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Government Policy

Choices Being Limited Under Some New Health Care Plans

Since the Affordable Care Act created marketplaces for private health plans last fall, insurers expecting to lure customers with low premiums have fashioned smaller networks of medical providers.

By cutting out expensive hospitals and negotiating favorable rates with doctors in exchange for sending more patients their way, insurers can keep premiums down. In one instance, Blue Shield’s new network includes 43 hospitals in Los Angeles County, about 64 percent of what its standard coverage offers. Read more…

Tracking Patient Data to Reduce Emergency Room Visit Frequency – and Cost

As the Affordable Care Act expands Medicaid to a greater number of patients, the need for states to keep emergency room costs in check will become more pressing.

In a trial program in Washington State, ERs are now required to upload information on patients they’ve treated into a new database.  This allows other ER doctors and providers to research incoming patients, making a big impact on cost savings, with doctors now able to track patients whose situations would be better served by far less expensive office visits.

Patients with multiple visits (those who went to the ER more than four times a year) — suggesting they are using the ER in lieu of visiting primary case visits — made up a fifth of all ER visits paid for by Medicaid.

Data released on March 20 shows that ER visits by Medicaid patients fell 10 percent in the 2013 fiscal year, and the rate of ER visits that resulted in a non-acute diagnosis decreased by more than 14 percent. Database use is credited for a substantial amount of the state’s $33.7 million reduction in 2013 Medicaid costs. Read more…

 

Health Care’s Road to Ruin

This article and comments put the lie to our health care system being among the best, or driven by the free market. It is politically and economically corrupt and untenable. The benefits that drive much of the hysterics against reform elude the many who have no coverage, and the rest of us, who are billed in irrational ways, ignorant of price until the bill is issued to a third party who ignores it and pays something else, are receiving care that is frequently unnecessary and without positive impact.

The 30-50% more of our GDP that we pay in the US system – as compared to our Canadian neighbors to the north and many other countries we have no problem admiring and vacationing in – is money that could go to education, higher salaries, or any number of other productive uses.

Waste and inefficiencies are not of benefit to any but a few. The zeitgeist is rapidly moving towards recognizing the debacle of our current system and doing something about it. Change is being fought and fought hard, but in the end, facts and data will hopefully win out. It may take longer than some would wish, but the facts that were closely held about excesses and irrationality are now being seen and studied by a wide group. And it is no longer unfashionable or “leftist” to consider and advocate for other options.

Planning (and funding) for fulfilling one’s potential

Being able to decide when to have children is central to fulfilling one’s potential. In the year ahead, many women will harness this power for the first time. Melinda Gates discusses funding for family planning in this  New York Times Op Ed piece:

In July 2012, I co-hosted a summit meeting on family planning in London. The evidence was clear: The world had been underinvesting in the field for years, with serious consequences for women, their families and their communities. We invited leaders from dozens of countries and key global health organizations and private industry, along with women’s health advocates, to put the needs of women back on the global agenda. It was deeply moving to see older advocates who’d given their lives to this issue pass their passion to a new generation. The participants signed onto a big goal: helping 120 million women who didn’t have access to family planning to get it by 2020.

Read more…

Adventures in Healthcare – a Short Chapter

I opened the mail to find a medical bill for some lab studies on a family member. Total billings from “Laboratory Corporation of America” for 8 line items of services was $568.50. The adjustments by our insurance carrier, United Healthcare, were a total of $495.56, leaving a remaining balance of $72.94 on which the carrier paid $58.35, leaving a balance payable by us of $14.49.

What does this mean to those who don’t spend much time thinking about this? It is quite simple. The lab, a large national company, billed $568.50, the retail price that they decided to charge, which had we lacked insurance, we would have been expected to pay. The discount was 87% of charges, which means that the carrier used some sort of fee schedule, which is acceptable to the lab as a member of their network, to determine what was likely “usual and customary.” I sampled one of the line items that was charged at $219.00, and while my carrier permitted $21.71, the maximum that Medicare would permit was $16.99. So my carrier is generous compared to Medicare, paying about 27% more.

Why does the lab charge so much relative to what they get from carriers? Because they can. They can make up any number they wish, but clearly are thriving and surviving on actual payments that are 15% or less of what they charge. The small number of uninsured or underinsured, those least able to pay, are getting billed six times or more what their insured neighbors or retired relatives on Medicare are expected to pay.

What if the person in the check-out line buying the same basket of groceries was asked to pay 6 times more than the person in the next aisle because of where they work, or because they are younger, older, or for any other reason? Would we stand for this? Why do we permit this?

That the real prices differ from billed is a given in health care. I am accustomed to seeing discounts of 40% or so. But 87% is a new one that reflects, to my view, flagrant behavior that must be called out and must be stopped.

Emotional Support, with Fur

Pocket, the author's pet, aka emotional support animal.

Pocket, the author’s pet, aka emotional support animal.

That a dog provides comfort to owners is a given. That’s why we call them pets. But now, under the guise of subjective criteria of any physician or licensed therapist and the perceived needs of certain individuals, some are claimed as a necessity that others must tolerate in the public sphere.

Some are claiming and demanding that their pets have therapeutic impact and address an emotional disability and must accompany them on planes, at work, in restaurants, and in pet-free housing. Others claim their animals can retrieve dropped items that they can’t stoop down for, or have the uncanny and improbable talent of detecting and stopping seizures.

