1. Evaluation of Medicare’s Bundled Payments Initiative for Medical Conditions. Karen E. Joynt Maddox, E. John Orav, Jie Zheng and Arnold M. Epstein. N Engl J Med 2018;379:260-9. https://www.ncbi.nlm.nih.gov/pubmed/30021090
2. Medicare ACO Program Savings Not Tied to Preventable Hospitalizations or Concentrated among High-Risk Patients. J. Michael McWilliams, Michael E. Chernew and Bruce E. Landon. Health Affairs 36:2017;2085–2093. https://www.ncbi.nlm.nih.gov/pubmed/29200328
3. Care patterns in Medicare and their implications for pay for performance. Pham, H. H., D. Schrag, A. S. O’Malley, B. Wu, and P. B. Bach. New England Journal of Medicine 2007; 356(11):1130-1139. https://www.ncbi.nlm.nih.gov/pubmed/17360991
4. Time Out — Charting a Path for Improving Performance Measurement. Catherine H. MacLean, Eve A. Kerr and Amir Qaseem. N Engl J Med 2018: 378;19.
5. Adherence and health care costs. Iuga AO and McGuire MJ. Risk Manag Helathc Policy 7:35-44, 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3934668/
6. Greater Use of Preventive Services in U.S. Health Care Could Save Lives at Little or No Cost. Michael V. Maciosek, Ashley B. Coffield, Thomas J. Flottemesch, Nichol M. Edwards and Leif I. Solberg. Health Affairs 29: 2010;1656–1660. https://www.ncbi.nlm.nih.gov/pubmed/20820022
7. Healthy Aging Brain Center improved care coordination and produced net savings. French DD, LaMantia MA, Livin LR, Herceg D, Alder CA, Boustani MA. Health Affairs 2014;33:613-8. https://www.ncbi.nlm.nih.gov/pubmed/24711322
8. Adding value to relative-value units. Stecker EC and Schroeder SA. N Engl J Med 2013;369 (23):2176-79. https://www.nejm.org/doi/10.1056/NEJMp1310583?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov
9. Principles Supporting Dynamic Clinical Care Teams: An American College of Physicians Position Paper. Robert B. Doherty and Ryan A. Crowley, for the Health and Public Policy Committee of the American College of Physicians. Ann Intern Med 2013:159;620-626. http://annals.org/aim/fullarticle/1737233/principles-supporting-dynamic-clinical-care-teams-american-college-physicians-position
10. Making It Safe to Grow Old: A Financial Simulation Model for Launching MediCaring Communities for Frail Elderly Medicare Beneficiaries. Antonia K. Bernhardt, Joanne Lynn, Gregory Berger, James A. Lee,Kevin Reuter, Joan Davanzo, Anne Montgomery and Allen Dobson. The Milbank Quarterly, 2016;1-29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020161/
RESEARCH FOUNDATION REPORTS:
1. Uncompensated Care for the Uninsured in 2013: A Detailed Examination. Teresa A. Coughlin, John Holahan, Kyle Caswell, and Megan McGrath. www.kff.org. May 30, 2014 https://www.kff.org/uninsured/report/uncompensated-care-for-the-uninsured-in-2013-a-detailed-examination/
2. Chronic Care: Making the case for ongoing care. Anderson, GF. Princeton, NJ: Robert Wood Johnson Foundation. 2010. The Effects of Medicaid Expansion under the ACA: Updated Findings from a literature Review, Larisa Antonisse, kff.org, Sep 2017 https://www.rwjf.org/en/library/research/2010/01/chronic-care.html
3. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America (2013). The National Academies Press Open Book. http://www.nationalacademies.org/hmd/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx
4. How have providers responded to the increased demand for health care under the Affordable Care Act? Wishner JB and Burton RA. Urban Institute, November 2017. https://www.rwjf.org/en/library/research/2017/11/how-have-providers-responded-to-the-increased-demand-for-health-care-under-the-aca.html
5. The cost and volume of comparative effectiveness research. In Learning what works: Infrastructure required for comparative effectiveness research: Workshop summary. Holve, E., and P. Pittman. Institute of Medicine. Washington, DC: The National Academies Press. 2011:89-96. https://www.nap.edu/read/12214/chapter/2#10
