cholesterol patient, but it all evens out in the long run. The rules for ‘coding’ a level of service for an appointment govern the fees, and they are relatively simple, as otherwise it would just be too complicated to have a different fee structure for every diagnosis. Anyway, the idea is that it all comes out in the wash. That might be true in a simple world, but of course we live in a complex world with a lot of moving parts.
As you can see, the fee-for-service environment does not really incentivize physicians to focus their efforts on chronic disease management. I’m not implying that physicians are not trying to do a good job or are just in it to make as much money as possible, but let’s face it: if you make the same amount per patient, and you can see 30 patients with ear infections or 15 diabetic/hypertensive/hyperlipidemic patients, which would you choose? How would you set up your schedule?
Everyone agrees that prevention is the most cost-effective way to keep people healthy. Vaccines, for example, are arguably the single most cost-effective thing in all of medicine (get your flu vaccine if you have not already done so, by the way!). Preventative care is now covered without a co-pay because of the ACA. That is awesome. However, better care/control of chronic disease doesn’t pay well, as discussed above. But better control of diabetes, of BP, of cholesterol, of COPD, of asthma, of heart failure will save lots and lots and lots of money in the long run because complications of all these diseases are expensive. It costs a LOT to be in the hospital, to have a heart bypass, to have dialysis, etc. A rough estimate is that a well-controlled diabetic costs the system an average of $4,000 per year to take care of, but an uncontrolled diabetic will cost $16,000 or more. So why would we pay doctors the same for an ear infection as we would to take care of serious chronic disease?
Part of the answer unfortunately is that people switch insurances and by the time they develop more significant complications, they are on Medicare anyway, so UHC, Humana, Anthem don’t need to worry about paying for dialysis. In the long run, though, it saves us all money if we do a better job of taking care of chronic illness. So it makes sense to try to incentivize doctors to improve our chronic disease management instead of incentivizing doctors to just see as many patients as possible in the day.
So enough background. Here’s the good stuff. The ACA provides funding and guidance for a new way to approach health care. The Comprehensive Primary Care initiative is a program that involves about 500 practices across the country, in several geographic areas. Southwest Ohio/N. KY, New Jersey, Arkansas, Colorado, New York, Oregon, and Oklahoma have participating practices. Practices were selected based on a number of factors, including past willingness to participate in such things as NCQA quality recognition, and patient-centered medical home (PCMH) certification. You can read more here: http://innovation.cms.gov/…
Basically, CMS (center for Medicare and Medicaid services) provides funding outside of the fee-for-service environment for practices to do a better job of chronic disease management. There is/was a detailed application process, and multiple milestones you have to meet, but a lot of it boils down to CMS providing additional monies for practices to use as they see fit in order to help improve the care for their patients, particularly (although not exclusively) those with higher risk chronic illness.
The whole thing is actually really interesting. While there are quite a lot of specifics, there are also a lot of areas open to interpretation. CMS is partnering with multiple private insurance carriers to provide a monthly fee (outside of any appointment or fee-for-service interaction) to physician practices in order to help those practices invest in infrastructure which will help improve patient care. The amount per patient per month is based on risk assessment. Basically, the more diagnoses, and the more complicated a patient is, the higher the monthly fee. A well-controlled diabetic would have a lower fee than a diabetic with chronic kidney disease, heart disease, and neuropathy. So right off the bat, you can see how this is a paradigm shift from the traditional fee-for-service environment. You may actually be paid more to take care of a more complicated person and try to keep them out of the hospital.
However, and this is a BIG part, the money from this CPC initiative can NOT be paid to physicians as compensation. It is to be used to improve infrastructure. This is actually pretty cool because . . .
A modern corporation focuses intensely on doing whatever it can to increase profit, and since $1 cut from costs means $1 more in profit (unlike $1 increase in revenue, which contributes much less to profit due to the need to deduct materials costs, production costs, marketing costs, and overhead from the $1), corporations are intensely focused on cutting costs. One way to do this is to “externalize” the costs: have the costs paid by someone other than the corporation. For example, many corporations have the pubic at large pay for the clean-up of their toxic sites: the government pays the cost, which means you and I pay the cost.
