It’s always fun to see my friends beating each other up in public….and if you read down in the comments on the post published yesterday you’ll see a significant dispute between Maggie Mahar and the Klepper/Kibbe/Lazsweski/Enthoven team (who I’m calling the Four Horsemen from now on). But I think that right now we need to change what we’re talking about.
I’m with Maggie in that there is potentially more in terms of changing the payment system in the current bills than nothing, but it’s not that much more than nothing. However, pressure from the the Four Horsemen and their fellow travelers on payment reform may increase that section of the bill as it gets worked out on the floor and in the Congress conference committee. Their pressure will also serve notice that aware, sensible people are looking at the issues of payment and delivery reform.
And at the least, the proposals in the bill don’t make the current delivery system any worse (other than the exemption from taxes for self-insured groups which clearly discriminates against integrated systems and must go).
Instead lets focus on what most of the bill consists of which is insurance reforms:
- Yes, they take way too long to be implemented (They’re starting in 2013? Why not 2011 or even middle of 2010?).
- Yes, the subsidies are too low–and it would be better if we had one tax-based insurance pool
- Yes there should be national, highly regulated, insurance regulation with everyone (or many more people) having access to a real exchange
- And yes if there is a public plan lets have it available everywhere to keep the private guys honest (even if its just more access to Medicare as Jeff Goldsmith suggests).
But what we’re going to get from the bills in Congress now is clearly better for poor and lower income people with health problems, and for small employers, than the alternative. The alternative is nothing this year, and probably nothing for a good long while after that. And those are the people the current system discriminates against the most.
I appreciate that what may pass the Congress is not what any of us Obama fans and Democrats would want in an ideal world. Yes, all of us would like serious campaign finance reform. Yes, I think we’re all appalled by the behavior of the unions and the large employers in stopping meaningful tax reform on health benefits. (Jeez, I even agree with Mark Pauly about one way out of that!)
But I remind you of the two rules for health reform I discussed a while back (and which Uwe Rheinhardt echoed in his three priniciples).
Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.
Rule 2 A health care reform bill needs to limit the amount of GDP that is going to health care to its current level, with an overall aim of reducing the share of health care going to GDP.
I think that the likely bill goes some long way towards the objectives in Rule 1. And makes a small start, albeit a very trivial, one towards the objectives of Rule 2–although I appreciate that it runs a substantial risk of breaking Rule 2. But I think that Rule 1 is more important than Rule 2–for now.
Maggie’s advocacy of the current bill fits Rule 1. The pressure from the Four Horsemen, Peter Orszag, Don Berwick, Zeke Emmanuel and others can hopefully make the Congress aware that on Rule 2 there’s lots of work to be done.
And I remind you all of perhaps the best post I ever wrote on THCB back in 2005. It was called “Why Hillarycare failed…and what we need to learn from that failure.“ Here was my conlclusion:
The main lesson of HillaryCare is that when the right moment comes along politically we need to get whatever form of universal reform can be agreed on shoved quickly through the Congress. Make no mistake, universal insurance is a big bang and a necessary big bang. Getting it through will be a hell of a confluence of opportunity and tactics. Once we get it done, then we have a while to worry about sorting out the system to the purists’ satisfaction later.
So will you all still please stop arguing about what it should look like!
I know that the bill in Congress now isn’t universal insurance–but it’s as close as we’re going to get for now. So let’s stop arguing and instead get as much pressure as possible on getting the right stuff that we agree on into the bill. And when I say “we” I don’t mean a bipartisan 80% we, I mean the Dartmouth loving, primary-care loving, universal pool approving readers & authors of THCB. A group which includes both Maggie and the Four Horseman. And me.
Filed Under: Matthew Holt
Oct 31, 2009
I’m in Mike’s boat, too.
Of course HB 3200 attempts to address these issues of usability and risk of using… I’m just describing the current pathology, not the brave new world we hope for.
SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.
A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent.
and
SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
(a) In General- In this division, the term ‘essential benefits package’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that–
(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice;
(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c);
…etc. etc. elsewhere.