6. Employer Health Benefits: 2017 Annual Survey. Gary Claxton, Matthew Rae, Michelle Long, Anthony Damico, Gregory Foster and Heidi Whitmore. The Kaiser Family Foundation and Health Research & Educational Trust. 2017. https://www.kff.org/health-costs/report/2017-employer-health-benefits-survey/view/print/
1. Centers for Medicare and Medicaid Services Financial Report, 2017. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwj63u_W0PTdAhVfIzQIHZnlAmMQFjAAegQIChAC&url=https%3A%2F%2Fwww.cms.gov%2FResearch-Statistics-Data-and-Systems%2FStatistics-Trends-and-Reports%2FCFOReport%2FDownloads%2F2017_CMS_Financial_Report.pdf&usg=AOvVaw1-Udg09bY8IZdj9vcX5H_l
2. Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy. Chapter 13. “Status report on the Medicare Advantage Program.” March 2017. http://www.medpac.gov/-documents-/reports
Healthcare News You Should Know About
1. WHAT DO DOCTORS THINK? THE AFFORDABLE CARE ACT IS GOOD FOR HEALTHCARE. INSURANCE COMPANIES ARE NOT. In a study reported in the September 2019 issue of Health Affairs, researchers surveyed U.S. physicians in 2012 and 2017. The majority of doctors now say the ACA has improved healthcare (53%, up from 42% 5 years earlier). At the same time, doctors say insurance companies have made it harder for them to care for their patients—67% say they now spend more administrative time on insurance issues and 59% say they have less time to spend with patients. Medicare for All would reduce the time doctors waste on administration and give them more time with their patients. That would also save money. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00224
2. SHORT-TERM HEALTH PLANS PROVIDE PROFITS, NOT HEALTHCARE. An analysis by the government (the Center for Medicare and Medicaid Services) and the Association of Insurance Commissioners came to the same conclusion: the short-term health plans President Trump is promoting to allow states to bypass the Affordable Care Act are cheap because the insurers spend very little of the premium dollars they receive on healthcare for their policyholders. They range from 10% to less than 80% (and almost all spend less than 60%). The ACA requires insurers to spend at least 80-85% (depending on the size of the group). Where does the rest of the money go? Profits. https://www.latimes.com/business/story/2019-08-12/health-spending-by-short-term-health-plans
3. THE TRUTH ABOUT MEDICAID WORK REQUIREMENTS. Some states are now adding work requirements to Medicaid eligibility, but a recent study by the Kaiser Family Foundation shows the large majority of Medicaid adults are already working or unable to work. Two-thirds are working, and 23% are either disabled, sick, or the primary caregiver for someone who is disabled or sick. Only 7% are not working due to retirement, inability to find work or some other reason. Adding work requirements to Medicaid eligibility will only make it harder for those in need to document that they are eligible, putting more people at risk of worsening health outcomes and costing states even more money in the end. https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work-what-does-the-data-say/
4. SIX DEMOCRATIC PRESIDENTIAL CANDIDATES SUPPORT MEDICARE FOR ALL WITHOUT DOING AWAY WITH PRIVATE INSURANCE. As reported by CNBC, three 2020 Democratic presidential candidates who cosponsored Sen. Sanders' Medicare for All bill--Sens. Cory Booker, Kamala Harris and Kirsten Gillebrand--don't think it's necessary to end private insurance to make it work. Three other candidates--Julian Castro, Andrew Yang and Rep. Tim Ryan--also support this approach. This is an important message. ACAMFA has shown that private insurance can have an important role under Medicare for All. Nobody has to give up any private insurance they want to keep.
