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Why don't we make that the Chinese/American Virus?
Masks don't work - hard science:
From another board and GoodGuyBill:
https://investorshub.advfn.com/boards/read_msg.aspx?message_id=154666650
Would our government poison us? Hell yes!
San Francisco’s incident was just one of 293 bacterial attacks staged by the United States government between 1950 and 1969. It was neither the most heinous, nor the deadliest.
In 1955, as an “experiment,” the CIA sprayed whooping cough bacteria over Tampa Bay, Florida. Whooping cough cases in the area subsequently increased from 339 and one death in 1954, to 1,080 and 12 deaths in 1955 -- but no hard evidence has ever surfaced linking the two incidents. In an infamous 1966 test, federal agents crushed light bulbs containing trillions of bacteria on the New York Subway, exposing thousands of rush hour commuters; the government never followed up to see how many people fell ill.
Before a crowd at Fort Detrick in 1969, Richard Nixon terminated the offensive use of biological weapons in the United States, effectively ending open-air testing.
It wouldn’t be until 1977 that the public learned any of this was even going on -- and even then, the U.S. government never admitted its fault, or seemed to show any indication of remorse for its actions.
Dr. Birx - "Models are models," she said. "When people start talking about 20% of a population getting infected, it's very scary, but we don't have data that matches that based on our experience."
....
"It's our job collectively to assure the American people," she also said. "There is no model right now -- no reality on the ground where we can see that 60% to 70% of Americans are going to get infected in the next eight to 12 weeks. I want to be clear about that."
https://www.realclearpolitics.com/video/2020/03/26/dr_birx_coronavirus_data_doesnt_match_the_doomsday_media_predictions_or_analysis.html
Would Biden be a sock puppet president?
Why isn't Biden, Trump's presumptive opponent in November, speaking to the American People during this time of crisis?
Bernie is...
But Biden is speaking remotely, through reporters. Afraid to face WE THE PEOPLE! Why?
March 20, 2020, 2:05 PM MDT / Updated March 20, 2020, 2:37 PM MDT
By Adam Edelman
Joe Biden, the 2020 Democratic front-runner, slammed President Donald Trump over his handling of the coronavirus pandemic Friday, accusing him of being “behind the curve through his whole response.”
Biden, speaking on a conference call with reporters, offered a series of blunt missives for Trump, and criticized him for repeatedly providing the American people with misinformation about the virus.
“Step up and do your job, Mr. President,” Biden said.
“In times of crisis, the American people deserve a president who tells them the truth,” Biden said. “Unfortunately, President Trump has not been that president.”
“People are scared. They’re worried. They don’t know quite what to do," he added. “He has been behind the curve throughout this whole response."
"Biden Sides With Big Pharma Against Affordable Coronavirus Vaccine Plan
Unlike Sanders and other Democrats, Joe Biden has not embraced a key executive authority: cutting the cost of a possible coronavirus vaccine and other pharmaceuticals developed with federal research dollars
.....
Hello from the Hotel Du Pont in Wilmington, Delaware, where former Vice President Joe Biden is scheduled to address the media on the Coronavirus.
— DJ Judd (@DJJudd) March 12, 2020
Campaign staff is working through an audio issue in the room, which has been characterized as either a buzz, a hum, or a hiss. pic.twitter.com/Tw0xTz6xF9
Biden’s COVID-19 plan calls for new authority for the Department of Health and Human Services Secretary to approve the commercial price of vaccines developed with federally funded research. Such authority would either require an act of Congress, which has not shown an ability to go against the pharmaceutical lobby, or specific language to be included in drug development contracts. For the many coronavirus drugs already being developed, such as the vaccine candidate currently being tested by NIH and Moderna, it’s likely too late for contractual language to be added.
The pharmaceutical industry has given Biden far more campaign money than anyone else who has run for president this cycle, including President Trump. Joe Biden’s campaign and the outside groups backing him have taken over $1.34 million from the pharmaceuticals and health products industry, according to the Center for Responsive Politics. For context, Trump has received about $752,000 from the industry this cycle, while Sanders has received about $422,000.
The Biden campaign’s ties to the drug industry go much deeper than the contributions it has received. His campaign chairman and top aide, Steve Richetti, is a longtime healthcare lobbyist who has personally represented drugmakers Novartis, Pfizer, Eli Lilly and Sanofi on issues related to pricing and patents, among other matters.
The pharmaceutical industry has given Biden far more campaign money than anyone else who has run for president this cycle, including President Trump.
The pro-Biden super PAC, Unite the Country, which has spent over $11.8 million supporting Biden so far, is led by multiple individuals with ties to the pharmaceutical industry. Among its leaders is longtime Biden friend Larry Rasky, the founder, chairman and CEO of Rasky Partners, a lobbying firm whose pharmaceutical clients have included Eli Lilly. Another member of the super PAC’s professional team, Amanda Loveday, is an associate director of NP Strategy, a public relations shop launched by corporate law firm Nexsen Pruet, which has clients in the healthcare and pharmaceutical industries. Unite the Country board member Mark Riddle has previously served on the board of a centrist think tank, the New Democrat Network, that received funding from the Pharmaceutical Research and Manufacturers of America, the drug industry’s top lobbying group."
Trump’s budget request for 2021 cuts the budgets for the Centers for Disease Control and Prevention or CDC by nearly 16%. The CDC is responsible for disease prevention and control in the United States.
But Trump isn’t worried about cutting funds to the entity that stops disease prevention because “it will all work out well.”
In addition to the cuts being made to the CDC, Trump is also proposing a cut to the global health fund, lowering it from $571 million to $532 million.
Short-sighted decisions such as these have many people worried the current administration is crippling the country’s ability to respond to coronavirus. Former Vice President Joe Biden pointed out in a USA Today piece that “diseases do not stop at borders. They cannot be thwarted by building a wall.”
Cuba may be the best place to land if you are on a cruise ship with Corona Virus.
https://cuba-solidarity.org.uk/news/article/3956/cuba-gives-permission-for-cruise-ship-carrying-corona-patients-to-dock-citing-solidarity-and-health-as-a-human-right
"President of the BioCubaFarma group Eduardo Martinez explained that the socialist island has developed 22 drugs that are set to be used to contain the outbreak.
So far it is known that one of the drugs manufactured by Cuba, Interferon B, has managed to effectively cure more than 1,500 patients from the coronavirus and is one of 30 drugs chosen by the Chinese National Health Commission to combat respiratory disease.
It was first developed in 1986 by a team of researchers from the Centre for Genetic Engineering and Biotechnology (CIGB) and introduced into the Cuban health system.
Mr Martinez described Interferon B as “the flagship product of the set of Cuban medicines” with the drug developed in both Cuba and China in a joint venture as part of an agreement between the socialist countries.
He said the drug could also be exported to other countries to help contain the spread of the virus and treat those that are showing symptoms."
Why America is less prepared for a pandemic than other countries
On many measures, the United States has one of the worst health systems among developed economies. A bigger share of the population lacks health insurance. We carry more medical debt. We die more often from preventable causes. The weaknesses in this system, which already puts the US behind its peers on many health outcomes, are exposed in an outbreak.
And the biggest single problem, the one most unique to the American system, is costs.
Americans face higher out-of-pocket costs for their medical care than citizens of almost any other country, and research shows people forgo care they need, including for serious conditions, because of the cost barriers. Patients here are much more likely than those in most other countries to say they had a cost-related barrier to getting medical care: 33 percent in America vs. between 7 percent (Germany) and 22 percent (Switzerland) in other developed economies. Americans are more likely to say they struggled to afford or couldn’t afford medical bills and that their insurance plan had refused to cover some of their medical claims.
Class impact of the Corona virus scare...
Low wage hourly workers are vulnerable to fear. A week or two down with the flu could mean that their family is left homeless and on the street.
Yes, they should stay home if they are ill, but they can't afford to because they are already living paycheck to paycheck.
This article is food for thought:
https://www.msn.com/en-us/money/careersandeducation/im-scared-to-lose-my-job-and-im-scared-to-die-retail-employees-describe-working-conditions-as-coronavirus-panic-heightens-nationwide/ar-BB10N4Cw?ocid=RSS_20200307_ENUS_4
Two Tucson doctors step up to support Medicare for All.
https://tucson.com/opinion/local/local-opinion-we-re-doctors-and-we-re-debunking-myths/article_b3c3196d-44d1-5d94-b1fb-be90ee6051b8.amp.html?fbclid=IwAR2vTf3eqZUdRsUnAR9_aKx5NZ6oWBDW4mj8oHyHVd_2FW7hRWPkaMEk4Z8
U.S. Pharmacy Benefit Managers..A modern day drug cartel.
Google "percentage of profit from healthcare insurance" and and the first thing you see is this:
Do Health Insurance Companies Make Profits? - Verywell Health
https://www.verywellhealth.com › Health Care › Health Insurance
May 22, 2019 - Under the MLR rules, insurers that sell individual and small group health insurance coverage must spend at least 80 percent of premiums on medical claims and quality improvements for members. No more than 20 percent of premium revenue can be spent on total administrative costs, including profits and salaries.
John Arnold: Are pharmacy benefit managers the good guys or bad guys of drug pricing?
By JOHN ARNOLD AUGUST 27, 2018
In the ongoing debate over drug prices, the pharmaceutical industry has been highly effective in shifting the blame to the middlemen — in particular to pharmacy benefit managers. As they currently operate, pharmacy benefit managers are part of the problem. But if incentives were realigned, pharmacy benefit managers could — and should — play more of a vital role in controlling runaway prices for prescription drugs.
PBMs started with the idea that their buying power would reduce health care costs and pass the savings on to consumers. They act like giant buying networks for drugs, representing consumers from multiple employers and insurers. In economic terms, they aggregate demand, which gives them leverage in the market.
PBMs use their buying power, combined with utilization management strategies, to lower the total cost of pharmaceuticals. They have been largely successful: Almost all payers have, at least until recently, chosen to contract with pharmacy benefit managers rather than manage drug procurement internally. PBMs are used by commercial insurers, in Medicare for its Part D benefit, and in the Medicaid program — particularly by Medicaid managed care organizations.
Moreover, in a market with competitive alternatives — such as generics and multiple name brands — pharmacy benefit managers should be able to move patients from more expensive brand drugs to less expensive versions and extract lower prices by playing brands off one another. Net prices are often lower than list prices, but because of the rules of engagement around pharmacy benefit managers and manufacturers, the true cost to the PBM is often opaque. And that’s where things start to go wrong with the PBM model.
Related: Imagine there are no PBMs. It’s easy if you try
These companies are supposed to use their formulary power, management tools, and price concessions to benefit the insurers they serve which, in turn, are supposed to pass the savings on to their customers through more generous benefits and lower premiums. In general terms, pharmacy benefit managers have three revenue sources: fees from the supply chain, rebates from manufacturers, and pharmacy “spreads” — the difference between what they pay for drugs from a pharmacy and what they get paid by the insurer.
This model has generated significant criticism lately for good reason. Commercial insurers complain that pharmacy benefit managers are not passing through the rebate revenue they should. In Medicare, the Medicare Payment Advisory Commission has consistently raised concerns that pharmacy benefit managers are not choosing the lowest-cost drugs. And recent work by 46brooklyn suggests that pharmacy benefit managers are charging Medicaid managed care organizations, or MCOs, much more for generic drugs than they are paying pharmacies.
So where did pharmacy benefit managers go wrong? In three areas: consolidation, rebate revenue, and transparency.
Like everything in else in health care, pharmacy benefit managers have consolidated. There are now three large PBMs — CVS, Express Scripts, and UnitedHealth’s Optum — that account for more than 70 percent of claims volume. Concentrated market share should allow pharmacy benefit managers to extract deeper concessions from manufacturers and the rest of the supply chain. But market power has made a flawed business model sticky, with payers finding few alternatives to the shared rebates.
Related: The Trump administration can’t decide whether drug industry middlemen are the enemy — or part of the solution
A second problem involves rebates. Many industries offer incentives of shared savings to align the interests of an intermediary and a buyer. And because payers do not know in advance which drugs and in what volumes they will need when signing a multiyear contract, a fixed-price contract is not realistic. However, rebates are now distorting incentives.
Instead of placing the lowest-priced drug on the formulary and passing the savings to insurers, pharmacy benefit managers may simply supply the drug with the highest rebate. Pharma argues that rebates increase list prices. They also fail to lower premiums if they are not passed on to insurers. But rebates aren’t the only cause of rising drug prices. For example, prices are high and increasing for drugs that don’t offer rebates and in markets without rebates, such as Medicare Part B.
Which brings us to transparency. The drug pricing world is shrouded in secrecy. Some economists argue that price discrimination — when no one knows what anyone else is paying — results in bigger discounts. This is similar to airline ticket pricing. Most travelers buy tickets without knowing what anyone else is paying for other seats on the same flight. Pharmacy benefit managers may be able to get deeper discounts from drug manufacturers if the drug companies can keep the size of the discounts secret and not have to offer them to every other PBM.
Yet economists argue that transparency is one of the characteristics of a well-functioning market. Most government contracting requires full transparency. Greater transparency in drug pricing could encourage competition and force manufacturers to cut prices to gain market share, especially for drugs that compete within a class.
The problem of secretive pricing is further complicated because the whole system of out-of-pocket expense is based on list prices. After all, it is difficult to build a copay model based on net prices if those prices are not transparent. Basing consumer expense on an artificial price to maintain the negotiating leverage of pharmacy benefit managers forces patients to overpay.
Related: Mega-mergers would mean the death of standalone PBMs. Should consumers mourn or rejoice?