Barry and all curious consumers part 2
1. Isosorbide Mononitrate – 30 mg — $36.97 per 90 pills. $10.00
2. Plavix – 75 mg — $445.97 per 90 pills. $444.49
3. Bisoprolol – 5 mg — $92.99 per 90 pills. $35.42
4. Simvistatin – 40 mg — $75.97 per 90 pills. $23.69
5. Ramipril – 10 mg — $175.97 per 90 pills. $19.20
This says a lot about why healthcare is expensive. It took me a ton of time to talk Wal Mart into opening this up for my small clients, now that it is available it is taking even longer to convince them to sign the agreement. Huge Rx savings just sitting there and people can’t be bothered to take it. When people cry that health care is to expensive and business can’t afford it that is not entirely true, if it where they would jump at the chance to cut their generic cost 70%.
Mike,
Can I make a suggestion? Your paying $1100 a month for a $1500 deductible. And your afraid to use it, I disagree with that fear but if you feel it then it is real. You don’t seem to have any problem acknowledging it so embrace it and take it into consideration when you purchase a plan. If your afraid to use it then admit it most likely wont be used and buy a $2500 or $5000 HSA. Not knowing your state these are guesses but going from $1500 to $2500 will probably save you $200-$300 a month. To $5000 will save you $450-$600. Take that premium savings and put it into your HSA. If something so bad happens you have no choice but to see a doctor you have the money saved to pay for it. If you continue to live in fear and don’t see the doctor after a few years you will have the entire deductible saved.
The only way you lose is if 2-3 family members all need care in the same year, something that doesn’t sound likley from your post.
Smarter consumerism will solve many problems.
pbnesbitt ?…..I thought we have been?….shush don’t tell anyone
Why Nate, that’s a perfectly sane approach to coping with a perfectly insane system.
Thanks for the suggestion on how to save a little money, but if I find a way to save $100 a month I think I’d rather send it to a politician working for a universal care system that will put people like you out of business, or at least stand up a strong and growing public option that will grab market share from the vultures.
Would my investment bring do me any good personally? It’s a long shot, but at least it would give me the satisfaction of not having cooperated with the myopic obsession with small differences that you like to encourage. Ever seen rats running in a maze, obsessed with making the right approach to getting the cheese, but unable to understand that they are in a maze?
As just another a rat in the maze your approach may make some sense in my situation, but for now, I’m looking down on the maze from above, watching all the rats following strategies like those that you recommend, and hoping that the Democrats will come to their senses and design an entirely new cage for us all, naturalistic and ecologically appropriate.
Unless their reforms begin to bite in 2010, they are going to do very badly at the polls. I may yet have to follow your ratty advice for how to get through the maze but I’m hoping for something much better.
Metaphorically speaking,
Mike
Nate – Those are indeed impressive savings on the four generics. I have no idea how much Express Scripts bills my employer for these net of my co-pay. As you probably know, the big Pharmacy Benefit Managers (PBM’s) including Medco Health Solutions, Express Scripts, and CVS/Caremark all claim to save employers money by driving up generic dispensing rates and by encouraging docs to agree to switch a brand to a generic or not checking the DAW box on the prescription form so the PBM can just provide the generic in the first place when filling mail prescriptions. We’re now approaching a 70% generic utilization rate nationally though they account for less than 20% of the dollars spent on drugs. As your research confirms in the Plavix example, nobody has any leverage with the big brand name drug manufacturers including Wal-Mart, the big drug retailers and the PBM’s. The drug companies’ attitude is if the docs prescribe it, you have to carry it and the price is the price. Drug retail and PBM profit margins on the sale of brand name drugs are extremely small. Almost all of their profitability is in the sale of generics.
That all said, if I were a self-payer, I would call Wal-Mart, Target, Costco or Sam’s Club to seek the lowest price for generic drugs. Interestingly, one positive unintended consequence of the crazy donut hole in Medicare Part D is that once seniors enter the donut hole, they suddenly become much more price sensitive and more willing to accept generic alternatives to brand name drug prescriptions. There’s that difference between spending one’s own money vs. someone else’s again.