5. MEDICARE PART D CASTASTROPHIC COVERAGE LEAVES 1 MILLION WITH HUGE OUT-OF-POCKET COSTS DUE TO EXPENSIVE DRUGS. A survey by the Kaiser Family Foundation reported on June 21, 2019 showed that in 2017, out-of-pocket spending for Medicare Part D enrollees who did not qualify for low-income subsidies had out-of-pocket spending above the catastrophic level. Their costs averaged over $3,200. The 10 drugs with the highest costs were for treatment of cancer, hepatitis C and autoimmune diseases. Their out-of-pocket costs averaged over $5,000 per drug. These costs to patients are because of the lack of any cap on out-of-pocket spending. Instead, Medicare Part D enrollees must pay 5% of drug costs after the catastrophic limit has been reachedCatastrophic coverage is not working for a large number of Medicare patients. Medicare for All would eliminate all deductibles and copayments and limit out-of-pocket costs for drugs to $200 a year. https://www.kff.org/medicare/issue-brief/how-many-medicare-part-d-enrollees-had-high-out-of-pocket-drug-costs-in-2017/
6. ONE CAUSE OF HIGH DRUG COSTS? NYS AUDIT FINDS CVS OWES OVER $2 MILLION IN DRUG REBATES TO STATE. New York State audited rebates from 6 drugmakers to CVS Health and found significant failures. CVS has paid $2.3 million to the State for outstanding claims from 2016 and 2017 and still owes over $300,000 more. CVS and other pharmacy benefit managers (PBMs) are under scrutiny by NYS and federal regulators for practices said to contribute to skyrocketing drug prices, like pocketing rebates instead of passing them on to plan holders or patients, and giving preference to high-cost drugs that they can get big rebates on, boosting their fees, instead of low-cost drugs that benefit everyone else. 3PBMs negotiate discounts from drug companies, but who gets the money?
7. ACAMFA JOINS NATIONAL GRASSROOTS CAMPAIGN FOR LOCAL COMMUNITY ACTION. ACAMFA has joined a major campaign that was launched in April 2019 by several national organizations. Medicare for All Resolutions is a grassroots effort to have local governments pass resolutions in support of Medicare for All. The healthcare costs to local governments have become overwhelming. It is time for them to have their voices heard by Congress. Learn how to get involved and start a local action in your community at www.medicare4allresolutions.org
or contact us.
8. WHAT’S THE FASTEST RISING HEALTHCARE COST?
Health insurance inflation hits highest point in five years. May 17, 2019.
According to the Bureau of Labor Statistics, the cost of private health insurance is rising faster than other costs in healthcare. It rose more than 10% while the cost of professional services and hospital services rose 0.4% and 1.4%--less than overall inflation. It’s all due to the growth of managed care, including Medicare Advantage, Medicaid managed care and commercial insurance, according to Paul Hughes-Cromwick, an economist at Altarum Institute. The eight largest publicly traded insurers posted net income of $9.3 billion in the first quarter of 2019, an increase of almost 30% with combined profits of almost $22 billion over the course of 2018.
9. ACA PREMIUMS VASTLY OVERPRICED IN 2018: $800 MILLION TO BE RETURNED TO CONSUMERS. A new analysis by the Kaiser Family Foundation (May 8, 2019) shows that premiums grew much more than costs in the ACA marketplace in 2018. This will result in expected rebates of $800 million from insurance companies to more than 3 million individual market consumers who were overcharged according to ACA regulations. Those rebates must be paid by September 30, 2019. The overcharges were likely due to uncertainty about the effect of policy changes, which led to over-correcting and raising premiums more than necessary to cover claims and administrative costs. https://www.kff.org/private-insurance/press-release/individual-market-insurers-are-expecting-to-pay-a-record-800-million-in-rebates-to-consumers-for-excessive-premiums-in-2018/
