An analysis by The New York Times found that in the first full year of the Affordable Health Care Act there were historic increases in coverage for low-wage workers and those in other demographics previously less represented in the health care system. The article from The New York Times illustrates the findings with a series of charts and graphics showing the scope of changes. As noted, the expanded coverage has had a significant impact for many Americans. Read more…
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Government Policy
Limiting Opioids for Patients with Chronic Pain
By Jen Jenkins
Pain is one of the main reasons people go see their doctor. Although it was once overlooked or often dismissed, it is now a standard vital sign in a patient’s work-up. However, unlike other tests administered in a medical setting, pain is difficult to measure because among other factors, pain tolerance is highly individual. The United States has had a long and complex history with chronic pain management. In the 1990s, doctors were reproached for under-treating pain and were told that opioids, including OxyContin, could not only bring unmitigated relief to patients but do so in a safe way. Today, doctors are again being admonished but for a very different reason. Politicians and policy makers continue to publicly denounce what has been labeled as the “opioid crisis,” due in part to doctors over-prescribing medication, namely opioids.
A growing number of states are enacting measures to limit prescription opioids and the federal government has issued the first national guidelines to help reduce the use of these highly addictive medicines. Dr. Robert L. Wergin, chairman of the board of the American Academy of Family Physicians, said he doesn’t want to stop prescribing opioids altogether but that he can see why some doctors have gotten to that point. Dr. Wergin has taken professional and personal risks in prescribing opioids. Closely monitored by state and federal officials, he must go through an elaborate prescription checklist. He has also been threatened by addicts, desperate for pills. His patients now sign “pain management contracts” and must agree to random drug tests before receiving an opioid prescription. “You don’t want to become so jaded that you assume everyone in the E.R. is a drug-seeker,” Dr. Wergin said, but he has seen firsthand a growing number of overdoses and opioid-related deaths during his emergency room shifts.
Collectively, primary care physicians write the greatest volume of opioid prescriptions and these same doctors are now scrambling to find alternatives for their patients dealing with chronic pain. Prosecutors and medical review boards closely scrutinize physicians who prescribe controlled substances. Many medical associations now offer doctors training about chronic pain, urging the use of other remedies such as physical therapy, acupuncture, anti-inflammatories, antidepressants, or counseling before prescribing opioids. Unfortunately, alternatives are unrealistic for some patients for a variety of reasons: physical therapy may be too expensive; anti-inflammatories cannot be taken by those with a compromised liver.
Some state medical boards have recommended limiting the number of opioid doses per month while others have recommended limiting the strength of daily dose. Dr. Wergin is careful not to promise patients a prognosis of being “pain-free” and chooses instead to talk with them about setting realistic goals to manage their pain. Although opioids help to alleviate severe pain, they are highly addictive. The epidemic of overdoses and death is real and the responsibility of monitoring patients for potential abuse falls largely on prescribing doctors.
Take a moment to read the following New York Times article and learn more about Dr. Wergin and what he is doing for his patients.
Deductibles: A Significant Component of Health Insurance
Until recently, health insurance deductibles have proven to be quite a catch 22. On one hand, Americans would rather not have to pay a deductible or co-payment before receiving healthcare; however, it’s simultaneously impossible to ignore that deductibles have helped to make health insurance more affordable and, for some Americans, possible to have at all. Bernie Sanders recently released his proposed health care plan featuring the promise that no American would have to pay a deductible again. Although light on the details, this part of the plan would mean removing something that has been working its way into the health care market since the early 1990s. Deductibles can be significant for some when an average out-of-pocket cost of around $1000 required before coverage kicks in. This is something that has been tolerated due to the standing argument that it makes health care more affordable overall. But is this actually the case? The truth behind the purpose of deductibles is something we do not often get to see up front. The fact that most Americans can’t afford steep deductibles has been one reason to reassess the system but the main question now appears to be: Are deductibles actually helping with health care spending, or deterring it?
In this article featured in the New York Times, Michael Chernew, a professor of health policy at Harvard, stated “If you make something free, people will spend a lot on it.” Recent research is now supporting this idea as studies have shown that more required out-of-pocket costs may be responsible for a downturn in health care spending altogether. Researchers are now beginning to agree that high deductible plans are not what they have been thought to be in the past. Multiple randomized experiments are showing that over time, people who pay more health care bills out of their own paychecks choose to use less health care, while people who have everything covered by insurance tend to utilize healthcare more because they have insurance available. Another important factor is that in comparing these two groups of people, those who were choosing to receive less health care were no less healthy than those taking advantage of using more. What could this mean about the future of health care deductibles? No one is sure at this point. According to some health economists, including Michael Chernew, it may require “smarter” albeit more complicated forms of health insurance. These plans would utilize economic incentives to reduce unnecessary health care spending without deterring necessary care for patients.