The flaws in the system have reached a breaking point. Anthem accused Express Scripts of failing to pass on rebates and sued for $15 billion. Ohio recently terminated its pharmacy benefit managers contracts for issues around spread pricing. Meanwhile, others are attempting to internalize the PBM-insurer conflict by reintegrating. Cigna is trying to buy Express Scripts and CVS Health is buying Aetna.
Pharmacy benefit managers could provide significant value, but the business model must become more closely aligned with the interests of patients and payers. Pharma would love nothing more than to see the PBM model implode, creating the opportunity to extract higher prices by negotiating against smaller, less sophisticated buyers.
Some have proposed that all rebates should be eliminated and pharmacy benefit managers should simply charge fees. But how would payers evaluate the effectiveness of the PBMs? The shared rebate system was designed to align incentives around discounts. A new fee model that better aligns the interests of consumers, insurers, and pharmacy benefit managers must be developed.
Perhaps foundations should support the formation of a nonprofit PBM governed by its customers, similar to the nonprofit generic drug company being launched. The Laura and John Arnold Foundation has supported the development of value-based pricing through the Institute for Clinical and Economic Review, which can be used by pharmacy benefit managers to select drugs that maximize patient value rather than the size of the rebate. CVS recently announced it would use ICER pricing in establishing its formulary.
It is easy to cast pharmacy benefit managers as the bad guys of drug pricing, but with changes to the basic business model, they may be consumers’ best hope for holding down the price of pharmaceuticals.
John Arnold co-founded, with his wife, Laura, the Laura and John Arnold Foundation in 2010.
With Cigna’s recent announcement that it intends to purchase Express Scripts, five of America’s top health insurance companies now own or plan to own pharmacy benefit managers (PBMs).
The move is the latest example of vertical integration in the health insurance industry. This pattern continues at a time when PBMs are receiving intense scrutiny regarding their candidness and effectiveness in lowering drug costs.
Which other big-name companies are bringing PBMs into their fold, and why are they doing it? As Aetna CEO Mark Bertolini said in his 2017 Q1 earnings call, it seems “going forward, the PBM relationship as a standalone model is a troubled relationship.” Let’s explore why.
A Trend in the Making
As recently as 2017, the three largest PBMs operated by completely different business models: Express Scripts remained independent, OptumRx was owned by an insurance company, and CVS Caremark was run by pharmacy chain CVS Health. Now, they could all soon be under the control of nationwide insurers.
Back in 2015, we saw UnitedHealth Group’s OptumRx purchase then fourth-largest PBM, CatamaranRx. We also saw Aetna announce its intention to acquire Humana; a deal which the Department of Justice blocked a year and a half later after their antitrust review. The failed acquisition would have brought Humana’s PBM services in-house for Aetna.
In October 2017, Anthem announced that it would not renew its contract with Express Scripts, but instead, launch its own PBM, IngenioRx, in 2020. More recently, Aetna also made clearer its intention to control a PBM with its December 2017 proposal to merge with CVS Health in a $69 billion deal. And just last month, Cigna divulged its agreement to purchase Express Scripts for $52 billion.
Five Top Nationwide Insurers and Their PBM Partners
Insurers PBM Partners
UnitedHealth Group OptumRx (in-house); CatamaranRx (purchased 2015)
Anthem IngenioRx (launching in-house in 2020)
Aetna CVS/Caremark (purchase under review)
Cigna Cigna Pharmacy Management (in-house); Express Scripts (purchase under review)
Humana Humana Pharmacy Solutions (in-house)
Clearly insurance companies have an interest in reining in control of PBM operations, but why the acquisitions and consolidation?
There are serious issues with the U.S. EHR record system. It is not something that should be controlled by a fragmented for profit industry.
Physicians in the United States are justifiably upset by the amount of time they spend using electronic health records (EHRs). This is true across primary care physicians and specialists, and it contributes to physician burnout. The annual cost of physicians spending half of their time using EHRs is over $365 billion (a billion dollars per day) — more than the United States spends treating any major class of diseases and about equal to what the country spends on public primary and secondary education instruction. This is a problem that can be solved now by taking three steps.
1. Standardize and reduce payer-imposed requirements. A recent study of U.S. health systems using the same major EHR system found that at the median organization the length of the average patient note in an EHR has more than doubled from 2009 to be about 700 words. To put the issue into context, if a physician sees 15 new patients, he or she would have to enter about 20 single space pages into the EHR. The study found that the average note length at the median health system in Canada, the UK, Australia, the Netherlands, and Denmark is less than one third of what it is in the United States.
These astounding findings indicate that a big part of the problem is the documentation requirements that payers impose on providers. Making matters worse, these requirements vary from payer to payer in the United States. Standardizing and rigorously reviewing their utility is essential. The U.S. Centers for Medicare and Medicaid Services (CMS) is beginning to make strides in reducing requirements with its Patients over Paperwork initiative, and we believe that private payers should adopt the same principles and agree on a set of standards, requiring documentation only when it truly adds clinical value.
In a fee-for-service payment system, there will always be a desire by payers to impose documentation requirements to try to limit the claims they pay. But as the United States shifts to other payment models, it has the potential to lessen the need for documentation to justify billing. Christopher Longhurst, the CIO and associate chief medical officer for quality and safety at UC California San Diego Health and a coauthor of the EHR note length study, explained that organizations that operate under risk-based payment models (in which the volume of services less directly influences payment) had shorter average note lengths. The Veterans Health Administration, which operates with fixed budgets and salaried physicians, has comparatively low documentation requirements.
2. Continuously improve EHR workflows. This is something every provider can do right now. There is significant potential to improve user workflows without any regulatory changes or technology innovation. Colleagues who have seen EHR implementations across multiple organizations estimate that there is the potential to improve workflows in the EHR by about 20%, on average, by removing steps that don’t have any value. For instance, Geisinger, which serves communities in Pennsylvania, streamlined the work to get patients to the right musculoskeletal provider from a frustrating multi-click process (or a five- to 10-minute phone call) to one that simply asked two questions: What is the patient’s complaint? and What is the location of the injury? This led to significant increases in provider satisfaction and decreased time for patients to be seen.
Jim Noga, CIO at Boston-based Partners HealthCare, believes that improving EHR workflows should be like painting the Golden Gate Bridge and ought to be done continually. Mark Vrahas, chair of orthopedics at the Cedars-Sinai Medical Center in Los Angeles, has been through EHR implementations at three hospitals and now assiduously reevaluates processes so that he does not add a click in an EHR workflow without also removing another one. Part of the process of optimizing EHR and related clinical workflows should also include examining the clinician or staff that should be involved in performing each activity. For instance, much of the task of entering information can be shifted from physicians to other staff.
3. Unleash innovation. Tech advancements — such as voice recognition, digital scribes, and connected devices — are already beginning to further automate and reduce time spent entering information into the EHR. But once all of the information is in the EHR, clinicians still need help with the other half of the problem: the EHR user experience, which is widely viewed as being many years behind that of other industries.
Innovation is needed to enable clinicians to receive contextually relevant insights without having to comb through reams of unstructured information in the EHR. Innovation is also needed around designing better user experiences and reconsidering what form factors (e.g., mobile) will work best. Today’s EHR user experience is centered around a desktop computer even though by the end of 2018 about two-thirds of website visits in the United States were expected to be from mobile devices.
Where will all this innovation come from? Historically, the EHR vendors developed the software themselves and largely did not open their platforms to others. This is beginning to change: They have recently introduced app stores for third-party developers akin to what smartphone companies did a decade ago. Examples include Epic’s App Orchard, Cerner’s App Gallery, and athenahealth’s More Disruption Please program.
We believe that third-party innovators have the most potential to dramatically improve both the user experience of clinicians and the health of patients. For example, using an open source framework called CareKit, Johns Hopkins developed the Corrie health app, which has helped reduce 30-day readmission rates from 19% to 3% for heart attack patients. Key to enabling similar experiences and fostering further innovation will be the creation of stronger standards so developers do not need to rebuild their apps for each EHR. One hopeful sign is the Argonaut Project, which has been steadily expanding the set of data elements in the Fast Healthcare Interoperability Resources (FHIR) API over the last several years. Another is CMS, as part of its Promoting Interoperability Program, is requiring health care providers as of January 2019 to make their data available through the FHIR API for patient-facing apps to query. For instance, a new feature from Apple, Health Records on iPhone, allows people to securely store and aggregate their own health records across their medical providers.
Another benefit of further standardizing APIs across EHRs is that it will allow data from one EHR to be more seamlessly integrated into another so that a physician can easily see a patient’s full medical history. The groundwork is already being laid to enable EHR-to-EHR data exchange. In November 2018, the two leading networks of EHRs, Commonwell Health Alliance and Carequality, both nonprofits, announced that providers on their networks would now be able to bilaterally exchange information with one another. This is akin to the Eastern and Pacific railroads coming together to form the first U.S. transcontinental railroad in 1869.
We are optimistic that better days are on the horizon for clinicians and that we are past the nadir of the EHR usability problem. Improvements will not occur automatically though, and there needs to be widespread recognition that physicians spending half their time using EHRs is a health care crisis that must be fixed. There should be a mandate for payers to standardize and reduce their documentation requirements. Equally as important, we should strengthen APIs and secure data-sharing standards to unleash transformative innovation. These efforts, combined with providers diligently reviewing and optimizing their EHR workflows, will transform EHRs from being a time sink to a time saver and joy to use.
This is downright scary:
'UnitedHealth's political and financial heft just keeps growing'
'UnitedHealth remains the most financially powerful private entity in the U.S. health care system, and any reforms would be up against its growing empire.
By the numbers: UnitedHealth is not just a health insurance company, but that is still its biggest component.
39 million people had full-scale medical coverage through UnitedHealthcare as of June 30. About two-thirds of its insurance premium revenue comes from government programs.
UnitedHealth continues to expand OptumRx, which is part of the pharmacy benefits triumvirate that controls how prescription drugs are paid for.
Perhaps most importantly, UnitedHealth increasingly is becoming your surgeon or doctor, and now it's taking over back-end operations for hospitals.
Why it matters: Because UnitedHealth touches almost every part of the health care system, it has every incentive to keep certain policies as they are or push for reforms that benefit its shareholders.
UnitedHealth retains 9 outside lobbying firms in addition to its own stable of state and federal lobbyists.
On the federal level, they have aggressively worked to eliminate the Affordable Care Act's tax on health insurers, won the battle over the drug rebate rule and have pushed for other things like expanding short-term plans.
UnitedHealth is also part of the national coalition to kill "Medicare for All" and actively denounced Medicare for All earlier this year.
The bottom line: Wall Street's reactions shouldn't obscure just how much power UnitedHealth Group has and continues to accumulate.'
https://www.axios.com/unitedhealth-empire-q2-health-reforms-lobbying-1e97d5f6-c2a5-4cd6-819a-cc6a3ca56856.html
Consider this:
California just updated its homeless population for 2018, and the results are staggering. In the city of Los Angeles alone, the total number of homeless residents spiked 16% to 36,300. Just as disturbing, third-world diseases such as typhus have exploded and begun to take root.
From December 2014 - and we still have a problem.
5,300 viewsDec 29, 2014, 01:00pm
How Rising Healthcare Costs Make American Businesses Less Competitive
By Natalie Burg
Reliable Production Machining and Welding has survived recessions, strikes and rising fuel prices since opening some 70 years ago in the basement of a casket maker.
But according to a report in business publication Inc., the Indiana-based company didn't face its toughest crisis until 2008, when health insurance costs for its 162 employees rose 25 percent to $750,000 in just two years.
Reliable's story is not an isolated one, and the days of leaving healthcare reform solely to the public and healthcare sectors are over. According to a Harris Poll commissioned by Castlight Health, approximately 90 percent of chief financial officers surveyed agreed they could invest more in their businesses if their company’s healthcare costs were lower. The effect on the American business sector is clear: Rising healthcare costs are hurting the enterprise.
That's not just the opinion of a few executives. A 2009 RAND study found U.S. industries with the highest level of employer-sponsored healthcare showed slower growth between 1987 and 2005—in both employment and contribution to GDP over time—than industries where health benefits were less common.
"This study provides some of the first evidence that the rapid rise in health care costs has negative consequences for several U.S. industries," said RAND senior economist and lead author of the study Neeraj Sood.
Though nearly a decade has passed since the period studied by RAND, a 2014 Altarum report shows that healthcare spending as a share of GDP has continued to rise since 2007. So it’s no surprise that Business Roundtable found healthcare spending to be the third top cost pressure facing CEOs in 2013.
Rising Costs for Employers
Just how much are healthcare costs rising for employers? Premiums for workers rose 114 percent over the decade preceding 2008, according to a report by the Robert Wood Johnson Foundation, and small businesses are less able to provide health insurance to employees than large businesses. Healthcare, the report said, is the most expensive benefit for U.S. employers.
Not all of those costs can be passed on to the consumer. U.S. businesses spend more than $620 billion each year on healthcare, and more than 80 percent of CFOs surveyed by the Harris Poll said healthcare costs drain company resources that could be better used elsewhere—including the wages and salaries of their employees, and investing in better technology.
This could be why 93 percent of respondents to the Harris Poll agree that the high cost of healthcare in the U.S. gives foreign companies a competitive advantage. They also agree about who's responsible for a coming up with a solution. It's not government. It's not the healthcare sector. Instead, nearly all respondents acknowledged that employers must help fix the system.
That the U.S. healthcare system is greatly troubled is no news to anyone. Just how high the costs are to businesses, however, may come as a surprise to some and as a rallying cry for others: from the public to the private sectors, we're all in this mess together—and everyone must take action to heal the wound.