Corporations now are working to avoid the costs associated with worker’s compensation, as described by Michael Grabell of ProPublica and Howard Berkes of NPR:
STANDING BEFORE A GIANT MAP in his Dallas office, Bill Minick doesn’t seem like anyone’s idea of a bomb thrower. But backed by some of the biggest names in corporate America, this mild-mannered son of an evangelist is plotting a revolution in how companies take care of injured workers.
His idea: Let them opt out of state workers’ compensation laws — and write their own rules.
Minick swept his hand past pushpins marking the headquarters of Walmart, McDonald’s and dozens of his other well-known clients, and hailed his plan as not only cheaper for employers, but better for workers too.
“We’re talking about reengineering one of the pillars of social justice that has not seen significant innovation in 100 years,” Minick said.
Minick’s quest sounds implausible, but he’s already scored significant victories.
Many of the nation’s biggest retail, trucking, health care and food companies have already opted out in Texas, where Minick pioneered the concept as a young lawyer. Oklahoma recently passed a law co-written by Minick allowing companies to opt out there. Tennessee and South Carolinaare seriously considering similar measures. And with acoalitionled by executives from Walmart, Nordstrom and Lowe’s, Minick has launched a campaign to get laws passed in as many as a dozen states within the next decade.
But as Minick’s opt-out movement marches across the country, there has been little scrutiny of what it means for workers.
ProPublica and NPR obtained the injury benefit plans of nearly 120 companies who have opted out in Texas or Oklahoma — many of them written by Minick’s firm — to conduct the first independent analysis of how these plans compare to state workers’ comp.
The investigation found the plans almost universally have lower benefits, more restrictions and virtually no independent oversight.
Already in Texas, plans written by Minick’s firm allow for a hodgepodge of provisions that are far different from workers’ comp. They’re whyMcDonald’s doesn’t cover carpal tunnel syndrome and why Brookdale Senior Living, the nation’s largest chain of assisted living facilities, doesn’t cover most bacterial infections. Why Taco Bell can accompany injured workers to doctors’ appointments and Sears can deny benefits if workers don’t report injuries by the end of their shifts.
Unlike traditional workers’ comp, which guarantees lifetime medical care, the Texas plans cut off treatment after about two years. They don’t pay compensation for most permanent disabilities and strictly limit payouts for deaths and catastrophic injuries.
The list of what the plans don’t cover runs for pages. They typically won’t pay for wheelchair vans, exposure to asbestos, silica dust or mold, assaults unless the employee is defending “an employer’s business or property,” chiropractors or any more than 75 home health care visits. Costco won’t cover external hearing aids costing more than $600. The cheapest external hearing aid Costco sells? $900.
The plans in both Texas and Oklahoma give employers almost complete control over the medical and legal process after workers get injured. Employers pick the doctors and can have workers examined — and reexamined — as often as they want. And they can settle claims at any time. Workers must accept whatever is offered or lose all benefits. If they wish to appeal, they can — to a committee set up by their employers.
In many cases, ProPublica and NPR found, the medical director charged with picking doctors and ultimately reviewing whether injuries are work-related is Minick’s wife, Dr. Melissa Tonn, an occupational medicine specialist who often serves as an expert for employers and insurance companies.
Workers’ comp was founded on the premise that employers owed a duty to injured workers and their families. And laws in every state require them to pay workers’ medical bills and some of their lost wages until they recover — or for life if they can’t.
Earlier this year, a ProPublica and NPR investigation detailed how states have chipped away at these guarantees. . .
Continue reading. It gets worse.
The government is supposed to protect the public, not assist corporations in undermining the general welfare.
The government really must take action. The goal of profits at any price is undermining care for the sick through extortionate schemes, such as the one run by Martin Shkreli. (It’s extortion rather than simple price gouging because of the threat involved: not taking some of these drugs mean that the patient will die.)
Take a look at how Valeant operates:
That’s from a NY Times article by Andrew Pollack and Sabrina Tavernise:
J. Michael Pearson has become a billionaire from his tough tactics as the head of the fast-growing Valeant Pharmaceuticals International.
And consumers like Bruce Mannes, a 68-year-old retired carpenter from Grandville, Mich., are facing the consequences.