We are interested to hear what you think about the possible new direction of health care and the role that deductibles and co-pays have. If you have a moment to read the more in depth New York Times article on this subject please leave us your thoughts in the comment section.
The Vaccine War
by Angela Sams
Many of us likely saw or at least heard about the picture that Mark Zuckerberg, co-founder of Facebook, posted on the social media site recently. Though perhaps it appeared innocent on the surface, the photo of his two-month-old daughter getting vaccinated surely ruffled some feathers amongst the anti-vaccination community. A recent Time article discusses the fact that this isn’t the first public statement that Zuckerberg has made regarding vaccinations. He recently used Facebook to publicize a book called On Immunity, by Eula Bliss. “The science is completely clear: vaccinations work and are important for the health of everyone in our community,” he wrote.
Despite the fact that links between vaccines and autism have been discredited, there are still many who believe that vaccines are harmful. But what about the harm caused by unvaccinated individuals who are spreading diseases that were once a thing of the past? Indeed, if Zuckerberg wanted to, he could shut down the Facebook pages of the “antivaxxers.” This does not violate any First Amendment rights, due to the fact that Facebook is a private company.
Another article on the Time website discusses the dangers of “tolerating” those who refuse to vaccinate their children. Recently, at a school in Melbourne, Australia, approximately a quarter of the school’s student body contracted chicken pox. Only 73.2 % of the students had been vaccinated. Apparently, the school does not require students to receive vaccinations, and instead wrote that “staff respects the right of every family to make choices about immunisation,” in a school newsletter back in May.
While tolerance is often a good thing, even called “the social and intellectual flexibility that allows a society to function at all,” at what cost does it come? Will our society eventually see a dangerous return of diseases that until recently have been kept at bay due to vaccines? The line has to be drawn somewhere, especially when the beliefs of certain individuals (despite the scientific facts) negatively impact those around them.
Measuring Medicine and Evaluating Education
by Jen Jenkins
The ability to measure quality in nearly every industry has proven to be a powerful and important component for success. In both healthcare and education, metrics and measurements are no less significant, but over time has this number gathering trend spun out of control?
According to Robert Wachter, a professor and chairman of the Department of Medicine at UC San Francisco and the author of this New York Times blog post, in healthcare and education “the focus on numbers has gone too far.” In medicine, the constant measuring that takes place has become more a matter of being included on a “top 100” or “best hospitals” list, rather than a chance to improve patient care. A significant amount of a doctor’s precious time is now being spent entering information into a computer system instead of having quality conversations with patients. A study done in 2013 found that during a 10-hour shift, emergency room doctors were clicking a mouse 4,000 times. That is an immense amount of time spent entering information and being away from patients, all in the name of producing numbers.
It’s true that spending time on metrics is not as much of an issue in industries where the focus and care of another person doesn’t possibly mean life or death. The issue isn’t whether or not to get rid of measurement in healthcare–it does play an important role–but to instead scale it back. Allowing time for more research could help produce a better understanding of what to measure and ensure that what is being measured really matters in terms of the betterment of the industry. Overall, according to Robert Wachter, one should fully appreciate that measurement does place a burden on professionals in the medical field. We need to learn how to minimize that burden so that measuring for quality does not mean a decline in the actual quality of care that patients receive from doctors.
In his post, Robert Wachter goes on to explore this phenomenon of metrics and measurement in another industry where the cons may outweigh the pros. As in medicine, measurement in education comes at an expense. According to educators, that expense is actual learning and a loss of some important subjects that are not as easily measured by tests – examples include art, music, and physical education. Is a preoccupation with test scores really worth the demise of a well-rounded education?
Avedis Donabedian, a professor at the University of Michigan’s School of Public Health, had a surprising answer regarding the secret behind quality. After a lifetime spent in the field of quality measurement, this data-driven scientist said, “The secret of quality is love.” It’s clear that we cannot let the business side of either healthcare or education dissuade people from becoming doctors or educators; these are both fields that should be able to adopt measurement without losing the compassion and altruism that exists at their core.