A former downtown development professional, Natalie Burg is a freelancer who writes about growth, entrepreneurialism and innovation.
Here's how Medicare Advantage companies wring out extra profits, it's all about the money:
Health insurers have perfected a way to wring billions more in revenue from the Medicare program by combing patient medical charts for additional diagnosis codes to submit to the federal government for payment.
The latest example of the massive returns that insurers reap from the practice known as a retrospective chart review was outlined in legal documents filed in a case against Indianapolis-based health insurer Anthem. The documents show Anthem pocketed more than $112 million in additional Medicare Advantage risk-adjustment payments in 2015 and $102 million in 2014 while spending little over $18 million each year to carry out the review program.
Identifying and documenting additional diagnosis codes to send to the CMS for risk-adjustment payment is perfectly legal if the patient's medical record supports it. In fact, the way Medicare pays Advantage organizations encourages them to code all diagnoses possible. Traditional Medicare providers do not have that incentive.
The Affordable Care Act calls for significant cuts in reimbursements to insurers providing Medicare Advantage (MA) coverage, which has been the most popular alternative to traditional fee-for-service Medicare. Opponents of these cuts argue that they carry serious negative repercussions for seniors, and have lobbied successfully to force their postponement. But research suggests that cuts to MA reimbursements actually are unlikely to harm consumer welfare. The research indicates that higher MA reimbursements do not translate into less expensive or higher quality care for consumers. But they do benefit insurance firms, which see higher profits, some of which they channel into increased advertising to encourage more people to enroll in the MA plans they offer. While lower reimbursements likely would reduce insurance firm profitability, they would substantially improve the federal budget—without negatively impacting the quality of care received by patients.
Why we're fighting the American Medical Association
The AMA protects corporate interests, not doctors and patients – and now it’s trying to stop Medicare for All
This Saturday, nurses, physicians, and medical students plan to walk out of their clinics and on to the streets of Chicago to confront the American Medical Association at the organization’s annual meeting. Health providers know that the outrageous costs and shameful inequality of American medicine are no accident – and that their patients’ lives are at stake.
The AMA claims to represent the interests and values of our nation’s doctors. But it has long been the public relations face of America’s private health insurance system, which treats healthcare as a commodity. This approach has resulted in some of the worst health outcomes in the industrialized world: the highest rate of infant mortality, the highest number of avoidable deaths, and health spending that eats up nearly 18% of America’s GDP.
The AMA is a major reason why 28 million Americans still don’t have health insurance. Despite recent polls showing that a majority of doctors support the single-payer system Medicare for All, which would fully insure all Americans, the AMA is leading the fight against universal coverage.
By money spent, the AMA is the nation’s third largest lobbying organization of the last 20 years, behind only the US Chamber of Commerce and the National Association of Realtors. By deploying powerful lobbying and misleading media campaigns, the AMA has opposed or hijacked nearly every health reform proposal of the last century, from Social Security to Medicare to the Affordable Care Act.
The AMA has also been a relentless opponent of universal healthcare. In 1949, the group waged an unscrupulous war against President Truman’s proposed national health insurance program, spending millions of dollars to have a political-consulting firm mislabel single-payer healthcare as “socialized medicine”. In 1961, the group doubled down on fearmongering when they hired Ronald Reagan to record an advertisement warning Americans that the passage of Medicare, an imperfect but popular health program for seniors, was a “short step to all the rest of socialism”.
Americans borrowed a whopping $88bn last year simply to pay for medical expenses. So much for private insurance
The AMA, however, is finding it increasingly difficult to keep healthcare providers and patients scared of single payer.
Despite industry claims that Americans are “satisfied” with their private health plans, insured patients are saddled with exorbitant co-pays, premiums, and deductibles that keep them from actually getting the care they need. A single illness or injury pushes many Americans into bankruptcy. According to a recent Gallup poll, Americans borrowed a whopping $88bn last year simply to pay for medical expenses. So much for private insurance.
Most Americans – 70% – now favor the creation of a publicly financed but privately delivered single-payer health insurance program, better known as Improved and Expanded Medicare for All. Americans are desperate for affordable healthcare, a system that prioritizes patients over commerce, centers clinical decisions in the hands of physicians, and results in lower costs and better outcomes.
In February, Representative Pramila Jayapal, along with 106 co-sponsors, unveiled the Medicare for All Act of 2019 (HR 1384), while Senator Bernie Sanders’ revamped Medicare for All Act enjoys support from most of the leading Democratic presidential candidates. Even former President Barack Obama recently admitted that his signature health initiative – the Affordable Care Act – is no substitute for single payer.
Faced with soaring public support for Medicare for All, this past summer the AMA joined the “Partnership for America’s Health Care Future”, a benign-sounding corporate group which represents the pharmaceutical and private insurance industries and aims to “change the conversation around Medicare for All”. In order to protect their own economic interests, the “Partnership” is waging a well-funded campaign to turn elected officials away from single-payer by rallying Democrats around the ACA and preventing the Democratic party from including Medicare for All in its 2020 platform.
The campaign is merely the latest example of how the AMA uses the prestige of its white-coated members to push for market-based health reforms that maintain the status quo of our fractured health system: one in which some Americans have a lot, others have a little, and some are left with absolutely nothing.
Medical students and professionals have had enough. This Saturday’s protest is only one example. Last year, the Medical Student Section of the AMA put pressure on their leadership with a resolution demanding the organization suspend its decades-long opposition to single-payer. Single-payer activism is growing on medical school campuses across the nation, perhaps a preview of what the next generation of doctors will expect.
The public agrees with the evidence that Medicare for All is the answer to our broken health system. Until the AMA’s priorities change, it will remain an obstacle to the good of our patients.
I know this is from last year, but I want to include this important link.
Rand Research report:
National Health Spending Estimates Under Medicare for All
by Jodi L. Liu, Christine Eibner
Related Topics: Health Care Financing, Health Care Reform, Health Insurance, United States
KOCH-BACKED THINK TANK FINDS THAT “MEDICARE FOR ALL” WOULD CUT HEALTH CARE SPENDING AND RAISE WAGES. WHOOPS.
Ryan Grim, Zaid Jilani
July 30 2018, 4:44 p.m.
A NEW STUDY from the Mercatus Center at George Mason University is making headlines for projecting that Independent Vermont Sen. Bernie Sanders’s “Medicare for All” bill is estimated to cost $32.6 trillion — a number that’s entirely in line with 2016 projections, and is literally old news. But what the Associated Press headline fails to announce is a much more sanguine update: The report, by Senior Research Strategist Charles Blahous, found that under Sanders’s plan, overall health costs would go down, and wages would go up.
The study, which came out of the Koch-funded research center, was initially provided to the AP with a cost estimate that exceeded previous ones by an incredible $3 trillion — a massive error that was found and corrected by Sanders’s staff when approached by AP for comment.
But despite that correction, the report actually yields a wealth of good news for advocates of Sanders’s plan — a remarkable conclusion, given that Blahous is a former Bush administration economist working at a prominent conservative think tank.
Blahous’s paper, titled “The Costs of a National Single-Payer Healthcare System,” estimates total national health expenditures. Even though his cost-saving estimates are more conservative than others, he acknowledges that Sanders’s “Medicare for All” plan would yield a $482 billion reduction in health care spending, and over $1.5 trillion in administrative savings, for a total of $2 trillion less in overall health care expenditures between 2022 and 2031, compared to current spending.
In order to arrive at this number, Blahous looked at how “Medicare for All” could lower administrative costs and provide savings in areas like drug spending. He concluded that by empowering the secretary of Health and Human Services to negotiate for lower drug prices, Sanders’s plan would add “$846 billion in additional savings over the 2022-2031” period. These savings, and others, are offset by certain other costs, like those which come from higher “utilization,” or the increased amount health care services used once everyone is insured.
Blahous’s report also acknowledges some substantial benefits to eliminating employer-sponsored insurance. He writes that these changes “should increase worker wage net of employer-provided health benefits,” while also “relieving individuals, families, and employers of the substantial health expenditures they would experience under current law.” The report even admits that the Sanders bill would serve as a boon to states, freeing them from most Medicaid obligations.
But despite the explicit benefits acknowledged by the Blahous study, health policy experts and single-payer advocates David U. Himmelstein and Steffie Woolhandler, who reviewed the Mercatus study, argue that Blahous actually significantly undercounts savings that could result from “Medicare for All.”
“The Mercatus Center’s estimate of the cost of implementing Sen. Bernie Sanders’ Medicare for All Act (M4A) projects outlandish increases in the utilization of medical care, ignores vast savings under single-payer reform, and fails to even mention the extensive and well-documented evidence on single-payer systems in other nations – which all spend far less per person on health care than we do,” Himmelstein and Woolhandler explain.
In a written analysis shared with The Intercept, Himmelstein and Woolhandler write that Blahous’s report undercounts administrative savings by more than $8.3 trillion over 10 years. Taking those savings into account would lower Blahous’s estimate from $32.6 trillion to $24.3 trillion.
Additionally, the policy experts believe that Blahous underestimates savings from drug prices; for example, ignoring the success the U.S. Veterans Administration, the Canadian government, and certain European governments have had in negotiating for lower drug prices. If the United States paid European prices, they conclude, another $1.7 trillion would be trimmed from Blahous’s total cost estimate, bringing it down to $22.6 trillion over 10 years.
Himmelstein and Woolhandler also claim that Blahous grossly overestimates how much extra care would be utilized as a result of expanding insurance coverage. Using Blahous’s projections, they note that he is essentially arguing that once every American is covered, there will be 100 million additional doctor visits and several million more hospitalizations each year. But Himmelstein and Woolhandler say that’s wildly off the mark. From their written analysis:
[T]here just aren’t enough doctors and hospital beds to deliver that much care. Doctors are already working 53 hours per week, and experience from past reforms tells us that they won’t increase their hours, nor will they see many more patients per hour.
Instead of a huge surge in utilization, more realistic projections would assume that doctors and hospitals would reduce the amount of unnecessary care to those who are currently not getting what they need. That’s what happened in Canada. Doctors and hospitals can adjust care to meet increasing demand, as happens every year during flu season.
Moreover, no surge materialized when Medicare was implemented and millions of previously uninsured seniors got coverage. Between 1964 (before Med
and 1966 (the year when Medicare was fully functioning) there was absolutely no increase in the total number of doctor visit in the U.S.; Americans averaged 4.3 visits per person in 1964 and 4.3 visits per person in 1966. Instead, the number of visits by poor seniors did go up, but the number of visits by healthy and wealthy patients went down slightly. The same thing happened in hospitals. There were no waiting lists, just a reduction in the utilization of unneeded elective care by wealthier patients, and the delivery of more care to sick people who needed it.
As you might imagine, any draft study like this is shown to many people along the way (at least 20 in this case) and goes through multiple rounds of re-estimation, editing and redrafting. Estimates in prior drafts were revised in both directions (higher and lower) in subsequent drafts on the way to final publication. One of the more recent drafts before final publication was shown to the Sanders office,” he said. “That draft contained an estimate of long-term care costs reproduced from another study, which was cited because this study had no long-term care model to draw upon. That previously-published study predated the introduction of the Sanders bill, the language of which the Sanders office asserted was not intended to increase federal financing of long-term care service utilization. In reality there probably would be some increase in long-term care utilization under M4A because its broader coverage expansion would enable more people to make use of long-term care benefits already authorized under current law through Medicaid. But rather than attempt to estimate that, I concluded the right thing to do was to reflect the language’s intended effect as represented by the primary sponsor, as was done throughout the study with the other provisions of M4A. I was very pleased to receive and incorporate their input.
Trump wants to export U.S. failure...
Trump threatens to use US trade talks to force NHS to pay more for drugs
Save
Health and Human Services Secretary Alex Azar says the US has 'skin in the game' and wants to reduce prices
CREDIT: SUSAN WALSH/AP
David Millward, us correspondent
15 MAY 2018 • 1:41PM
Donald Trump is ready to use trade talks to force the National Health Service to pay more for its drugs as part of his scheme to "put American patients first”.
Mr Trump has claimed that the high costs faced by US patients are a direct result of other countries’ health services “freeloading” at America’s expense.
Alex Azar, the US Health and Human Services Secretary, has said Washington will use its muscle to push up drug prices abroad, to lower the cost paid by patients in the United States.
"On the foreign side, we need to, through our trade negotiations and agreements, pressure them," Azar said on CNBC.
"And so we pay less, they pay more. It shouldn't be a one-way ratchet. We all have some skin in this game."
He continued: "The reason why they are getting better net prices than we get is their socialised system."
In the UK, prices are dictated in part by National Institute for Health and Care Excellence (NICE) which has been successful in securing discounts for some of the costliest drugs.
Single-payer government-run health services like the NHS are able to use their negotiating muscle to pay far lower prices than their fragmented insurance-based private American counterparts, to the fury of the US president.
Donald Trump CREDIT: MANDELSON NGAN/AFP
“America will not be cheated any longer, and especially will not be cheated by foreign countries,” Mr Trump said.
“In some cases, medicine that costs a few dollars in a foreign country costs hundreds of dollars in America for the same pill, with the same ingredients, in the same package, made in the same plant. That is unacceptable.
“It's unfair. It's ridiculous. It's not going to happen any longer. It's time to end the global freeloading once and for all.”
The pharmaceutical companies in the US are among the biggest corporate political donors and Democrats accused the US president of looking after the industry rather than patients.
Lowering drug prices was one of Donald Trump's key campaign promises and he hopes to achieve this by making other countries pay more.
"I think this applies to all advanced countries, including the UK," said Paul Ginsburg, professor of health policy at the University of Southern California.