10. FIVE DRUG COMPANIES SETTLE ANTI-KICKBACK CHARGES FOR $250 MILLION. The Justice Department announced April 25, 2019 that 2 more large drug companies agreed to settle anti-kickback charges in addition to 3 others that settled on April 4, bringing the total paid to the government to almost $250 million. The government alleged the companies covered copays for their drugs through supposedly independent nonprofit “copay assistance” foundations, but illegally made deals with the foundations to use the money exclusively or almost to cover their own drugs and not competitors’ products. Copay assistance programs sound like drug companies are doing good, but according to the Justice Department, they are just keeping their prices high and writing off their costs illegally. https://medcitynews.com/2019/04/amgen-astellas-to-pay-government-nearly-125m-to-resolve-copay-kickback-allegations/
11. NEW SURVEY SHOWS HIGH-DEDUCTIBLE PLANS ARE FINANCIAL BURDEN FOR MOST
Over 20% with employer health insurance benefits have high-deductible plans. Most of them don’t have savings to cover their deductible and skipped or delayed treatment because of cost. Many have to increase credit card debt or take an extra job. https://www.kff.org/private-insurance/report/kaiser-family-foundation-la-times-survey-of-adults-with-employer-sponsored-insurance/
12. KAISER RELEASES LATEST POLL SHOWING CONTINUED STRONG SUPPORT FOR MEDICARE FOR ALL. Americans Overwhelmingly Want Federal Protections Against Surprise Medical Bills. April 24, 2019. Kaiser Health News. A Kaiser Foundation poll from April 2019 shows continued support for Medicare for All among a majority of Americans (56%). The poll also showed concerns that people thought the top priorities for Congress should be: lowering drug costs (68%), continuing the Affordable Care Act protections for pre-existing conditions (64%), and providing protection from surprise medical bills when someone is inadvertently treated by an out-of-network provider (50%). That last problem happened to 20% of those polled at least once over the previous two years and 76-78% said they thought the federal government should take action to stop it. (This can occur if you are taken to an out-of-network hospital in an emergency or have treatment in an in-network hospital but get care by an out-of-network provider.) Most people favor a national Medicare for All program. Drug costs and pre-existing conditions are top concerns, as are surprise medical bills. These problems would be addressed by Medicare for All. https://khn.org/news/americans-overwhelmingly-want-federal-protections-against-surprise-medical-bills/
13. LOCAL GOVERNMENTS OVERWHELMED BY RISING HEALTHCARE COSTS. In New York, School Employee Health Care Costs Outstripping Aid, Inflation Rate. Times Union. (Albany) April 13, 2019. A survey from the state School Boards Association showed that school employee health care costs are expected to increase more than 6% next year—much higher than inflation. Premiums cost between $8,900 and $24,000 a year (depending on single or family coverage). Teachers contribute between 13% to 16% of the cost. And between 2013 and 2018, costs in New York State rose 22% compared to aid to local school districts, which rose only 10%. The bulk of increases is from the cost of prescription drugs. “These increases will be unsustainable in the long-term,” said Michael Borges, executive director of the business officials group. Getting concessions in health costs was the top priority in recently negotiated contracts and 70% of districts got some savings from health costs in their most recent contracts. Healthcare costs are rising beyond the ability of local budgets to cope. Cutting benefits is the short-term answer. Where do they turn when there is nothing left to cut? https://www.timesunion.com/news/article/School-employee-health-care-costs-outstripping-13763702.php?utm_source=newsletter&utm_medium=email&utm_campaign=Timesunion_DailyeEdition
14. GALLOP POLL SHOWS MOST AMERICANS KNOW HEALTHCARE COULD BANKRUPT THEM AND THE US ECONOMY. The U.S. Healthcare Cost Crisis. Gallup. 2019. The Gallop Corporation released finding of a new poll showing that Americans borrowed $88 billion to pay for healthcare and 65 million adults report not seeking treatment for a health issue due to cost over the past 12 months. The vast majority (77%) fear rising healthcare costs will damage the US economy and 45% fear a major health problem will lead to bankruptcy. Americans know we can’t keep our current system—it isn’t working. Gallop poll