Mr. Mannes has been taking the same drug, Cuprimine, for 55 years to treat Wilson disease, an inherited disorder that can cause severe liver and nerve damage. This summer, Valeant more than quadrupled its price overnight.
Medicare will now have to cover about $35,000 for the 120 capsules he takes each month, and Mr. Mannes will have to pay about $1,800 a month out of pocket, compared with about $366 he paid in May.
“My husband will die without the medicine,” said his wife, Susan, who is now working a second part-time job to help pay for health care. “We just can’t manage another two, three thousand dollars a month for pills.”
Cuprimine is just one of many Valeant drugs whose prices have spiked as part of the company’s concerted strategy, which has richly rewarded its investors and made it one of Wall Street’s most popular health stocks.
But Valeant’s habit of buying up existing drugs and raising prices aggressively, rather than trying to develop new drugs, has also drawn the ire of lawmakers and helped stoke public outrage against the growing trend of higher and higher drug prices imposed by big drug companies. This year alone, Valeant raised prices on its brand-name drugs an average of 66 percent, according to a Deutsche Bank analysis, about five times as much as its closest industry peers.
Some presidential candidates have also seized on the issue. Hillary Rodham Clinton, who is seeking the Democratic nomination, called for efforts to control “price gouging” after a public outcry over the actions of Turing Pharmaceuticals, which abruptly increased the price on a drug to $750 a tablet from $13.50.
And last week, Democrats on the House Committee on Oversight and Government Reform demanded that Valeant be subpoenaed for information about big price increases on two old heart drugs that the company acquired in February. . .
Valeant defended itself, saying in a statement that it “prices its treatments based on a range of factors, including clinical benefits and the value they bring to patients, physicians, payers and society.” It says patients are largely shielded from price increases by insurance and financial assistance programs the company offers, so that virtually no one is denied a drug they need.
But Mr. Pearson, a former McKinsey & Company consultant, has been blunt about saying he has a duty to shareholders to wring the maximum profit out of each drug. And in some cases old neglected drugs sell for far less than newer drugs for the same diseases.
If “products are sort of mispriced and there’s an opportunity, we will act appropriately in terms of doing what I assume our shareholders would like us to do,” he told analysts in a conference call in April.
Valeant is an extreme example of practices that have been around in the pharmaceutical industry for years. The United States, unlike most countries, does not control drug prices, and pharmaceutical manufacturers have relied heavily on steady and sometimes outsize price increases in this country to bolster their revenue and profits.
Valeant is known for buying one company after another, and laying off their employees to achieve savings, while accumulating a debt of about $30 billion. It spends an amount equivalent to only 3 percent of its sales on research and development, which it views as risky and inefficient compared to buying existing drugs. Traditional big drug companies spend 15 to 20 percent of sales on research and development. Valeant also pays extremely low taxes because it is officially based in Canada, although Mr. Pearson operates from New Jersey.
Price increases provide an extra boost to the company’s sales and profits.
For example, after Valeant acquired Salix Pharmaceuticals this year, it raised the price of one Salix drug, the diabetes pill Glumetza, about 800 percent, in two steps. . .
Read the whole thing. There’s a lot more. It sure doesn’t sound like the best healthcare system in the world. Later in the article:
Ronny Gal, a pharmaceutical analyst at Sanford C. Bernstein & Company, said smaller price increases on widely used drugs had a much bigger effect on health care spending than the larger increases by Valeant on drugs with small sales.
Dr. Irl B. Hirsch, a diabetes specialist at the University of Washington School of Medicine in Seattle, said insulin prices had risen so much in recent years that some patients were scrimping on groceries to pay for it. The price of a package of five Lantus injectable pens from Sanofi has gone from about $179 in 2010 to $372 last year, he said, and insurance will often cover only one package at a time.
“All of this stuff that makes life so inconvenient, this would have been unheard of five or 10 years ago,” he said.
UPDATE: Business Insider has a good story with more charts displaying the effects of greed—for example, this one:
Read the whole article. Something should be done.