“This effort to change other nations' health policies will be driven by the US Trade Representative Bob Lighthizer when he is negotiating deals to avoid application of US tariffs or, in the case of the UK, a bilateral trade deal post-Brexit,” said Brandon Barford, a partner at Washington-based Beacon Policy Advisors.
“The second goal is that, for the UK in particular, trade negotiations will likely occur in the run-up to the US Presidential election in November 2020.
“The President and his team want to be able to use the NHS and NICE as a foil for his plan that reduces costs for consumers at the point of sale, but without rationing and access restrictions for which the UK system is infamous in the US, particularly amongst conservative media.”
Britain’s lower drug prices date back to an agreement reached between the industry and the NHS in 1957, which was designed to “achieve a financial balance in the interests of patients, the National Health Service, taxpayers, and the pharmaceutical industry."
While prices in the UK are controlled, in the US they are left to the market and the differences can be dramatic.
For example, Americans paid an average of £1,964 ($2,669) for Humira, an injectable drug used to treat an array of autoimmune diseases including ulcerative colitis. The cost for a British patient is £1,003 ($1,362).
According to the latest figures the NHS spent £15.4 billion on medicines in 2016-17; only salaries cost the health service more.
In the UK there was some debate over whether the US could impose higher drug prices on the UK.
“How much the UK spends on healthcare and on medicines is a matter for the UK government and it is not clear to us how the US or any other government would influence this,” said Richard Torbett of the Association of the British Pharmaceutical Industry.
“The way medicines' prices are set in the UK is governed by a voluntary agreement called the Pharmaceutical Price Regulation Scheme, which is negotiated between the global industry and the UK government.”
Nigel Edwards, chief executive of the Nuffield Trust, an independent health think tank, disputed that British patients were freeloading at the expense of their American counterparts.
“There is no reason to suppose that more expensive prices for drugs in Europe would translate into cheaper prices in the US.
“USA healthcare prices are generally higher than in Europe and the absence of the sort of large-scale negotiation by the US government does not help.
“This is more likely to be the cause of high drugs pricing, rather than one side of the Atlantic subsidising the other. "
John Stossel: Insurance Makes Healthcare Far More Expensive
Published on Aug 29, 2009
Health care CEOs took home $2.6 billion in 2018
https://www.axios.com/health-care-ceo-pay-compensation-stock-2018-0ed2a8aa-250e-48f1-a47a-849b8ca83e24.html
Politics and Money - the reason why the U.S. pays more for less:
WASHINGTON — In an unusual move, House Republicans are warning drug companies against complying with a House investigation into drug prices.
Republicans on the House Oversight Committee sent letters to a dozen CEOs of major drug companies warning that information they provide to the committee could be leaked to the public by Democratic chair Elijah Cummings in an effort to tank their stock prices.
Cummings requested information from 12 drug companies such as Pfizer Inc., Johnson & Johnson, and Novartis AG in January as part of a broad investigation into how the industry sets prescription drug prices.
In their letters, Reps. Jim Jordan and Mark Meadows — leaders of the hardline conservative House Freedom Caucus — imply that Cummings may be attempting to collect the information in order to bring down the industry’s stock prices.
They write that Cummings is seeking sensitive information “that would likely harm the competitiveness of your company if disclosed publicly.” They then accuse Cummings of “releasing cherry-picked excerpts from a highly sensitive closed-door interview” conducted in an investigation into White House security clearances. “This is not the first time he has released sensitive information unilaterally,” says the letter. The authors say they “feel obliged to alert” the drug companies of Cummings’ actions.
Democrats expressed bafflement at the letters. While politicians routinely spar over committee work, warning companies not to comply with an investigation is unconventional — perhaps even unprecedented, Democrats say.
“Rep. Jordan is on the absolute wrong side here,” Cummings said in an emailed statement to BuzzFeed News. “He would rather protect drug company ‘stock prices’ than the interests of the American people.”
In their letter, Jordan and Meadows say that “while we cannot speculate about Chairman Cummings’ motives,” the committee should not pursue an investigation designed to impact stock prices.
This hinges on a quote from Cummings saying he has three staffers he calls “the drug team” who work on the high cost of drugs and that their work has lowered drug company stocks.
The quote omits the full context of Cummings’ remarks. At the time he was appearing before the Committee on House Administration seeking an increase in funding for his committee. (Jordan, as the ranking Oversight Republican, objected to a funding increase.)
The letter quotes Cummings as saying of his drug team: “If you follow the headlines, we have already seen the impact they have had… on stock prices with regard to drugs. I mean, it has been astronomical.” The letter omits the rest of the sentence: “saving the taxpayers money.”
In the edited quote, Cummings seems to be bragging about an “astronomical” impact on drug company stocks. In the context of his statements before and after, he seems to be saying the “astronomical” impact is on taxpayer savings, which justify giving his committee more resources. A minute later he says: “Whatever you all give us, we will give it back in savings by rooting out fraud, waste, and abuse.”
Jordan’s office insisted that the letter does not tell companies not to respond to Cummings’ requests, and in fact encourages the companies to cooperate with “responsible and legitimate” oversight. However, Jordan’s office reiterated that he has grave concerns that in this case Democrats are out to destroy drug company stock value.
Could this be the reason Gottleib quit????
Public Health & Policy > Health Policy
Senators Seek Answers From HHS Chief on ACA Reforms, Title X Funds
Organ allocation, unaccompanied minors also discussed at appropriations hearing
savesaved
by Joyce Frieden, News Editor, MedPage Today
April 04, 2019
WASHINGTON -- Overturning the Affordable Care Act (ACA), maintaining women's access to birth control, and taking better care of unaccompanied minors entering the country without papers were just a few of the issues Health and Human Services (HHS) Secretary Alex Azar addressed during a Senate Appropriations committee budget hearing on Thursday.
"The fact is the administration is doing everything it can to sabotage healthcare, and this budget appears to be just more of the same," said Sen. Patty Murray (D-Wash.), ranking member of the Senate Appropriations Subcommittee on the Departments of Labor, Health and Human Services, and Education, and Related Agencies, which was holding the hearing. "Your budget calls for repealing and replacing the ACA with the failed Trumpcare bill, which was rejected by the last Congress, and ... last week President Trump sided with the [district court] ruling that all of the ACA should be struck down -- all of it."
"According to reports, you initially opposed President Trump on that and issued a statement of support," she continued. "Did you initially object to the president's decision to side with the Texas court because you know the impact this would have; it would be devastating for so many families?"
'Reasonable Minds Can Differ'
Azar did not answer the question directly. "The advice of a Cabinet member to the President of the United States is highly confidential and it wouldn't be appropriate for me to comment on that," he replied. "The position the administration took in the ACA litigation is an appropriate position; it's supporting a district court's decision ... Reasonable minds can differ on this question of legal issues. This is not our policy position; that is a legal conclusion about the ACA ... We want to protect preexisting conditions; if the litigation ends up in that position we want to work with you to secure better care for people and make sure all the issues you raised are taken care of."
Sen. John Kennedy (R-La.) was a little more friendly to the secretary. "I remember when Congress passed [the ACA], we were promised ... that it would make health insurance more affordable. Has it done that?" he asked.
"No it has not," Azar said. "We were promised health insurance would cost half what it cost at the time; in fact, during President Obama's tenure, it doubled in cost for people having to buy insurance."
"Congress also promised us it would make health insurance more accessible," Kennedy said. "Has it done that?"
"No it has not; in fact it has restricted choices for individuals now, with a large percentage of states having only one carrier in the individual market," said Azar. Kennedy then asked whether the president supported repealing the ACA without a replacement. "The president has always supported replacing the Affordable Care Act with something else that is better," Azar said.
If the years were still aligned on the graph the U.S. wouldn't have legions of working poor.
That is somewhat horrifying.
I wish the years were aligned on the graph :)
Ted Talk on blaming the victim:
As a young ER doctor, Peter Attia felt contempt for a patient with diabetes. She was overweight, he thought, and thus responsible for the fact that she needed a foot amputation. But years later, Attia received an unpleasant medical surprise that led him to wonder: is our understanding of diabetes right? Could the precursors to diabetes cause obesity, and not the other way around? A look at how assumptions may be leading us to wage the wrong medical war.
A Stanford study of the effect of Medicare Part D on advertising and subsequent drug use:
https://med.stanford.edu/content/dam/sm/hsr/documents/AlpertHealthEconSeminar_Sep2018.pdf
"You have a system of pharmaceutical promotion that changed the way medicine is practiced and no one stopped it".
The quote is from the video below:
https://www.cbsnews.com/news/opioid-epidemic-did-the-fda-ignite-the-crisis-60-minutes/?ftag=MSF0951a18
The entire system of "pharmaceutical promotion" is the root cause, that must be stopped. The U.S. and New Zealand are the only countries in the world that permit drugs to be advertised to end users.
Excerpt from an interesting study:
There is a lack of consensus on whether DTCA serves primarily to inform or persuade,
which matters for assessing its value to patients. This distinction hinges partly on the extent to
which DTCA impacts drug utilization and the mechanisms underlying advertising’s impacts,
such as whether the effects of DTCA stem from the initiation of therapy versus adherence and
whether there are spillovers of advertising on non-advertised drugs. However, identifying
DTCA’s causal effects on utilization has been challenging empirically, since demand factors
often influence both the amount of advertising and the timing of advertisements. Some studies
have tried to address these endogeneity concerns with instrumental variable strategies, though it
is difficult to find appropriate instruments given the close relationship between demand and
advertising decisions.
We address these challenges by introducing a new quasi-experimental approach to estimating
how DTCA influences drug utilization. We exploit a large shock to DTCA driven by the
introduction of Medicare Part D in 2006. Our instrumental variable strategy exploits variation
across geographic areas in the share of the population that is covered by Medicare (ages 65+) to
predict changes in advertising exposure across areas. We show that there was a large relative
increase in advertising exposure immediately following the introduction of Part D in geographic
areas with a high share of elderly compared to areas with a low elderly share. Prior to Part D,
both the levels and trends in advertising exposure across high and low elderly share areas were
nearly identical. Since advertising cannot be perfectly targeted to the elderly, we use the sudden
differential increase in advertising exposure for non-elderly that live in elderly-dominated areas
to estimate the effects of advertising on drug use. This strategy hinges on the observation that
non-elderly individuals are exposed to the increase in DTCA but do not receive Part D insurance
coverage, which may independently impact drug utilization.
This paper makes four main contributions. First, we exploit a major policy change to
identify the effects of DTCA on drug utilization. The use of policy shocks as natural
experiments has been scarce in the existing advertising literature, although it is a promising
approach for obtaining variation in advertising that is unrelated to individual demand. Second,
the large policy shock provides an ideal setting for estimating a broad array of behavioral
responses to advertising on both the extensive and intensive margins, including drug initiation
and adherence. We isolate these responses to explore welfare implications of advertising. Prior
studies on the revenue consequences of advertising have largely focused on overall utilization
and spending. Third, we use data from two novel sources. We measure pharmaceutical
advertising using data on Nielsen “ratings” – a measure of the fraction of people in a target
audience that view advertisements. We observe ratings for two target audiences: the non-elderly
(under 65) and the elderly (65+). While most of the prior DTCA literature uses advertising
expenditures or the volume of ads to quantify advertising, ratings are a more direct measure of
actual advertising exposure.4This measure is more often used outside of the DTCA literature to
measure exposure to other types of television programming (e.g., Kearney and Levine, 2015;
Kanazawa and Funk, 2001). We obtain measures of drug utilization using administrative
pharmacy claims from a database covering about 18 million person-years. Finally, we quantify
spillover effects of Part D on the non-elderly population. Numerous studies have examined the
effects of Part D on the elderly but few have considered the effects on the non-elderly.5
We find that drug utilization is highly responsive to advertising exposure. Following Part
D, there was a 6 percent increase in the number of prescriptions purchased by the non-elderly in
areas with high elderly share, relative to areas with low elderly share. Event study results using
quarterly utilization data show that this differential effect coincided precisely with the
implementation of Part D in 2006. The event study also confirms that there were no differential
pre-trends in utilization across higher and lower elderly share areas, providing support for the
identifying assumption that the trends would have continued to be the same in the absence of
Part D. Our results show that a 10 percent increase in advertising views leads to a 5.4 percent
increase in total prescriptions filled for advertised chronic drugs, which implies an advertising
exposure elasticity of 0.54, and an estimated advertising expenditure elasticity of 0.23.
Expanded take-up of prescription drugs accounts for about 70% of the total effect of
advertising, while increased adherence to drug therapy accounts for the remaining 30%. While
advertising increased drug adherence for existing patients, we also find that individuals who
initiate drug treatments due to advertising are on average less compliant suggesting some
potential wasteful spending. We find evidence that advertising also increased the use of nonadvertised
drugs in the same therapeutic class as advertised drugs. This effect is concentrated
among generic drugs. DTCA on net does not cause substitution away from lower-cost generics
to higher-cost advertised drugs; it leads to increased use of generics rather than decreased use.
Is the FDA responsible for the opioid epidemic?
We have reported on the causes and effects of the opioid epidemic for several years — interviewing government whistleblowers, doctors, and Americans who've grown dependent on the powerful pain pills. We have not had a high-ranking executive from the pharmaceutical industry sit before our cameras, until now. Tonight, Ed Thompson, a drug manufacturer who spent decades managing and producing opioids for Big Pharma, breaks ranks to denounce his industry and its federal regulator, the Food and Drug Administration, which he says opened the floodgates on the crisis with a few little changes to a label.
The opioid epidemic: Who is to blame? - 60 Minutes Overtime
Ed Thompson: The root cause of this epidemic is the FDA's illegal approval of opioids for the treatment of chronic pain.