15. FRUSTRATION OF BIG CORPORATIONS UPSETTING THE HEALTHCARE INDUSTRY. Amazon, Berkshire Hathaway and JP Morgan Team Up to Disrupt Healthcare. NY Times. Jan. 30, 2018; Clash of Giants: UnitedHealth Takes on Amazon, Berkshire Hathaway and JP Morgan Chase. NY Times. Feb. 1, 2019. Amazon, Berkshire Hathaway and JP Morgan announced in January 2018 that they would form an independent healthcare company for their employees in the US. “The alliance was a sign of just how frustrated American businesses are with the state of the nation’s health care system and the rapidly spiraling cost of medical treatment.” The announcement sent “stocks for insurers and other major health companies tumbling.” It so unnerved the healthcare industry that some big companies are suing to stop the plan. But the courts are wary, suspicious they are just trying to find out what the companies are going to do so they can make plans of their own. The insurance industry is not in control anymore because of runaway costs. https://www.nytimes.com/2018/01/30/technology/amazon-berkshire-hathaway-jpmorgan-health-care.html
16. PRIVATE HEALTH INSURANCE COMPANIES TAKE ADVANTAGE OF MEDICARE PART C “ADVANTAGE” PLANS. The Personal Toll of Whistle-blowing. The New Yorker. Feb. 4, 2019. About 30% of people on Medicare sign up for Part C instead of standard Medicare to get extra perks like gym memberships and drug plans, usually for an extra premium. The plans are supposed to lower costs, but Medicare does not save any money on them. Information from whistle-blowers now shows that Medicare Advantage plans extract billions of dollars in excess payments from Medicare by “cherry picking” the healthiest patients to enroll and “lemon dropping” patients with serious illnesses or large claims, convincing them to drop their coverage (both illegal practices). They also select the codes they use for diagnoses to ensure the highest reimbursement (upcoding). Estimates of the cost to Medicare in overpayments are more than $10 billion a year. Private health insurance companies are making big profits on Medicare Part C without reducing costs to Medicare or patients. According to Medicare, they don’t always get their profits by legal means. https://www.newyorker.com/magazine/2019/02/04/the-personal-toll-of-whistle-blowing
17. LARGE HOSPTIAL ORGANIZATION SETTLES FOR MILLIONS AFTER BEING ACCUED OF BILKING MEDICARE IN PART C ADVANTAGE PLAN FRAUD. Sutter Health Accused of Inflating Medicare Costs, Agrees to $30 Million Settlement. San Francisco Chronicle. (Reported by Kaiser Health News 4/15/19). Sutter Health, a non-profit organization that runs several medical foundations with contracts with Medicare Advantage plans. Sutter was accused of submitting unsubstantiated diagnoses to Medicare that elevated their risk scores so their private plans could collect more money. They agreed to a $30 million settlement. By some accounts, private insurance companies are settling for a fraction of the amount of money they falsely receive from Medicare each year. No wonder Part C “administrative” costs are so much higher than standard Medicare—and savings to the government are non-existent. https://khn.org/morning-breakout/calif-based-sutter-health-agrees-to-30m-settlement-over-allegations-of-submitting-inflated-diagnosis-codes-to-cms/
18. BYE BYE DRUG REBATES, HELLO HIGHER PREMIUMS. With Drug Rebates on the Chopping Block, Stakeholders Should Prepare for Change. Delotte Consulting for Health Solutions. April 17, 2019. Earlier this year the Department of Health and Human Services proposed rules slated to go into effect on January 1, 2020 that would prohibit drug rebates in Medicare Part D and Medicaid Managed Care plans, allowing continued exemption for price reductions at the point of sale and for some pharmacy benefit manager service fees from counting as kickbacks. It’s not clear how these will affect overall prices, but there will be strong pressure on drug companies to reduce list prices and this will likely affect commercial plans in addition to Medicare and Medicaid. Premiums for Part D and Medicare Managed Care (Advantage Plans) will probably go up as out-of-pocket costs for consumers go down. The effect on individuals will depend on what kind of drugs they are prescribed. Bottom line: expect change in drug costs, some for the better, some worse, as a result of the proposed rule. https://blogs.deloitte.com/centerforhealthsolutions/with-drug-rebates-on-the-chopping-block-stakeholders-should-prepare-for-change/