The advantage the big box retailers have is that they have lots of other merchandise to sell once the customer is in their store. While drug retailers sell general merchandise as well, selling drugs is their core business (over two-thirds of sales) and, for PBM’s, it’s their only business.
LOL, ya mike Keep telling yourself your above the maze. If that is what you need to hear as you sit in the corner and starve to death so be it. Some people take responsbility for themselves, others send $100 to politicians and hope for help.
Barry we have another product we use for brands, it’s like reverse ebay with pharmacies from all over the country competing to fill the Rx. Usually at any given time someone has some extra Plavix sitting around they want to get rid of.
No meaningful cost reduction will accure until people fill something else like you said. I like plan designs that have no deductible but co-insurance from first dollar on. Make the consumer contribute to every expense, throw in some information and alternatives and we might start making some progress.
Mike makes a good point. Access to affordable healthcare should not have rely on how good your group (over other groups) can negotiate prices, fine tune small print contracts, or finesse your way through the maze of healthcare intricacies – even though it might elevate the ego of your TPA.
The Plavix story is interesting. It’s a good drug although it essentially does the same thing as aspirin with fewer side effects but an order of magnitude greater price.
However, its sales, already blockbuster in nature, I am sure exploded when studies found that in order to avoid the rare but fatal late thrombosis(clot) complication of coronary stents, patients must remain on Plavix pretty much indefinitely. Of course, way too many people were stented for years until studies accumulated showing that only certain subgroups benefited from it…….so now we have all these people on permanent Plavix, who shouldn’t have even had the need for it in the first place….. I am sure its manufacturer will fight like heck to keep it on patent, it’s supporting the company.
Who said we don’t have a great medical system?
Bev MD,
The good news about Plavix is that it is scheduled to lose its patent protection in 2011. Lipitor, Pfizer’s cholesterol lowering drug and the #1 drug in sales, goes off patent in 2012. With generic competition coming in 2-3 years, help (with costs) is clearly on the way. Unfortunately, I can’t say the same with respect to serious malpractice reform, sensible end of life care, robust price and quality transparency tools, widespread use of interoperable electronic medical records, reductions in regional practice pattern variations, serious efforts to mitigate fraud or cultural changes among either doctors or patients.
I would single out hospitals for killing us financially when they’re not killing us with infections. On the drug front, ultra expensive specialty drugs, especially those that attempt to fight cancer, are likely to be the biggest contributors to cost growth within the drug space. This is an area that lends itself well to QALY metrics, but I don’t think this country will be ready to embrace that concept or approach anytime soon.
speaking of hospitals, have a 288K hospital bill in my hands for 7 days to put in a defliberator. Medicare payment 20K or so, cost basis says 15K or so. Group was with a major carrier who took a 5% prompt pay discount then tried to pass the bill to the employer.
Before we fight the bio drug battle, which will be nasty, we need to win this hospital war.
Nate, Some people send $100 to politicians while some industries send millions of dollars to politicians. Seems like insurance companies are looking after their interests, pretty much like I would be doing with my contribution. It’s not a fair fight, but we all do what we can.
I posted my situation not because I was looking for insurance advice (although advice such as yours is useful, both as a practical suggestion and as an object lesson in how bad the situation really is) but because my situation seemed to exemplify at least 2 pathologies of the current system.
But your crowing about “personal responsibility” is tiresome and suggests a limited moral vision. I participate in political action and campaigns for progressive ideas because my sense of self (my “personal responsibility” in your terms) extends beyond my self to include all the other selves running through the insurance maze.
Self benefit in the narrowest sense is all that rats and insurance salesmen really trade in. Some of us however have a vision in which our self interest is intertwined with the collective interest.
It’s the relationship between personal responsibility and social responsibility that you fail to grasp.
“If I am not for myself, who will be for me? But if I am only for myself, who am I? And if not now, when?”
(As for the “when” question, it had better including advancing implementation dates to 2010, or the Democrats will pay at the polls.)
Mike, this must be the most eloquent, thoughtful, well written comment that I have seen in a long time.
is that what the Russians where telling each other as millions where starved? As Pol Pot masacured millions did they hold hands comforted by knowing they served the larger self purpose?