Bill Whitaker: The FDA ignited this opioid crisis?
Ed Thompson: Without question, they start the fire.
Caregivers are in real trouble.
Many of them have to hold down three jobs:
1) Real world job
2) Taking care of mum or pop
3) Acting as a legal and medical advocate, dietitian, and physical therapist for mum or pop.
The truth is that the elderly are not getting the best possible care under current standards because it isn't possible financially or physically due to finite resources. It is completely absurd to propose a program that requires effort and resources that is magnitudes above the current SOC. (referring to the exhasustive program proposed in this link: https://www.prweb.com/releases/reversal_of_cognitive_decline_100_patients/prweb15929561.htm)
It ain't gonna happen.
As the Baby Boom generation ages, 10,000 people turn 65 daily. For the first time in U.S. history, there are more than 50 million seniors. This trend is expected to continue until 2029, when the youngest Baby Boomers will turn 65 years old. A third of those older than 65 live alone, and half of the "oldest old" — those beyond 85 — are on their own at this late life stage.
The aging population, coupled with the high cost of senior living and in-home care, is driving a growing demand for family caregivers – a trend that is expected to continue through the next several decades and beyond.
This guide provides a comprehensive look at the state of caregiving in 2018, as well as information to help family caregivers move forward with practical tools they can use today.
THE NEW NORMAL
A 2015 survey conducted by the National Alliance for Caregiving and AARP, Caregiving in the U.S., approximately 34.2 million Americans provided unpaid care to an adult age 50 or older in the last 12 months, while 43.5 million provided unpaid care to an adult or child during the same 12-month period. Other findings include:
More than 8 out of 10 caregivers (82%) provide unpaid care for one other adult.
--15% provide care for two adults.
--3% provide unpaid care for three or more adults.
--16.6% of Americans (39.8 million caregivers) provide care for an adult (age 18 or older) with a disability or illness.
In a new Merrill Lynch study, eight in ten Americans say caregiving is "the new normal." While four in ten Americans 50+ believe they're likely to need care at some point in their lives, the truth is, seven in ten Americans turning 65 today will need care for prolonged periods.
The price tag for informal caregiving is staggering: more than $500 billion. If these family members were replaced with skilled nursing care, the cost would jump to $642 billion annually. In fact, in 2013, the value of unpaid care exceeded the total value of Medicaid spending and paid home care in the same year – a total of $470 billion, an increase of $20 billion from 2009.
These numbers only continue to climb as the population ages. And aging it is, with the U.S. Census Bureau reporting that the number of U.S. residents age 65 and older reaching 49.2 million (15.2% of the population) in 2016, a rise from 35 million (12.4% of the U.S. population) in the year 2000. The median age is also increasing in many areas of the U.S. In 2016, two-thirds of all counties (66.7%) in the United States experienced an increase in median age, and two counties had median ages over 60:
--Sumter, Florida: 67.1 years
--Catron, New Mexico: 60.5 years
Between 2000 and 2016, nearly all counties (95.2%) across the U.S. experienced an increase in median age, with 56 counties having an increase in median age of 10 or more years. This trend is driven by a longer life expectancy: The average life expectancy in the U.S. was 68 years in 1950, rising to 79 years by 2013.
...
Caregivers of adults are 49.2 years old, on average, but nearly half (48%) of all caregivers of adults are between the ages of 18 and 49. Caregivers who provide more hours of care per week tend to be older (an average of 51.8 years old) compared to those who provide less hours of care per week (48.0 years old). Overall, the majority of caregivers are adults between the ages of 45 and 64, with nearly one-fourth (23%) of adults in this age group caring for an aging adult. Nearly one in five (17%) of adults age 65 and older are caring for an aging adult, and among this group, 29% are providing care for a spouse or partner, while 33% are providing care for a friend or neighbor.
... full article at link below
Obama Wasn't Forced To Take Single Payer Off the Table - He CHOSE to do so!
I’m skeptical about … the FDA
July 28, 2016 Bob Clare
The Food and Drug Administration is a huge federal bureaucracy overseeing the safety and efficacy of more than a trillion dollars’ worth of consumer goods annually, ranging from medicines to cosmetics to foods, vaccines, and veterinary products. But you should think twice before believing that the FDA has only your best interest at heart. Over the past 25 years the ties between the FDA and Big Pharma have become increasingly cozy. Starting in 1992 with the Prescription Drug User Fee, the FDA began charging for drug approval, a cool $2,374,200 per drug as of 2016. This certainly gives the impression of a quid pro quo relationship (even if it doesn’t exist). Additionally, appointing folks who used to lobby and conduct research for Big Pharma into key leadership positions within the FDA reeks of conflict of interest. For example, in 2009, President Obama appointed former lobbyist and Monsanto executive, Michael Taylor, as Deputy Commissioner for Foods. Then, in February of this year, Robert Califf was promoted from his position as Deputy Commissioner for Medical Products and Tobacco to head the agency. This is interesting because, in a former life, the Duke cardiologist and researcher had financial ties to Eli Lilly, Merck, and Novartis, among others, and served as a board member and consultant for Faculty Connection LLC, a company whose sole purpose is to help pharmaceutical companies evade and manipulate FDA regulations. Isn’t this akin to putting the wolf in charge of the hen house? Of course, none of this started with Obama. Similar issues plagued the Bush administration where the FDA chair proved a difficult position to fill. Lester Crawford served just 2 months before resigning, and for nearly half of Bush’s tenure, the FDA chair remained vacant.
In 2000, USA Today reported that more than half of the FDA’s investigators had financial ties to the pharmaceutical companies whose drugs they were evaluating. It is a testimony to the power of self-delusion that many of these same investigators report that their evaluations are free of bias or conflict of interest. In 2006, the Union of Concerned Scientists and Public Employees for Environmental Responsibility distributed a 38-question survey to 5,918 FDA scientists to evaluate the state of science at the FDA. The results were not pretty:
--18% responded, “I have been asked, for non-scientific reasons, to inappropriately exclude or alter technical information or my conclusions in an FDA scientific document.”
--61% knew of cases in which Department of Health and Human Services or FDA political appointees had inappropriately injected themselves into FDA determinations.
--60% knew of situations where commercial interests had attempted to induce the reversal, withdrawal, or modification of an FDA determination.
--Only 47% believed that the “FDA routinely provides complete and accurate information to the public.”
--40% felt that they could not express public health concerns without fear of retaliation.
--Fewer than half (44%) reported respect for the integrity and professionalism of FDA leadership.
--40% rated agency morale as “poor” or “extremely poor.” Only 4% rated morale as “excellent.”
Wow, and I thought morale in the ER was lousy. Compared to the FDA we’re as happy as pigs in slop.
The pressure to approve drugs has gotten so bad that, in 2009, the Wall Street Journal reported on a letter received by President Obama’s transitional team leader, John Podesta, in which nine FDA scientists alleged that managers ordered, intimidated, and coerced them to manipulate data in violation of the law, further stating that the FDA is “fundamentally broken.” Regardless of the truth of their allegations, the fact that they were made is cause for concern.
Despite the expense, time, and red tape involved with drug approval, the hurdles aren’t all that high. A drug need show only that it is safe and more effective than a sugar pill to gain the FDA’s blessing. But what is “safe?” Rezulin, a diabetes drug with a monthly prescription rate of 300,000, was pulled 3 years after its approval in 2000, due to a mere 90 cases of Rezulin-associated liver failure and just 63 deaths. The overwhelming majority of patients taking the drug benefited from it. Just 1 in 23,000 patients experienced liver failure, and yet this was enough to get the drug pulled.
Meanwhile, t-PA, a clot dissolving drug used to treat stroke, remains on the market and heavily promoted by the American Stroke Association despite causing fatal brain hemorrhages in 1 in every 33 patients who receives it. Even under the best of circumstances, the drug is only marginally effective, helping just 12% of stroke patients. In 10 of the 12 major randomized controlled trials, thrombolytic drugs like t-PA fared no better, or performed worse, than a placebo. But the FDA put its faith in the 2 trials with positive findings. There are no trials showing a mortality benefit; the fatality rate is about 1% higher in patients receiving t-PA than in those who don’t. Although the data suggests t-PA fails on both safety and efficacy counts, it remains the first-line agent used to treat stroke at every major stroke center in the country. Whereas, I’ve seen several deaths from t-PA, I’ve seen no cures. And still the band plays on.
With all the forces of greed aligned against it, perhaps we should be thankful that the FDA gets it right as often as it does, but the agency can do better. New drugs are approved based on data supplied by manufacturers and selected peer review studies, so it’s not fair to blame the FDA if the data provided has been fudged, smudged, or smeared. Even when the data is accurate, there may not be enough of it. Most of the time there simply aren’t enough test patients to reveal all the side effects destined to surface once the drug gains a wider audience. This is why a post-market surveillance system is so important. An example where both the FDA and the manufacturer failed to protect the public is the drug Vioxx (rofecoxib).
Coming on the heels of Pfizer’s blockbuster drug Celebrex, Merck’s copycat version, Vioxx, was approved by the FDA in May of 1999 to treat inflammatory pain, promising fewer GI side effects than traditional NSAID drugs like naproxen, ibuprofen, and aspirin. It won FDA approval after just 6 months (usual time 10 to 12 months) based solely on unpublished, non-peer review data supplied by Merck. And just like Celebrex, Vioxx became a blockbuster, garnering sales of $280 million during its first year, on it way to $2.5 billion in annual sales. Questions regarding Vioxx’s safety, however, emerged almost immediately with publication of the VIGOR (VIoxx Gastrointestinal Outcomes Research) Trial. The goal of the study was to demonstrate Vioxx’s superiority over a traditional NSAID (naproxen) with regard to GI side effects when used to treat rheumatoid arthritis. And Merck was certainly pleased when their drug passed this hurdle, showing a 50% reduction in clinically relevant GI events like ulcers and GI bleeding. Unfortunately, compared with the much cheaper naproxen, Vioxx-takers suffered a five-fold increased risk of heart attack (0.1% vs 0.5%). Merck spun this to mean that naproxen must be cardioprotective, because the alternative was to admit that their billion-dollar baby was killing people. Merck dug in its heels, starting with a press release issued in May of 2001 entitled “Merck Reconfirms Favorable Cardiovascular Safety of Vioxx.” But there was nothing favorable about the drug. It was expensive, it didn’t work well to relieve pain, and it caused heart attacks. As the evidence mounted, so did the lawsuits. After initially standing behind their claims, Merck ended up pulling the plug on Vioxx less than 4 ½ years after its approval. A year later, researchers with access to Kaiser Permanente’s huge data base of patients, proved that naproxen was not protective, that Vioxx was harmful, and that the drug was likely responsible for between 88,000-140,000 heart attacks and cardiac deaths during its short-lived life. It took until January of this year for Merck to settle the last of the class-action lawsuits, agreeing to a payout of $830 million, raising the company’s total expenditures for lawsuits and government investigations to $8.5 billion—pretty much wiping out all of the drug’s prior earnings. Could this debacle have been prevented?
Merck may not have been culpable in knowing the cardiovascular dangers when it first filed for FDA approval, but it certainly put on blinders afterward. Once a drug is on the market, post-market surveillance continues with companies required to report safety data to the agency at quarterly intervals for 3 years. The FDA also relies heavily on its Adverse Event Reporting System, a voluntary, anonymous, non-peer-review system wherein manufacturers, doctors, and patients can report adverse events through the FDA’s website (see: www.fda.gov/Safety/Medwatch/HowToReport/default.htm). The data is reviewed quarterly by scientists at the Center for Drug Evaluation and Research who then report on their findings. The FDA has the authority to require manufacturers to conduct additional safety trials, but the agency never requested anything from Merck. Meeting in August of 2001, more than 2 years after the drug’s approval and more than a year after the VIGOR Trial, the FDA’s Arthritis Advisory Committee pointed no fingers and requested no safety studies. Meanwhile, Merck kept its head in the sand and continued pouring $100 million annually into direct-to-consumer-advertising (another reason why this practice should be banned). Each time a new study appeared reporting on the cardiovascular dangers of Vioxx, Merck predictably and unashamedly pooh-poohed the science. But it was Merck who was guilty of bad science having funded their own seeding trial to promote Vioxx’s use. Such trials are not designed to further scientific inquiry, but rather to promote drug sales. To get around the illegality of outright bribery, drug companies pay doctors to enroll patients into a trial, ostensibly to look at some property of the drug—safety, efficacy, comparative effects—it doesn’t really matter; the real purpose is to get physicians into the habit of writing for the drug. After a review of Merck’s internal documents, a group of independent researchers concluded that the Merck sponsored ADVANTAGE Trial “was actually a sophisticated marketing tool designed to allow optimal ‘seeding’ of positive experiences among primary care physicians.” Shame, shame, shame.
So the Vioxx thing happened a long time ago. Isn’t it safer today? The short answer is no. Avandia, a diabetes drug, remains on the market despite a plethora of lawsuits and a study showing a 43% increased risk of heart attack with its use. A similar diabetes drug, Actos, has been associated with an increased risk of heart failure and bladder cancer. It, too, remains on the market. And there are many, many more examples.