The NY Times has an interesting story about how common concussions are as a result of the requirement that first-year students at the military academies take boxing. It’s not surprising that boxing would produce concussions, and it’s only in recent decades that we’ve learned about how much long-term damage concussions, particularly repeated concussions, can cause.From the story:
Twenty years ago, the Air Force announced plans to end mandatory boxing because of mounting pressure from the medical community. But boxing continues. The Air Force did not respond to questions, or make any staff members available for interviews.
So the story is interesting as another instance of something known to be a problem that requires fixing or replacement. (Another recent story told how high schools are starting to drop their football programs in favor of soccer, sometimes simply because the number of studies willing to accept the risk of concussions and injuries has dropped too low to field a team.)
The most interesting aspect of the story is how the military immediately started stalling and developing ways to cover up or minimize the problem—and that’s a story in itself, this one by Dave Philipps in the NY Times:
Two top Army generals recently discussed trying to kill an article in The New York Times on concussions at West Point by withholding information so the Army could encourage competing news organizations to publish a more favorable story, according to an Army document.
The generals’ conversation involved a Freedom of Information Act request that The Times made in June for data on concussions resulting from mandatory boxing classes at the United States Military Academy. The Times also requested similar data from the Air Force Academy in June, and from the Naval Academy this month.
During a Sept. 16 meeting at the Pentagon, the Army surgeon general, Lt. Gen. Patricia D. Horoho, recommended to the superintendent at West Point, Lt. Gen. Robert L. Caslen Jr., that the Army delay responding to The Times’s request, according to the document. General Horoho then suggested trying to get The Wall Street Journal or USA Today to publish an article about a more favorable Army study on concussions.
According to the document, described by Army officials as an executive summary of the meeting, the public affairs staff at West Point and the surgeon general’s office were instructed to promote that study, by a West Point sports medicine doctor, Col. Steven Svoboda, to the other publications. . .
The report contains stunning examples of bad faith by the Army surgeon general, Lt. Gen. Patricia Horoho:
. . . Chris Gates, president of the Sunlight Foundation, which advocates transparency in government, called the details of the meeting as described in the document “disturbing.”
“To think that high-level officials at the U.S. Army and West Point would intentionally delay responding to a FOIA request in order to place a more favorable story in another outlet,” he said in an email. “Every level of the U.S. government should follow the spirit of the law and comply with FOIA, not use it as an opportunity for media manipulation.”
In the Sept. 16 meeting, according to the summary, General Horoho cited having successfully undermined the news media in the past, referring to how she manipulated coverage of the Army’s Fourth Infantry Division at Fort Carson, Col., last year.
“We were able to do something similar with the 4th ID when The Colorado Springs Gazette attacked them with treatment of wounded warriors last year — killed any scrutiny from the media and killed their story,” the document summarizes General Horoho as saying.
The media coverage that the document says the Army surgeon general “killed” at The Gazette focused on an investigation into mistreatment of soldiers by psychologists at the Army hospital at Fort Carson in 2014, according to The Gazette’s military reporter, Tom Roeder. The Gazette waited six months to receive a copy of the Army Medical Command’s completed investigation, Mr. Roeder said in an email.
About a week before the investigation was released to The Gazette, General Horoho held a “media round table” inviting competing military reporters to the Pentagon to learn about the investigation. The event resulted in several stories that had her playing down the mistreatment of soldiers with mental health issues.
The Gazette article, which came out 10 days later, found that “some workers in the hospital’s behavioral health department were demeaning, patronizing, foul-mouthed” and that they felt pressured by commanders to push mentally ill soldiers out of the Army.
The briefing summary also quoted General Horoho as saying that she felt blindsided by coverage of a pillow fight at West Point, first reported by The Times, that caused 24 concussions — more this quarter than boxing or football.
“Next time when cadets are injured and it is sensationalized, please let me know ahead of time,” she is summarized as saying. “I can help shape the reaction from my position as surgeon general. I actually learned about this incident from the news.”
Lt. Gen. Horoho should be encouraged to leave the Army, or at least be removed from the position of surgeon general. Her priorities are clearly not to protect the health of service members but rather to protect the Army’s image, and to do that regardless of ethical considerations. She apparently thinks her primary responsibility is not medical but public relations.