Who Is Paying the Price for Drug Coupons?
by Angela Sams
Many of us have probably at some time or another been faced with an expensive prescription that we wish we didn’t have to pay for, instead wishing for some kind of coupon or discount to help foot the bill. According to a recent article in Bloomberg Business, some pharmaceutical companies are providing just that, spending approximately $7 billion to generate discounts and coupons for patients’ drug co-payments.
Why are some prescriptions so wildly expensive? The short answer is that insurance companies want the drugs to be so unaffordable that patients won’t use them. Much to the chagrin of insurers, pharmaceutical companies have responded by paying for patients’ prescription co-pays, handing the rest of the balance right back to insurers. This is not allowed everywhere, however. Because the cost of a patient’s co-pay directly influences whether or not they will pay for their prescription, co-pay coupons are banned in the Medicare program, cited as an illegal inducement.
Drug companies see the coupons—distributed online, in magazines, and in doctor’s offices—as helpful to consumers. Holly Campbell of the trade group Pharmaceutical Research and Manufacturers of America states that “co-pay offset programs can play an important role in maintaining access to needed medicines, especially for patients taking specialty medicines or with chronic conditions.” But providing these coupons helps the drug companies as well. Indeed, they “can earn a 4-to-1 to 6-to-1 return on investment on co-pay coupon programs.”
Insurance companies are resisting the coupons by nixing drugs from their plans, and creating a rewards program that would give cash to patients who don’t use the coupons. United Healthcare has been leading the way in the fight against the co-pay coupons, in part due to the fact that the discounts can keep patients from seeking drug alternatives that are equivalent to the more expensive option. A spokeswoman for United argues that when consumers choose a pricier drug because they have a coupon, this can have a huge impact on healthcare costs overall. The battle between insurers and drug-makers leaves consumers caught somewhere in the middle. And it leaves one to wonder, could the problem potentially be solved if drug prices were simply lowered?
Denialism vs. Skepticism
by Angela Sams
“You’re entitled to your own opinion, but not your own facts.” A common phrase indicating that everyone can have their opinion on any variety of matters, but when it comes to clear, objective facts, there’s really no point in arguing. Needless to say, there are plenty of opinionated people out there, and sometimes having an unsubstantiated opinion on unarguable facts can come at price.
Political arguments overwhelm our country as we read about the Paris climate change conference and prepare for elections next year. It takes a well-informed and discerning individual to separate fact from fiction (or, opinion), when sometimes one may be presented as the other. As a recent Op-Ed article in New York Times points out, “disbelieving science isn’t skepticism, it’s a form of willful ignorance.” Skepticism is something that is evidence-based. For example, we may read about a topic, but are not convinced enough by the facts to believe that whatever the article states is true. Denialism, on the other hand, is more about believing what we want to believe (“I don’t want climate change to exist, so I just won’t believe in it,”), pushing aside obvious evidence, and focusing on so-called “facts” that would help support our own opinions on the matter.
In order to avoid denial, it’s important to understand science. Science does not mean that there is only one answer, and it does not mean that if new evidence comes along it will not change the current understanding of something. Rather, it’s something that’s always evolving, something that is never “settled.” And while it may turn out that a theory is false, science’s “successful track record suggests that there is no superior competitor in discovering the facts about the empirical world.” Rejecting the current scientific evidence on a topic such as global warming is not just being in denial—it could also come at a price. Instead of pretending that something doesn’t exist, wouldn’t it be smarter instead to prepare for it or try to prevent it, until further evidence suggests that this is not necessary?
Could you be Paying for Someone Else’s Prescription?
by Angela Sams
You get what you pay for, right? Not necessarily. Whether Americans realize it or not, they may in fact be paying $124 or more for the expensive prescriptions of a neighbor, a family member, or a complete stranger!
A recent op-ed article in the New York Times discusses a drug that “is a new class of cholesterol-lowering agents called PCSK9 inhibitors” as an example of a medicine that may result in higher insurance premiums for all of us. This new inhibitor, just approved by the FDA in July, is thought to reduce bad cholesterol (LDL) by up to 60 percent more than a placebo. And, though there is no solid proof that the drug (and others like it) can prevent heart attacks, strokes, and deaths caused by heart disease, researchers are still optimistic.