What can we learn, and what can be done? First, these episodes show us that shareholder pressures on pharmaceutical companies to recoup R&D costs and generate profits are enormous. When companies spend more on marketing than they do on R&D, that’s a problem. Unfortunately, it’s not one that can be solved by letting the markets fend for themselves. In a for-profit healthcare system, greed will always trump science, so unless we want to eliminate privately owned pharmaceutical companies altogether, we are stuck with regulating them. Simple fines won’t cut it. Here’s a partial list of some of the more recent fines imposed on the pharmaceutical industry: Nov. 2011, Merck, $950 million; May 2012, Abbott, $1.5 billion; Jul. 2012, GlaxoSmithKline, $3 billion; Oct. 2012, Boehringer Ingelheim, $95 million; Dec. 2012, Amgen, $762 million; Dec. 2012, Sanofi-Aventis, $109 million; Nov. 2013, Johnson & Johnson, $2.2 billion; Feb. 2014, Endo, $193 million. Get the picture? Fines of even a billion dollars aren’t adequate to induce these companies to clean up their act. Without jail time, don’t expect things to change.
Second, regulators working for the FDA haven’t kept us safe. They, too, face enormous pressures both from within and outside the agency to approve drugs. The growing private/public alliance serves only the pharmaceutical industry. The public pays for government regulatory agencies. The public also pays for drugs. We have both the right and the moral obligation to demand better from the FDA. To pick a former pharmaceutical lobbyist to head the agency is a disgrace. There needs to be a major culture change, starting at the top. But with either Trump or Clinton as our next president, I don’t see this happening. Both are in bed with industry
Third, it is vital that we, as a society, continue to finance independent research. More than 80% of all trials are now industry sponsored. Trials demonstrating positive findings are 5-times more likely to be published than those with negative findings, although it is the latter that often provide the more relevant information. Encourage your congressman to continue funding independent research. Most breakthroughs are serendipitous. Research for knowledge’ sake is far more likely to generate new findings that can then be used for clinical application, whereas research for profit simply introduces more “me too” drugs into an already crowded market.
Fourth, these examples show the importance of maintaining vigilance. Side effects, both good and bad, often only become manifest when hundreds of thousands of people begin taking a drug. The FDA must be free and willing to impose after-market studies without fear of industry reprisal. Consider that after the FDA approved the diabetes drug Januvia (sitagliptin) in October 2006, Merck had a fully functional website up and running within 90 minutes, drug reps were seeing physicians regarding the drug’s use within 2 days, at which point webcasts and educational programs were already airing on the internet. By day 8, Merck had reached 70% of their target physicians, and shipments of the drug were stocked on pharmacy shelves. By week 2, Merck had discussed their drug with managed care organizations responsible for 73% of the entire insured US population. By the end of the first month, 20% of all new diabetes prescriptions written by endocrinologists and 14% of those written by primary care physicians were for Januvia. If drug companies can achieve such amazing efficiency and success in their efforts to make money, we should be able to employ similar tactics to save lives. In the meantime, remain skeptical of pharmaceutical ads, and don’t forget that the best way to prevent yourself from becoming a guinea pig is to engage in a healthy lifestyle. Instead of medicating, try meditating. Instead of running to a doctor, try running to a park. You’ll thank me; no, seriously, you will.
References:
“Voice of Scientists at FDA: Protecting Public Health Depends on Independent Science,” Union of Concerned Scientists: Citizens and Scientists for Environmental Solutions, 2006; Cambridge, MA, ucsusa.org.
Alicia Mundy and Jared Favole, “FDA Scientists Ask Obama to restructure Drug Agency,” Wall Street Journal, Jan 8, 2009, online.wsj.com.
A. Faich et al., “Troglitazone (Rezulin) and Hepatic Injury,” Pharmacoepidem. Drug Safety 2001: 10 (6): 537-47.
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, “Tissue Plasminogen Activator for Acute Ischemic Stroke,” NEJM 1995; 333 (24): 1581-87.
Claire Bombardier et al., “Comparison of Upper Gastrointestinal Toxicity of Rofecoxib and Naproxen in Patients with Rheumatoid Arthritis,” NEJM 2000; 343; 1520-28.
David Graham et al., “Risk of Acute Myocardial Infarction and Sudden Cardiac Death in Patients Treated with Cyclo-Oxygenase 2 Selective and Non-Selective Non-Steroidal Anti-Inflammatory Drugs: Nested Case-Control Study,” Lancet 2005; 365: 475-81.
Kevin Hill et al., “The ADVANTAGE Seeding Trial: A Review of Internal Documents,” Ann Intern Med 2008; 149: 251-8.
Eric Topol, “Failing the Public Health—Rofecoxib, Merck, and the FDA,” NEJM 2004; 351: 1707-11.
Simon Maxwell, David Webb, “Cox-2 Selective Inhibitors—Important Lessons Learned,” Lancet 2005; 365: 449-51.
David Kao, “What Can We Learn From Marketing Efficiency?” BMJ 2008; 337: a2591.
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I worked for a company that was negotiating with the Chinese for technology to create an elder care robot to assist in their elder care effort.
In China one younger person may be responsible for four elders because of Mao's one child policy. They are in crisis mode but you don't hear much about it. The image below is from a 1990 journal article.
The Chinese knew this was coming, it was probably the impetus for creation of a Universal Healthcare policy.
https://www.jstor.org/stable/pdf/2949087.pdf?seq=1#page_scan_tab_contents
The living conditions described to us were worse than this:
Boxed in: life inside the 'coffin cubicles' of Hong Kong – in pictures
Coffin cubicles in Hong Kong.
https://www.theguardian.com/cities/gallery/2017/jun/07/boxed-life-inside-hong-kong-coffin-cubicles-cage-homes-in-pictures
Studies like this 2004 study do not address the issue of living conditions;
https://www.tandfonline.com/doi/abs/10.1080/13607860412331336823
This is the public face of elder care in China as of 2010:
https://confuciusmag.com/elderly-in-china
China's senior care demands continue to increase: survey
Source: Xinhua| 2018-05-20 19:03:39|Editor: Lu Hui
BEIJING, May 20 (Xinhua) -- Some 15.3 percent of China's elderly reported a need for additional care, according to a recently released report on the living condition of the country's senior citizens.
This figure has increased by 9 percentage points from 2000, according to the Survey Report on the Living Conditions of China's Urban and Rural Older Persons (2018), which was published by Social Sciences Academic Press.
The percentage of urban elderly reporting a need for care rose from 8 percent to 14.2 percent between 2000 and 2015. In comparison, the percentage in rural areas increased from 6.2 percent to 16.5 percent during the same time.
The need for care among elderly aged 80 and above displayed a sharper increase. The rate rose substantially from 21.5 percent in 2000 to 41.0 percent in 2015, while those aged 79 and below requiring care rose from 5.1 percent to 11.2 percent.
The types of care desired by elderly include at home doctor visits, housework services, health education, and psychological counselling, according to the report.
A total of 222,700 Chinese aged 60 and above from across the country answered the survey, which has been conducted every five years since 2000 by the China National Committee on Aging.
My week in Lucky House: the horror of Hong Kong's coffin homes
A general view of residential and commercial buildings in Yau Tsim Mong District, a popular location for ‘coffin homes’ in Hong Kong.
by Benjamin Haas in Hong Kong
The residents of Lucky House in Hong Kong are anything but fortunate. They are some of the poorest people in the most expensive city in the world.
In one of its 46 sq metre (500 sq ft) apartments, 30 residents live in purpose-built plywood bunk beds each with its own sliding door, colloquially known as coffins. Two rows of bunks, 16 bunks in each row – still space for two more people.
The residents are retirees, working poor, drug addicts and people with mental illnesses, mostly those unable to keep pace with the spiralling cost of housing in Hong Kong.
In many ways their home feels like a railroad sleeper car, but even more cramped and uncomfortable, and with none of the charm or romanticism that comes with train travel.
For a week I lived at Lucky House, crammed in a stuffy bunk teeming with bed bugs at night, my days spent lazing around with not much to do besides talk to the other residents, stare at my mobile phone and sleep.
more...
About a year ago, her devoted GP advised that we consider 24/7 care – not immediately, as robbing her of autonomy would only accelerate her descent to dependence – but soon.
I couldn’t afford to buy a house with a granny flat, or convert our home, which has stairs, to accommodate my mother’s limited mobility. My brother lives abroad and travels extensively. So with my mother’s grudging approval (she is a fiercely independent spirit), he and I looked into other options. They were not good. “Domiciliary carers”, who’d visit mother at home, are expensive. If we wanted someone with a proven track record, we’d have either to rely on the local authority and top up, out of our own pocket, the assistance they offered, or turn to agencies, which charge about £20 an hour.
The alternative, a care home, was terrifyingly pricey: a single room in a London care home costs over £30,000 a year.
.....
Cost was only one concern, however. The past few years have thrown up hair-raising stories about the abuse of elderly patients in care homes, where staff have been caught on hidden cameras beating their charges, kicking and mocking them.
Viola Richter works in the Emmendinger Altenpflegeheim (care home) in southern Germany, near the country’s border with Poland. She claims the practice of Germans going east to spend their last days is set to spread, as other northern European countries face a similar care crisis prompted by a dramatic increase in the ageing population, lack of care workers and rising prices.
East European care enjoys a good reputation. “One reason,” according to Richter, “is that the concept of ageing is very different there. Because it is a family-centred society, everyone pitches in to help with elderly relatives. They may have very little autonomy, but the elderly stay at the heart of the family.” Richter has noticed that, while her fellow Germans look on her job as nothing more than “wiping bottoms”, in the east assisting the elderly is respected as a crucial contribution to the nation’s welfare.
It is true that carers, in both Britain and Germany, have low status. Madeleine Starr, head of innovation at Carers UK, thinks it “scandalous that we don’t value our care sector more”. She points out: “This is a low-skilled sector with relatively poor pay: although agency recruits can charge more, it’s not unusual for the rest to earn only the minimum wage and pay their own travel expenses on top of that.”
In Britain, the sector is also heavily regulated. A family wishing to hire a carer would be responsible for doing CRB and employment checks, as well as income tax. The state, explains Starr, is keen to formalise such arrangements, to avoid the Treasury being cheated out of taxes.
The scenario is very different in Italy, where, as Starr reports, “light touch registration” prevails. Families who hire badanti pay the equivalent of their employee’s NI contributions (contributi). The rest is about employer and employee succeeding in arrangiarsi – coming to an agreement. The badanti usually hail from eastern Europe – thousands of women from Ukraine and Bulgaria have come to Italy since the Soviet Union collapsed – and lack professional training. Italians don’t seem fussed, and I can see why. Registered nurses may offer clinical competence, but “caring” is holistic: interesting conversation, a healthy diet, a walk outside. For that, the only requirement is a compassionate individual who regards their charge as a human being rather than a tiresome burden.
Katerina Ivanova, my father’s Ukrainian carer, fits the bill admirably. Patient, good-humoured and energetic, she values her role not only for the 2,000 euros a month, but for the relationship she has forged with my father. “He can make me terribly cross,” she admits during one of our regular Skype sessions, “but the truth is, I’m very fond of him. Back home, we’d never allow an elderly man to live on his own: loneliness is more debilitating than illness.”
Katerina, who has a doctorate in chemical engineering, lives with my father in a spacious flat that costs a fraction of what it would in London. She works six days a week, and assists him with bathing and dressing. She ensures he gets out for a walk, takes his medicines daily, and eats properly (no hardship, given that she is a fabulous cook). Katerina drives him to doctors’ appointments as well as on excursions; and when we come to visit, she spoils my nine-year-old daughter with gelati and the local amaretti.
More than 20% of the total Italian population is aged 65 or more. By the year 2050, this figure is expected to rise to 34% because of the country’s longer life expectancy, which is currently at 78 to 80 for men and 84 to 85 for women. In fact, about 20% of the senior citizens and 6% of the country’s total population are over the age of 80. Therefore, Italy definitely needs to focus on its elderly care as well as in-home senior care services.
Unlike the US and UK, when it comes to caring for the elderly in Italy, there is a lot of emphasis on family support. Looking after the older members of the family is regarded as a responsibility or a “social duty”, especially by the women and this also includes taking care of extended family. Normally, Italian institutions and communities only get involved if an elderly person has no family; old age homes are regarded as the “last resort” in Italian culture. Therefore, less than 1% of the senior population is currently using home care services.
However, in the recent past, the demand for elderly homecare services has increased to a great extent; yet, the supply remains fairly limited. Considerable differences can also be seen in the development and distribution of services for the elderly, particularly between the northern and southern parts of the country.
Unfortunately, there are no gated communities only for the elder, as often seen in the US. Elderly people, who are fairly fit and independent live in regular properties, with no special amenities for senior citizens.
Healthcare for the elderly
While the National Health System and the Local Health Authorities in Italy have been controlled by the municipality since 1978, care for the elderly was entrusted to communities and general practitioners that are organized by associations as well as the municipality. In fact, right up until the 1990s, the Italian authorities were oblivious to the health problems and requirements of older people. However, things began to change in 1992 with the “Objective: Ageing Persons”. The National Plan for senior citizens now aims at better coordination of medical and social services, which can be integrated within a person’s home care service system. Their framework for elderly care includes –
Home care: This consists of a service with social importance like personal care, house help, meals, as well as health importance, like medical and nursing care, which can be provided to a senior citizen within the comfort of his own home. Integrated homecare services seek to keep an older person at home for as long as possible.
Day centers: These comprise of a semi-residential structure within a district, where elderly people can spend a couple of hours each day. These centers are operational 5 days per week, 7 hours each day and can admit up to 20 elderly people. They provide not only healthcare services but also many types of social care services, like promotion of personal autonomy, job therapy, entertainment and so on.
Nursing homes: These services include residential structures that have been organized into smaller groups to provide healthcare, social care services and functional rehabilitation for those who are disabled. The support staff in nursing homes generally includes doctors, nurses, social workers and psychologist. Elderly patients staying in nursing homes may receive extensive or intensive care, depending upon their situation.