For humankind to succed and fullfill its potential we must each fulfill our personal potential. When millions of liberals don’t work and decide to live off others that creates a parasitic relationship that slows the growth of all. Intentially carrying a parasite doesn’t make you a nobel person it just makes you a less efficient person.
American society carries millions of people who are perfectly capable of contributing to society but choose not to. We aren’t talking about the truly disabeled but those that insist on making poor decisions becuase the personal ramifications are minimal or positive, i.e. paying welfare moms more for each kid they had. Liberals wheren’t helping welfare moms by doing that they where enableing them to make more poor decisions. Creating a larger burned on society.
Lets look at the history of progressive ideas, we’ll leave out non american cases so you don’t look so bad.
Public Housing, it was progressives who thought rounding up the poor and locking them in high rises was morally rightous. Generations of minorities destroyed
Public Education pushed by progressives leaves the majority of our poor uneducated and without a HS diploma
Medicare created a 34 trillion dollar liability and didn’t provide the catostrophic care seniors needed.
You get the point don’t you? As a progressive you really are closer to a disgusting tyrant who has directly murdered tens of thousands and is responsible for destroying millions of lives then a saint. If your proud to wear the label then bask in your destruction.
A man that cared for himself never died waiting for a handout from his master. Far more then can be said about your progressive movement
Barry;
Speaking of QALY metrics for drugs, see the link below for such metrics on Plavix vs. aspirin.
http://content.nejm.org/cgi/content/short/346/23/1800
Now, I am just speaking theoretically and therefore no offense intended, but maybe if you had to pay for Plavix yourself you would be bringing this data to your physician’s attention. Therein lies another part of our problem.
And, the patent on Plavix was supposed to expire in 2003, but was extended by the company simply separating the 2 molecules that comprised it and offering the one with the blood-thinning effect as “new”, thus extending the patent. We will see what they come up with in 2011.
yes, pharma is only one of the issues driving cost. However, like curing different types of cancer, it looks like we are going to have to address each issue one at a time, solving them one by one.
And I accidentally read Nate’s post about the 288K bill.
Wonder of wonders, I agree about the hospital war! The additional irony is, did the patient really need the defibrillator(those are overused too)??!! Rhetorical question, of course.
Bev M.D.,
As you pointed out in a prior comment, patients who receive stents, especially the drug eluting type, are likely to be on Plavix indefinitely. That includes me. As it happens, I also take the small (81.25 mg) aspirin each day.
As I’m sure you know, when interventional cardiologists find a significant blockage during angiography, the team is already there and a stent can be inserted in about 15 minutes. While there may be unnecessary stent procedures, there are also less than half as many CABG operations performed now than there were 10 years ago when I had mine. Moreover, even if stents don’t extend life for many patients, they often significantly increase the quality of life by reducing the incidence of angina which causes plenty of anxiety in heart patients as well as discomfort. It’s hard to put a value on that.
I would like to know more about how easy it is to distinguish among patients who need these procedures and those who don’t before the fact. If it’s a relatively easy matter to determine, perhaps there should be more post procedure audits to see how many are unnecessary, which specific doctors are performing disproportionate numbers of unneeded procedures, and then sanctioning them appropriately. While there are certainly risks associated with angiography, stents, and CABG operations, the potential adverse consequences of treatment that is too conservative (medication plus a sensible diet and exercise regimen) for too long can also be severe. It’s different from trying physical therapy before resorting to back surgery or putting off that hip or knee replacement for another six months. Those conditions are not life threatening.
Regarding the hospitals, it’s interesting to note that 85% of hospital beds nationwide are owned by non-profit institutions. The non-profit market share is 100% in the high cost New York City and Boston markets. I think this is an area that deserves a lot more attention that it’s gotten so far.
Finally, regarding brand name drugs, the industry has lost many billions in sales just within the last several years due to patent expirations. I benefited personally by being able to switch from Zocor to Simvistatin and from Altace to Ramipril. In other therapeutic categories, Fosamax and Prozac are now available as generics. Believe it or not, the drug retailers and PBM’s actually make more gross profit dollars on a $20 generic than on a $100 brand name drug but the brand drug manufacturers take a significant sales and profit hit as they should.