So what’s the problem with a drug that could potentially improve quality and length of life? The hefty price tag. The companies who create these drugs have disclosed that a prescription will cost more than $14,000 per year, per patient. Multiply this by the number of years that a patient must take that drug, and the number quickly becomes unfathomable. Those costs will then fall to insurers, and eventually trickle down to the rest of us. Policymakers and academics have a couple of proposals that could help save patients money, “such as separating out deductible limits for drugs from deductibles from other health benefits and limiting co-pays for these drugs to $100 to $250.” However, this won’t get rid of the fact that the drugs cost a certain price. That price must still be paid, even if it falls to the insurance company.
Here is where the idea of value comes into play. Are we really getting what we pay for? And how is one to determine the value of a particular medicine? Other items in our economy (think cars, phones, or TVs) are purchased by consumers, depending on whether or not that consumer thinks it’s a good “value.” In the case of medicine, value could potentially be determined by measuring the improved quality of life it gives to patients. Since we are all affected by the rising costs of these prescriptions, it is up to us as a society to determine the value of these medications, and how much they are worth, monetarily.
Restoring Sight to the Poor
by Angela Sams
Can you imagine a life without sight? Those who are blind face many challenges on a daily basis—challenges that probably don’t even occur to those who can see. Enter Dr. Sanduk Ruit, a Nepali ophthalmologist who is on a mission to help the blind see, using a procedure called the “Nepal Method.” A recent article in the New York Times delves into his miraculous work.
Living blind in a country that is poor presents its own unique challenges, as access to healthcare may not even be an option. Dr. Ruit is pushing past these barriers by offering a cataract microsurgery to patients for only $25. It is a technique that he developed, and it is now being taught to medical students in the United States.
For the powerful impact the microsurgery has on its recipient, you would think it wouldn’t be so simple. That could not be further from the truth. The entire process takes about five minutes, and involves removing the cataract on a patient’s eye and replacing it with a new lens. A procedure that was once seen as something that could only be done with expensive machines, Dr. Ruit’s procedure is just as effective. The big difference is that it is much more affordable.
The cure for blindness extends beyond Nepal. A charity called the Himalayan Cataract Project helps ensure that other countries such as Ethiopia and Ghana can also benefit. The charity was started by Dr. Geoffrey Tabin, another eye specialist who has been working next to Dr. Ruit in Nepal.
In addition to removing the cataracts of the blind, Dr. Ruit founded the Tilganga Institute of Ophthalmology, which includes “hospitals, outreach clinics and training programs and an eye bank, using fees from better-off patients to support impoverished ones.” Approximately 30,000 patients will receive eye surgery from the institute annually.
It seems that the success in Nepal is just the beginning of something great. Stories such as this give us reason to believe that blindness can eventually be eradicated, one eye at a time.
The FDA and Supplement Regulation
by Jen Jenkins, Market Analyst
Although we see the topic wending its way in and out of the media spotlight, the Federal Drug Administration remains quietly under fire for its lack of effectively enforcing laws within the supplement industry. A rather surprising and intriguing reason for this lack of enforcement has been traced to a cross-contamination of the hierarchy of the FDA and industry officials in the supplement industry. However, this is disputed by a current chief executive of the Natural Products Association, Dr. Daniel Fabricant, who was formerly running the FDA’s division of dietary supplement programs up until last year. “I did more there in three and a half years than was done in the 16 years prior,” Dr. Fabricant has said.
At the beginning of April of this year, 14 state attorneys general insisted Congress provide the FDA with more power to regulate supplements. More attention has been paid in the last few years to supplements invading shelves that have dangerous hidden ingredients “with amphetamine-like chemicals” labeled only under obscure plant names. BMPEA is a chemical nearly identical to amphetamine that is currently causing the most concern. Canadian health authorities pulled all supplements containing the chemical from their shelves this past December. Meanwhile, the FDA has been aware of nine specific supplements containing the dangerous chemical for the past two years but chose to never make the names of those supplements public.
The biggest concern for consumers is that BMPEA is not listed as being an ingredient in many products that are still on store shelves. Many large retailers of supplements, such as the Vitamin Shoppe, are supportive of the FDA using the authority it has to regulate supplements the way it does other drugs in order to keep the industry safe. As suggested by the linked New York Times article, it remains in the best interest of the public to remain wary when incorporating new weight-loss and workout supplements into any diet: until we can fully trust that supplements are being properly regulated by the FDA, the safe bet is to stick to products that have familiar ingredients or to run it by a doctor.
See this New York Times article for a list of current supplements that are known to contain BMPEA.