Extensive care at nursing homes for the elderly comprises of long-term rehabilitation and accommodation though hospitalization is limited to the acute stage only.
Intensive care includes rehabilitation with high medical importance as well as hospice for terminal patience. This service also provides palliative care for patients as well as their families.
Retirement for expats
Italy does not offer any kind of retiree program. In spite of the fact that Italian elderly care is not at par with countries like the US, UK and Canada, several people above the age of 65 choose to retire in Italy. Senior expats living in Italy need to obtain a retirement visa or an elective residency visa.
When do we get it right??? 60 years is too long.
"Senate Inquiry On Drug Prices Echoes Landmark Hearings Held 60 Years Ago" story on NPR
On Tuesday, Kenneth Frazier, CEO of pharmaceutical giant Merck, is set to face senators who say drug costs are "sky-high" and "out of control."
But Frazier doesn't need new talking points. Sixty years ago, a different panel of senators grilled a different Merck boss about the same problem.
To a striking degree, the subjects likely to surface Tuesday — high drug prices and profits, limited price transparency, aggressive marketing, alleged patent abuse and mediocre "me too" drugs — are identical to the issues senators investigated decades ago, historical transcripts show.
Healthcare and the myth of American Exceptionalism:
An interesting paper presented over 30 years ago.
Torrance, G. W. (1984). "Health Status Measurement for Economic Appraisal." Paper presented at the Aberdeen meeting on Health Economics.
AMERICAN EXCEPTIONALISM: IMAGES AND REALITIES
Tocqueville observed that the "great advantage" of the American lay in that he did not have to "endure a democratic revolution".(4) That insight into American life is one of the earlier and more well known attempts to explain why the United States is different from Europe. Why, in the United States, did there not develop either a mass socialist movement, or the kinds of social democracies that still prevail in Western Europe or Canada?(5)
In comparison to Canada and Western Europe, the United States is commonly regarded as a "welfare laggard" (Wilensky 1975); or, at best, as a "reluctant welfare state" (Bendick 1985). In this respect, the case for American exceptionalism is most often based on two contentions. First, the United States was no pathbreaker in the adoption of major social programs. Social security, workmen's compensation, unemployment insurance and public housing were generally adopted later in the United States than in Western Europe and Canada. Second, the scale of public expenditure on social programs in the United States was generally smaller than in Western Europe and Canada.
Both of these contentions hold in the health sector. Indeed, two distinguishing characteristics of the American health system are the absence of a compulsory and universal national health insurance (NHI) program and the relatively low level of public expenditure on health care. Although the component elements of an NHI system already exist in the United States (Medicare for the elderly and handicapped and Medicaid for the very poor), these programs were adopted later than in Western Europe and Canada. What is more, long before these programs were adopted, the United States opted in the 1930s for a system of private health insurance. Although this was not the outcome of explicit health policy decisions, a number of federal policies outside of the health sector, e.g., the exemption of fringe benefits from wage controls during World War Il and their largely tax-exempt status since then, provided indirect subsidies to the private health insurance industry (Starr 1982). As a result, beginning in the 1930s this industry grew and remains an important source of health care financing.
In summary, there is some evidence for American exceptionalism in the health sector. But there are also important ways in which the health sector in the United States resembles that of Western Europe and Canada. Let us examine this issue from the vantage point of three characteristics that typically distinguish the United States from Western Europe and Canada: (1) American values and popular opinion; (2) the structure of health care financing and organization; and (3) policy responses to health sector problems.
Will vaccines become "personalized medicine"?
Lawrence Solomon: One-size-suits-all vaccines will soon be replaced by safer, more effective ones
Today’s vaccines are failing. Personalized vaccines that reflect an individual’s genetic profile are coming
Vaccines as we know them are on the way out. On the way in are personalized, precision vaccines, created through a new discipline called vaccinomics that promises to protect a higher proportion of the population at far lower cost and without the real and potential harms that mass vaccination programs inflict on some people.
“The old paradigm isn’t working anymore,” Dr. Gregory Poland, head of the Mayo Clinic’s Vaccine Research Group explains matter-of-factly. “It didn’t work with HIV, it doesn’t work with other complex viruses and pathogens.” It didn’t even work with measles, which countries in the west had declared eliminated. Now measles is coming back and it isn’t likely to stop, not until old-school vaccine scientists give up their “cherished dogma,” recognize the many limitations in today’s vaccines and adopt 21st century thinking.
Traditional vaccines work on a century-old model of “Isolate, Inactivate, Inject” — the tried-but-not-always-true method of making a vaccine by isolating a pathogen, stripping it of its potency and then injecting it into us. This crude approach to developing a vaccine, reliant on observation rather than theory, becomes all the cruder by delivering it in one-size-suits-all fashion. As one example, women tend to be much more responsive than men to vaccines, yet women are given the same high dose as men, even though women report far higher rates of adverse effects after vaccination. Are we “over-dosing” women, Dr. Poland asks? Likewise, different ethnic groups, different age groups, and other demographics, though responding differently, are treated indiscriminately.
Vaccinomics — vaccinology informed by genomics — turns the traditional vaccine model on its head by making the individual the starting point, rather than the end point, in the vaccine creation process. Vaccines work — or don’t — on the basis of cumulative interactions in our bodies driven by a host of immune response genes and other factors. Because different gene sequences determine how different vaccines at different doses affect us, vaccines in the ideal should be customized to the individual.
In Dr. Poland’s view, that ideal, once unthinkable, is now within reach. The cost of determining an individual’s gene sequence is today $1000. Within a year, the cost is expected to plummet to $100 or less, making it economically feasible to produce gene sequences for us all. Armed with that information, vaccine doses can one day be sized to an individual’s particular genetic profile, eliminating today’s one-size-suits-all approach that sees some individuals receive doses too weak to offer any protection, others doses several times stronger than needed. These gene sequences can also save lives. Dr. Poland described the case of a young woman who arrived at the Mayo Clinic, her brain destroyed by a rare adverse reaction to the yellow fever vaccine, taken because she planned to be a missionary in Africa. Once gene sequencing is the norm, and science can identify what genes or gene combinations pose dangers in response to which vaccines, such tragedies can be avoided.
For reasons such as this, the vaccine research team at Mayo Clinic — one of the world’s largest, most respected and most prolific — promotes the growing discipline of “adversomics,” which aims to understand the adverse effects that can come of vaccines. The science here is daunting, since the variables that could cause a vaccine to do harm involve “a complex interaction of past exposures and infections, current physical and emotional health, and the individual’s genome and microbiome,” or the countless microorganisms that reside in our bodies. Yet this science is also doable, with some successes already logged.
Adverse reactions to vaccines may be in part “genetically predetermined,” Dr. Poland says, giving examples of different reactions, linked to genes, in various vaccines. “For example, a small percentage of children who get vaccine-induced fever after MMR [measles, mumps and rubella] will develop febrile seizures. I’d like to see predictive tests or preventive therapies that could be administered with the vaccine to prevent these reactions.”
The sciences of vaccinomics and adversomics depend on advances in collecting and analyzing biological data, and here a massive research effort is required, to comprehensively track all the adverse events that occur, and the circumstances surrounding them. This effort could pay off both directly, in the scientific discoveries to be had, and indirectly, in winning over the growing number of people who are now skeptical of vaccine safety, and have helped create the demand for adversomics. These skeptics often come from the elite in society — they tend to be well educated, affluent, and highly motivated — making their buy-in necessary for widespread vaccine use to occur. “The current science doesn’t allow for an informed understanding of an individual’s genetically determined risk for an adverse event due to a vaccine,” Dr. Poland explains. His expectation: Once people have risk information, informed choices will follow.
Dr. Poland has had his detractors — when he first unveiled vaccinomics in 2005 many in his field reacted with hostility. Many still see him as unrealistic. Inertia in the establishment is also working against him. Although he has close working relationships with both the U.S. Centers for Disease Control and major pharmaceutical companies, neither are vaccinomics enthusiasts, both prefer the security of the status quo. Yet vaccinomics is already a force, with the air of inevitability. Scientific American calls it “one of the most innovative scientific concepts of the decade.” The Scientist calls it “one of the hottest omics fields.” The vaccinomics concept is now being proposed to promote vaccine safety by researchers at major institutions in Canada and Europe as well as the United States.
As vaccinomics becomes mainstream, its commercialization will likely come not from the ranks of Big Pharma but from that of the many entrepreneurial pharma upstarts, backed by venture capitalists. Big advances generally come from outside the establishment, notes Dr. Poland, the man who coined the term “vaccinomics” and who will be known as the Father of Vaccinomics.
Vaccines - more testing and more personalized medicine is needed.
U.S. Supreme Court Decision
CHASE BOATMON & MAURINA * PUBLISHED DECISION
CUPID, parents of J.B., deceased, *
* No. 13-611V
*
Petitioners, * Special Master Gowen
*
v. * Entitlement Decision; Diphtheria-
* Tetanus-acellular Pertussis (DTaP)
SECRETARY OF HEALTH
Single Payer needed to balance Corporate Greed...
THE NEW HEALTH CARE
Hospital Mergers Improve Health? Evidence Shows the Opposite
The claim was that larger organizations would be able to harness economies of scale and offer better care.
An M.R.I. technologist at the Yale-New Haven Hospital Saint Raphael Campus. A merger of the hospitals in 2012 raised hospital prices in New Haven. But there are also questions about whether such mergers can hurt the quality of care.
Credit
Christopher Capozziello for The New York Times
An M.R.I. technologist at the Yale-New Haven Hospital Saint Raphael Campus. A merger of the hospitals in 2012 raised hospital prices in New Haven. But there are also questions about whether such mergers can hurt the quality of care.
CreditCreditChristopher Capozziello for The New York Times
Austin Frakt
By Austin Frakt
Feb. 11, 2019
Many things affect your health. Genetics. Lifestyle. Modern medicine. The environment in which you live and work.
But although we rarely consider it, the degree of competition among health care organizations does so as well.
Markets for both hospitals and physicians have become more concentrated in recent years. Although higher prices are the consequences most often discussed, such consolidation can also result in worse health care. Studies show that rates of mortality and of major health setbacks grow when competition falls.
This runs counter to claims some in the health care industry have made in favor of mergers. By harnessing economies of scale and scope, they’ve argued, larger organizations can offer better care at lower costs.
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In one recent example, two Texas health systems — Baylor Scott & White, and Memorial Hermann Health System — sought to merge, forming a 68-hospital system. The systems have since abandoned the plan, but not before Jim Hinton, Baylor Scott & White’s chief executive, told The Wall Street Journal that “the end, the more important end, is to improve care.”
Yet Martin Gaynor, a Carnegie Mellon University economist who been an author of several reviews exploring the consequences of hospital consolidation, said that “evidence from three decades of hospital mergers does not support the claim that consolidation improves quality.” This is especially true when government constrains prices, as is the case for Medicare in the United States and Britain’s National Health Service.
“When prices are set by the government, hospitals don’t compete on price; they compete on quality,” Mr. Gaynor said. But this doesn’t happen in markets that are highly consolidated.
In 2006, the National Health Service introduced a policy that increased competition among hospitals. When recommending hospital care, it required general practitioners to provide patients with five options, as well as quality data for each. Because hospital payments are fixed by the government — whichever hospital a patient chooses gets the payment for care provided to that patient — hospitals ended up competing on quality.
Mr. Gaynor was an author of a study showing that consequences of this policy included shorter hospital stays and lower mortality. According to the study, for every decrease of 10 percentage points in hospital market concentration, 30-day mortality for heart attacks fell nearly 3 percent.
The "private sector" would still exist in private practices and private medical facilites just as it does in Canada and elsewhere.
Why Doctors Are Warming to Medicare for All
Burnout, cynicism, and endless insurance red tape. As America’s private health care system crumbles, doctors are waking up to the need for Medicare for All.
By Meagan Day
Jacobin, August 23, 2018
According to a poll earlier this year in the New England Journal of Medicine, a majority of American physicians say that single-payer is the best path forward. Doctors are not traditionally a progressive bunch — in the 1960s, the American Medical Association famously hired Ronald Reagan to attack Medicare as “socialized medicine.” So why might this be?
A new study exploring the phenomenon of physician burnout holds some clues. Researchers from University of California, Riverside School of Medicine found that under the current system, doctors are increasingly unhappy at work. They observed a sharp rise in physician burnout, which they define as “1) a feeling of a lack of accomplishment; 2) feelings of cynicism; and 3) a loss of zeal, zest, and enthusiasm for work.”
One of the reasons for this dissatisfaction is that, as researcher Kenneth A. Ballou pointed out, “the doctor-patient relationship has been morphed into an insurance company-client relationship that imposes limitations upon the treatment doctors can provide to the insurance company’s members.” In our current system, there are usually three parties involved in every medical decision: the doctor, the patient, and the insurer. The doctor and patient may agree on a course of treatment, but the insurer decides whether it will be covered. And since many Americans can’t afford ever-growing out-of-pocket medical costs, that often means that insurers have the final say in whether the treatment will be administered at all.
The majority of Americans receive health coverage from a private insurance company. And while doctors and patients are both theoretically focused on patient health, the insurer is driven by an entirely different motivation: to maximize profit. Insurance companies are financially motivated to deny claims, and they do it all the time, even in life-or-death situations. One in four patients with a chronic or persistent illness or condition have had claims for medication, tests, or procedures denied by their insurer. In 70 percent of those cases, the condition was described as serious. Only 1 percent of patients said they trusted their health insurance provider’s judgment over their doctor’s or their own — and yet the buck stops with insurance companies.