19. PATIENTS ARE STOPPING DRUGS DUE TO COST, FORCING DRUG COMPANIES TO CUT PRICES. Amgen Slashes the Price of a Promising Cholesterol Drug. NY Times. Oct. 25, 2018. Amgen announced that it was immediately cutting the price of an expensive cholesterol drug, Repatha, from $14,000 to $5,850 per year. The reduction comes after rivals slashed what they charge prescription plans but not the list price for their similar medication. “Patients, insurers, politicians and others have criticized escalating drug prices that are putting medicines out of reach for many people.” Drug companies have lost control of their market because of patients’ actions. https://www.nytimes.com/2018/10/25/health/amgen-repatha-cholesterol-drug.html
20. DRUG COMPANIES HAVE LOST CONTROL OF CONGRESS—THEY ARE NOT THE ONLY ONES LOBBYING. How Pharma Lost Its Edge in Washington. Bloomberg News. March 4, 2019. The heads of three major pharmaceutical companies testified before the Senate Finance Committee in February. Chairman Chuck Grassley told them they couldn’t blame high prices on pharmacy benefit managers. He told reporters “he thought the companies ‘realize there is a problem’ and expressed the expectation that ‘every one of them is going to help us solve it.’” Patients for Affordable Drugs raised $10 million in 2018 for lobbying and they are getting help from partners like the Campaign for Sustainable Rx Pricing. “PhRMA was blindsided by a change lawmakers made to Medicare [last February], putting drugmakers on the hook for more of seniors’ prescription costs [when they fall in the doughnut hole].” When drug companies aren’t the only voice Congress hears, they don’t get their way. BloombergNewsPoliticsMar042019
21. SOME DRUG COMPANIES TRY TO APPEASE PRESIDENT WITH PRICE DROP BUT KEEP BIG PROFIT-MAKERS OFF LIMITS. Merck Is Lowering Drug Prices, but There’s a Catch. NY Times. July 19, 2018. Merck said it would lower several drug prices 10%. This followed recent announcements by Pfizer and Novartis that they would freeze increases for the rest of the year. This came after President Trump slammed drug makers for high prices—he rewarded them with thanks after their announcements. But the prices they reduced were little used drugs that were getting few sales. Their blockbuster drugs like Keytruda for cancer and Januvia for diabetes brought Merck over $1.3 billion in sales in the first quarter of 2018 in the U.S. Their prices remained untouched. Drug companies know they have to cut prices but some of them are still trying to get as much money as they can while it lasts. Will they get away with it? https://www.nytimes.com/2018/07/19/health/merck-trump-drug-prices.html
22. SEVERAL LARGE HOSPITAL GROUPS ARE FED UP WITH GENERIC DRUG COSTS AND UNEXPECTED SHORTAGES. THEY ARE INVESTING MILLIONS OF DOLLARS TO START THEIR OWN DRUG COMPANY. S
ay Goodbye to Skyrocketing Drug Prices, Shortages. Salt Lake Tribune. Jan 19, 2018. Intermountain Healthcare in Utah announced it was starting its own generic drug company, along with four other large hospital groups, to combat unpredictable prices and drug shortages. Generic drug costs have become a major source of uncontrolled expense for hospitals and shortages often lead to exraordinary costs when more expensive (and sometimes more dangerous) replacements need to be found. Brand-name drugs are not the only problem. Hospitals are not willing to let drug manufacturers put them out of business and are taking things into their own hands. https://www.sltrib.com/news/health/2018/01/19/utahs-intermountain-healthcare-fights-skyrocketing-drug-prices-shortages-by-forming-its-own-company-project-rx/
23. THE TRUTH ABOUT MEDICAID EXPANSION AND RURAL HOSPITALS. Rural Hospitals in Greater Jeopardy in Non-Medicaid Expansion States. Stateline. The Pew Charitable Trusts. Jan. 22, 2019. Rural hospitals in states that have not expanded Medicaid under the ACA are in greater financial trouble with more closings and more at risk of closing than in other states. Medicaid expansion provides a resource for hospitals in rural areas that is necessary for their survival. Cutting Medicaid hurts rural communities. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2019/01/22/rural-hospitals-in-greater-jeopardy-in-non-medicaid-expansion-states