This says a lot about why healthcare is expensive. It took me a ton of time to talk Wal Mart into opening this up for my small clients,
I agree with Mike. Again.
Interesting you guys are talking about stents and possible over-use. Did any of you see “Money Driven Medicine?” The interventional cardiologist in the film said “When you’re a hammer, everything looks like a nail.”
Mike–
A gret comment on narrow self-interest. Just a tiny addition Hillel said “If I am only for myself WHAT am I?”
The man who is totally self-interested is no longer a who, he is a “what.”
Barry;
I will try to assemble the references for you regarding stents. As I said, this is not my specialty, but I have been reading about it in the NEJM. I will see if there is a review article that may summarize it all and get back to you.
Interestingly, there has been some evidence to suggest that some patients are getting stented who may benefit more from cardiac bypass. I will try to find that too.
Ughhh…I don’t want to disagree again, Maggie
The literal translation from Hebrew is “When I am for myself, what am I?”
The common commentaries explain this as a moral question as to one’s role in the world or in society considering that one has to also be able to take care of himself. It’s a question regarding the balance between self interests and social responsibility.
At least that’s what I learned in school…..
Barry;
I had a very difficult time finding one review reference that would address the scope of your questions regarding the efficacy of stents. I think there is no question that in a patient presenting in an unstable situation (so called acute coronary syndrome as well as myocardial infarction with or without characteristic EKG changes), percutaneous coronary intervention (PCI) with stenting is beneficial. The controversy lies with patients having stable coronary disease, such as stable angina. Here is what I could find, of recent origin, regarding that (I THINK these links will work):
NEJM — Effect of PCI on Quality of Life in Patients with Stable Coronary Disease
NEJM — Optimal Medical Therapy with or without PCI for Stable Coronary Disease
One on the risks of drug-eluting stents:
NEJM — Unanswered Questions — Drug-Eluting Stents and the Risk of Late Thrombosis
And here is one on stents vs. CABG:
NEJM — Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease
As far as can you tell ahead of time who needs stenting and who doesn’t, I would defer to your cardiologist to answer that specific question. My guess is mostly yes, but this is far away from my specialty.
I think the gross over-stenting of patients in the early years has now abated due to the newly discovered side effects and comparative effectiveness research noted above. However, it provides a valuable historical lesson on medical knowledge, medical faddism, fee for service medicine, and other issues of current interest.
Bev M.D.,
Thanks very much. That’s very helpful. I think it would be interesting to look at the trend in the number of coronary angiography studies that have been done in recent years and the percentage of those that led to stent insertions or referrals for a CABG.
Just to play devil’s advocate, if something new comes out and you don’t do a lot of it, how do you study comparative effectiveness over time?
Margalit;
Your point is well taken of course, but rather than doing “a lot of” something new, what happens is that the docs just switch en masse from the old treatment to the new treatment. Witness, the articles regarding medical treatment vs. stenting for stable coronary disease. Because stenting was new and sexy, reimbursed better, and seemed logical to both drs and patients (e.g. if you physically open an artery, wouldn’t that obviously have a better outcome than treating with medical therapy? turns out it didn’t); there was an incredible exponential increase in stent procedures in a short period of time.
It is this unsupported mass migration to the “new” that payment reform and more thoughtful and timely comparative effectiveness studies would provide. What if, for instance, everyone receiving the new treatment was required to be on a study protocol? That would accumulate the evidence much faster. (just throwing that out off the top of my head.)
Bev, I can’t really fault the en masse move to a new treatment that seems logical to everybody. It would be maybe immoral to not do so. However, when it becomes evident that the new treatment is no better than the old and cheaper one, is there a parallel en masse movement back? If not, this is probably where payment reform should step in.
Wow, I think this pretty much defines liberal elitism…
“And when I say “we” I don’t mean a bipartisan 80% we, I mean the Dartmouth loving, primary-care loving, universal pool approving readers & authors of THCB. A group which includes both Maggie and the Four Horseman. And me.”