Please note that highly trained service animals such as seeing eye dogs actually DO something and deserve respect and access to any setting. But a clear line must be drawn when it comes to animals whose sole talent is BEING. By all means, enjoy your pet, dress it up in silly costumes, feed it from the table, and pay for its chemotherapy. But someone else’s pet provides zero social good to society at large. It will never pay taxes, teach our kids, or shovel the snow off your walk out of altruism. They have earned no dispensation or right to privilege or sacrifice from the rest of us. As one commenter queried, she derives comfort from their husband — can he fly free and sit at her feet on a plane? One’s perceived needs and wishes need not be indulged by society, or endorsed with misguided and abused rules.

US Incarceration Policies: Public Shame, and Personal Tragedies

Going about one’s day becomes more challenging when one is confronted with articles such as this, describing a situation that is shameful for society and tragic for individuals and families. In our war on drugs, zealotry, government bullying, and perhaps no small component of self-interest and greed have combined to place the US as number one in incarceration rates among all nations.

Who is served by this situation and why is it tolerated at all? The manifest injustice of indeterminate sentencing for non-violent crimes that are clearly disproportionate to sentences for assaults, serious theft, and other matters where there is serious victimization and deprivation of the rights of others is compelling. Read the comments by readers for more insight.

Hidden Profits in Rare Diseases

As the parent of two small children, this is the kind of article that haunts me—a child with an incurable disease, a photo of that child, hopeful, bald due to medical treatment. Now deceased. I’m tempted to skip stories like this, but then again if nobody had the stomach to hear about the situations which are hard to face, solutions to problems would never be reached.

The gist of the situation is that thirty years ago, Congress passed the Orphan Drug Act as a way to lure pharmaceutical companies to develop drugs for rare diseases that had been “orphaned” — abandoned or ignored because they were unprofitable. The hope was that drugmakers would break even or post modest profits.

The act paid off, with hundreds of new drugs. But over the years, its good intentions have been subverted by the pharmaceutical industry, which has increasingly found ways to exploit this once-obscure health-care niche, transforming it into a multibillion-dollar enterprise. Read more…

Transporting Drugs Across The Border

No, this is not a story about recreational drug use and the US-Mexican border. As this article in The New York Times highlights, moving pharmaceutical across the US-Canadian — and many other — border(s) is big business. The Canadian International Pharmacy Association, a 10-year-old group, said its members fill prescriptions for one million Americans each year.

Per the Centers for Disease Control, about 2%  of adults — about 5% of the uninsured —said they had bought prescription drugs from other countries. The Food and Drug Administration says on its Web site that “in most circumstances it is illegal to import drugs into the U.S. for personal use” because the agency cannot guarantee they are safe and effective. The government also prohibits “reimportation” of drugs made in the United States because it cannot guarantee the medications were not tampered with or stored improperly.

The agency said it does not track the volume of such imports. However, it “typically does not object” to people buying imported medicine for personal use “under certain circumstances,” the agency said. Often the medications are available in other countries at a fraction of the cost here in the United States, even for those with health care insurance.

Personally, I’ve purchased prescription medications — with no prescription — in Spain, France, and Hungary. (I drew the line at Niger though it would have been interesting to see what the pills actually were. In 1999 in Niamey it was not uncommon in public places to be approached by a man with a foot-tall spinning rack of colorful pills in home packaging balanced on his head that he was eager to sell. None was in any sort of original packaging or had any directions included, much less was the name of the drug stated anywhere. Given the 20% literacy rate and the fact that cheap pink toilet paper for foreigners imported from China was about the only paper available in the country, this was probably reasonable in its way. There were of course dispensairs where you could be treated by a nurse if necessary, and given the country’s 47-year life expectancy at the time finding humor in the system is hardly the point. In Hungary in 2003 I paid $20 cash for a house call and some quite effective anti-nausea pills that lasted me a couple of years; in France in 1985 it was $5 and a couple of jokes at my father’s expense for the blood pressure medication he had forgotten to packet. He was traveling around Europe before settling into Spain for an extended stay and we left the pharmacy with enough medication to last a year.) Aside from the quirky cultural interactions, the situation itself is again a reminder of the ineffectiveness of how health care availability and costs are managed in the United States. The Times article is full of examples of purchasing medications on a regular basis from overseas as the only affordable way for many, including the insured, to manage their health. The title sums it up well: “As Drug Costs Rise, Bending the Law Is One Remedy.”

The (shocking) cost of asthma

What consumer items in the US are priced at such a massive differential to Europe and elsewhere besides medications? Lobbying pays nicely it would appear. This is not just a problem for those with asthma or other illnesses requiring increasingly costly drugs. This is a problem for every patient, every insured, every taxpayer, and every employer who pays for insurance. This is of course due to the risk sharing inherent in any insurance system, where the healthier pay for the sicker. This means higher premiums, copays, deductibles, lower business profits, and lower pay due to business costs being shifted to higher benefits.

It is also a problem for caring physicians who are faced with the dilemma of helping their patients who may have to pay all or some medication costs out of pocket due to no, or limited, insurance coverage.

We are currently in a government shut-down, in part due to a small number of politicians who want to preserve this status quo – or at least it appears they do. The rhetoric attacks reform and change. The corollary of these attacks is that we leave things largely alone, including these windfall abuses of regulation.

In the free market that most believe in theoretically, safe drugs like those sold in Europe would be available in the US, unimpeded by protective and restrictive regulations that protect certain companies and products from competition. We currently have a system that is a far cry from free, rational, or equitable.

Innovation is not always comfortable. Change when it takes place will be disruptive, and it will be resisted. But it is necessary.