When they deny claims, insurers give doctors and patients all kinds of excuses packaged in obscure industry terminology: formulary exclusion, prior authorization. But the simple fact is that patients aren’t getting the care they need — and doctors aren’t getting the opportunity to actually do their job. All too often, this is deadly for patients. For doctors, it’s depressing and demotivating. It hinders physicians’ ability to practice medicine, makes them feel powerless at work, and divests them of a feeling of personal accomplishment.
Another factor contributing to doctor burnout is depersonalization. Patients change doctors constantly under our current system. People switch jobs, or their employers switch insurers, and as a result patients are required to change networks and providers. Or people’s income fluctuates and they drift in and out of Medicaid eligibility, often going through periods where they aren’t insured at all. The ACA marketplaces are more or less designed to rupture relationships between doctors and patients, appealing to patients as consumers and communicating that if they shop around they can find a better plan, one that will finally meet all their needs — though it rarely does.
As a result of our jigsaw insurance network system, doctors and patients meeting for the first time can’t assume they’re embarking on a meaningful long-term relationship. “The doctor–patient relationship has sustained the happiness of both doctors and patients for generations,” write the UC Riverside researchers. “This centuries-old relationship has only recently been threatened by a de facto insurer–employer–provider relationship.” Seeing little purpose in getting to know patients intimately, doctors can become cynical. The lack of continuity leads to feelings of alienation and disinvestment for physicians who may have been attracted to the profession by the prospect of helping and healing people.
Finally, the study’s authors point to the proliferation of mandated use of Electronic Health Records (EHRs) as a cause of physician burnout. “No humanistic physician gets up with zeal in the morning, hopeful for a chance to have a meaningful relationship with Epic or MEDITECH,” they write. One time-motion study found that doctors spend twice as much time on EHR and desk work as on clinical face-time with patients. These medical records software programs are designed to facilitate documentation required for billing, more than for care itself. The upshot is that the clerical tasks associated with our byzantine insurance system take physicians away from the bedside and from practicing actual medicine.
This wouldn’t be the case if we had a simpler health care financing system — for instance if there were only one insurer, or single payer, for all patients. What makes the health system so complicated and time-consuming is that it’s carved up into private insurance networks, instead of a standardized system where a single public plan finances medical care for virtually everyone, as in dozens of other countries. Of course, the health insurance companies profit from this arrangement, and so does the rapidly growing health informatics sector intent on monetizing the management of our complex system. But there is no value for patients in private insurance — and, increasingly, doctors are finding that they too get the short end of the stick.
In a 2015 international survey of primary care doctors by the Commonwealth Fund, only 16 percent of US doctors said the US health care system “works pretty well and only minor changes are necessary,” while 14 percent said it “has so much wrong with it that we need to completely rebuild it” — versus 22 percent and 11 percent in the UK and 36 percent and 3 percent in Canada, both countries with single-payer systems.
Under a single-payer or Medicare for All system, there would be no private corporations with the motivation and the power to deny coverage just to improve their bottom line. In fact, since the government would be the sole financer of every individual’s care from cradle to grave, it would be incentivized to keep people healthy in ways that insurance companies — which play musical chairs with patients and ultimately hand them off to the government in old age — simply aren’t. Under a single-payer system, the insurer would want doctors to do their jobs and treat people, instead of thwarting them when financially convenient.
Moreover, under a single-payer system, nobody would change networks — because there wouldn’t be any networks. Doctors could build long-lasting, rewarding relationships with patients again. Between less time on billing paperwork, more continuity in care, and no private insurers prohibiting them from healing the sick, it’s really not so hard to see why physicians are warming to Medicare for All.
Obamacare is a failure as will universal healthcare for all be. Need the private sector to a point.
2012 article from AMA Journal of Ethics..
VIEWPOINT
NOV 2012
A Single-Payer System Would Reduce U.S. Health Care Costs
Ed Weisbart, MD, CPE
Citation
We Have Not Yet Solved the Health Care Crisis
The Affordable Care Act (ACA) is introducing insurance reforms that will improve the lives of millions of Americans, but we need to go much further to solve the crisis in health care.
Without correcting the fundamental structural flaws in health care financing, overall health care costs will remain poorly controlled. Though our clinical outcomes are mediocre by comparison [1], the average per capita cost of health care in the United States is twice that of other modern nations [2]. Increasingly, these costs are being borne by patients and government, driving personal bankruptcies and ever more austere public policies [3, 4]. Under the ACA, 30 million people will still have no coverage [5], and countless more will have inadequate coverage [1].
For most Americans, the glory days of “Cadillac health plans” are over, if they ever existed. The declining actuarial value of plans offered by employers means that the ACA will still leave those who need health care with financial hardships and high rates of bankruptcy, in spite of the subsidies for premiums and out-of-pocket expenses. (The actuarial value of a plan is the percentage of a patient’s predictable costs within the covered list of services that would generally be paid by the insurance company.) In order to participate in one of the ACA’s new health insurance exchanges, insurance companies are required to offer at least one “silver” and one “gold” plan, with 70 percent or 80 percent actuarial value, respectively. An insurance policy with a 70 percent actuarial value would, by definition, leave patients responsible for 30 percent of the overall cost of the care on the list of covered services. Many other medically necessary services, such as home and long-term care, dental treatment, hearing aids, and basic vision care, will not be covered and are therefore not captured in out-of-pocket maximums.
Health insurance exchanges are envisioned to function like many familiar online marketplaces, such as Travelocity or Amazon. The fate of the ACA’s health insurance exchanges may not be determined entirely until after the upcoming elections. At the moment, only a handful of states have fully committed to implementing exchanges [6]. States that do not implement an exchange will have an exchange implemented for them by the federal government, assuming Congress allocates the appropriate resources. They will be available on January 1, 2014, for uninsured individuals and small groups to compare insurance plans.
Comparison shopping makes sense when buying a product like an automobile, about which individual preferences vary widely. With health insurance, however, we all need the same thing: affordable access to high-quality health care. We need to be able to select our own physicians, but the complexities of selecting an insurance company distract us from genuinely beneficial health care activities. Given the currently dominant role of insurers in our health care, the exchanges are a step forward. But what we need is a leap forward, changing the insurance companies’ role and allowing us to focus on our health, not our insurance.
In the 6 years since Massachusetts adopted legislation very similar to the ACA, the cost of health care has continued to drive patients into financial ruin [7]. The state has achieved nearly universal coverage, but, like the ACA, its legislation has yet to effectively address cost and sustainability. Its newly enacted cost-containment law relies heavily on unproven measures such as capitated payments and wellness programs, offering little promise of success [8].
We will not solve our health care crisis as long as private insurance plays a dominant role. We should correct the flaws of the current Medicare program and extend this coverage to all age groups. This approach was well described in 2003 in the Physicians for a National Health Program’s “Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance” [9].
Major Deficiencies Remain
The Dartmouth Atlas of Health Care has repeatedly documented “glaring variations in how medical resources are distributed and used in the United States” [10]. They attribute much of this variation to supply-sensitive care, that is, care determined by resources and capacity rather than by medical need, and conclude that supply-sensitive care “accounts for more than half of all Medicare spending” [11], some of which is of no medical value and a waste of resources.
A second problem is that the uniquely American plethora of private insurance companies drives a squandering of resources. Legions of staff manage independent computer systems. Each insurance company devotes an enormous number of personnel to responding to emerging regulations from a variety of disparate governmental programs. The expense of this redundancy is considered “overhead” and passed along to the consumer. The intent behind those regulations could instead be implemented once, in a single system servicing the entire country.
Each insurance company develops its own programs for utilization management, prior authorizations, and evidence-based drug formularies to compel the use of that plan’s preferred vendors and pharmaceuticals, consuming resources but adding little proven value to health outcomes. No two “evidence-based” formularies have the same drugs on their lists. It’s virtually impossible for a physician to remember which low-molecular-weight heparin is preferred by which insurer. Medical groups and hospitals all dedicate staff to managing within this environment, eroding their profits and contributing to a demand for higher reimbursement.
Cost-containment efforts today are focused on the back end of delivery, placing economic pressures on individual physicians and patients who cannot realistically be expected to pursue systemwide solutions [12]. This is the illogic behind “pay for performance” and “consumer engagement.”
In a cynical denial of the responsibility for national planning, patients and physicians are expected to be able to control costs today. Information about the prices of treatment regimens is seldom available at the point of health care delivery, especially not for the complex needs of the desperately ill who consume the lion’s share of resources. It is inhumane to ask someone dealing with the most dangerous phase of a major illness to attempt a cost-benefit comparison of a variety of therapies and health care providers.
Furthermore, pretending that health care is a commodity does not make it easier to reduce it to something simplistic like a spreadsheet comparing airline tickets. Neither the full cost nor the relevant quality is readily available for comparison-shopping.
The ACA began an important discussion of cost containment through the modernization of broad systems such as electronic health records, prevention, and accountable care organizations. While these may hold promise, there is little reason to anticipate their leading to the savings necessary to reverse the crisis [13, 14].
A Single-Payer System Would Improve Resource Allocation
A single-payer system offers several strategies that have succeeded in other countries. As Marmor and Oberlander have written, “they may not be modern, exciting, or ‘transformational.’ But they do have the advantage of working” [15].
Consolidate fragmented finances. It’s been said that when you are trapped in a hole, the first rule is to stop digging. Certainly don’t dig faster.
Profound administrative excesses divert resources into activities that do not improve health outcomes. They often represent the entire careers of countless highly skilled and compassionate people who could be spending their time delivering health care rather than impeding it.
Insurance companies have balked at the ACA’s requiring them to spend at least 80-85 percent of their revenue on delivery of health care. (In contrast, more than 98 percent of Medicare’s expenditures are clinical [16].) Estimates vary, but one-quarter to one-third of our current costs are driven by insurance company overhead, profits, and the administrative costs embedded in clinical settings. Roughly half of these costs would be recovered under single-payer and could be reallocated to the delivery of meaningful health care services [17, 18].
A single-payer model would eliminate the inefficiencies of fragmentation by converting public programs such as Medicare, Medicaid, and CHIP into a single administratively efficient financing system. Streamlined billing under single payer would save physicians vast amounts in overhead [19].
In addition to reduced billing expenses, physicians would also enjoy a meaningful drop in their malpractice premiums. Roughly half of all malpractice awards are for present and future medical costs [20], so if malpractice settlements no longer need to include them, premiums would fall dramatically.
Use bulk purchasing to negotiate lower costs. We spend more but use less of most services [21] than other member nations of the Organization for Economic Cooperation and Development. In other words, our prices are much higher [22]. As health care economist Uwe Reinhardt noted,
prices for identical products or services in the U.S. tend to be, on average, twice or more than the prices of the same products and services paid in other countries…. Prices are high here because the payment side of the health system is so fragmented that few payers have sufficient market power to bargain for lower prices from an increasingly consolidated supply side [23].
Drug formularies vary widely among health plans. The medical evidence behind the formulary selections is the same in Florida and Alaska, yet the drug lists are sometimes as different as the geography. Although pharmacy benefit managers work within the boundaries of medical evidence, they also consider the prices they have negotiated and the local drug market shares on their formulary selections. Any industry’s power to negotiate prices depends upon its purchasing volume.
Only a single-payer system enables the kind of bulk purchasing of drugs and medical devices that would give the buyer power. A model for this structure exists today in the United States: the Department of Veterans Affairs. Due to governmental authority to negotiate drug prices for the VA, it pays roughly half of the retail price of drugs [24].
Negotiations with clinicians should ensure adequate reimbursement of expenses plus fair profits, while ensuring value for taxpayers. A recent careful analysis found that this model is effective and does not lead to a loss in physician income [25].
Adopt responsible, rather than profit-driven, strategies. The United States has little national planning of health care resource allocation. Uncontrolled costs consuming an ever-increasing percentage of the GDP create the appearance of inadequate resources, but the experience of other nations [20] belies this. Under a single-payer system, regional planning of resource allocation would be aligned with public health needs rather than duplicating services and driving up medically questionable utilization. Investing in health care buildings and equipment for reasons other than anticipated need duplicates services and drives up utilization. Intelligently planning capital investments to match community health care needs is the key to aligning utilization of services with public health priorities.
According to the Physicians’ Working Group for Single-Payer National Health Insurance, “Capital spending drives operating costs and determines the geographic distribution of resources. When operating and capital payments are combined, as they currently are, prosperous hospitals can expand and modernize while impoverished ones cannot” [9], threatening the viability of safety-net institutions that serve vulnerable populations. This self-stimulating relationship is dependent upon market opportunities, often not the same as public health priorities. Regions with excess capacity inevitably have excess utilization [10]; better planning could also ensure adequate capacity in underserved areas. Divorcing capital from operating budgets eliminates the ongoing pressure to reap future capital growth by limiting reimbursement to clinicians. Capital, operating, and educational budgets would be nationally funded, regionally administered, and nonfungible. Applying national planning to regional budgeting would right-size capacity.
Today’s fragmented system is akin to requiring each household in a community to anticipate their needs for the coming year and negotiate their own fees and scope of services with the local police and fire departments. Imagine instead how much of their budgets these life-saving community services would be obliged to devote to marketing to and negotiating with each household and the rampant disparities in service that would result. That is precisely what is happening today in health care, and it is absurdly wasteful. For police and fire departments, we have recognized that it is significantly less wasteful to give all citizens the same “coverage” for set prices and to administer it with regional coordination. Global budgeting is the only sensible strategy for such unpredictable yet universally needed services.
Conclusion
The ACA has begun the process of much needed change. Now we need to go further in reforming health care finance to enable all Americans to achieve their fundamental human right to comprehensive coverage. The rest of the modern world has run the laboratory studies for us; now is the time for us to adopt this well proven solution.
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