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Time to Start Over!

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By STEVE FINDLAY

The CBO’s analysis of the House and Senate health bills should kill them both—permanently.

Republicans should go back to the drawing board and work with Democrats in both the House and Senate to achieve bipartisan fixes to the ACA/Obamacare marketplaces for 2018 and 2019.

That is the far and away the best thing to do from a policy and political perspective.   The vast majority of Americans would stand up and cheer. Two polls out this week, for example, add to previous surveys showing deeply low public support for the Republican bills.

A USA TODAY/Suffolk University poll found that just 12 percent of Americans overall support the Senate Republican plan, including only 26 percent of Republicans. Similarly, an NPR/PBS NewsHour/Marist poll found 17 percent in favor overall, with Republican support at 35 percent.

Just 25 percent of respondents in the latter poll say the want Congress to repeal the ACA completely—consistent with other polls since late 2016.

Trump has suggested a bipartisan path several times in recent months, although there’s no evidence he ever reached out to Democrats and he just as frequently demonized them as “obstructionists.”

Did “Medicus economicus” Kill Medicare Part B Reform?

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When doctors complain about proposed changes to health care reimbursement, do they speak for patients or their pocketbooks? As the recent debate over Medicare Part B shows, even with access to publicly available billing data, it’s hard to disentangle financial motivations from more altruistic ones.

Since 2005, Medicare Part B has paid for physician-administered drugs like infused chemotherapeutics by reimbursing 106% of the average selling price (ASP) – a formula commonly referred to as “ASP+6”. In order to reduce overall spending and the program’s apparent incentive for physicians to preferentially use high-priced drugs, CMS proposed a pilot program last year to test a new payment formula that would have reduced the 6% markup to 2.5%, but added a flat per-infusion payment – effectively rewarding doctors more for choosing cheaper drugs, and reducing their profit from expensive ones.

The plan to revamp Part B reimbursement was scrapped after many groups – including professional organizations representing cancer doctors – vigorously objected. Oncologists argued that there are few cases in which a cheap anti-cancer drug is therapeutically equivalent to a more expensive one, and that the proposed change would mainly harm oncologists’ ability to provide high-quality care.

These may be valid arguments, but it’s hard to disentangle oncologists’ clinical interests from their financial ones. Many economists might reasonably view cancer doctors who object to Part B reform as the physician manifestation of “Homo economicus,” acting solely to maximize their personal gain. Neeraj Sood at the University of Southern California summed up many observers’ knee-jerk response: “Doctors are human. The fact is, this [new proposed] model changes how much money they’ll make.”

But that raises a key question: how much do oncologists make from “ASP+6,” anyway?

A Real (Living, Breathing) Health Care Reform Plan: Drop MACRA

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Dear Washington,

Congratulations! You have listened to the AMA and practicing physicians and made it a little easier to comply (at first) with the Medicare Quality Payment Program, part of the massive MACRA “pay for value” law. 

But CMS’ announcements in The Federal Register and “fact sheet” are incomprehensible gobbledygook that will be understood by neither doctors, patients, nor the rest of society. The language personifies the complexity, unwieldiness and confused thinking in this huge national policy. 

MACRA is a $15 billion boondoggle that the best research shows will neither improve quality nor control costs. Paying doctors for quality (e.g., doing a blood pressure exam) or efficiency may make sense theoretically, but it doesn’t work. Rather than making a dent in the continuing upward spiral of healthcare costs in America, it can even result in some doctors avoiding sicker patients because it affects their quality scores and income.

Early, poorly designed research suggested that paying for health or cost savings was effective, but these research designs did not account for already occurring improvements in medical practice that the policymakers took credit for. Decades of stronger, well-controlled research debunked these early findings and conclusively showed no effects of these economic policies.

So why does the Congress and administration continue to press ahead with this same tired and impotent policy?

Death and Medicaid

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I remember 7 South at the Children’s hospital very well. I remember the distinctive smell, the large rooms, the friendly nurses, and Shantel. For a brief period of time, Shantel and her little boy – a too skinny child named James – were there every time I was there with my little girl. 7 South was the GI floor – Shantel and I were there because our children had the same dastardly liver disease that, for the time being, was winning. And that was it. We had nothing else in common.

She grew up in North Philadelphia, not far from where I was finishing a residency program in Internal Medicine. She had three other children, was a single mother, and in the year that I spent shuttling to the hospital I never saw the father of her child. Shantel did not work, and relied almost exclusively on the welfare programs to make life work.

I was a medical resident, our family had a combined income north of $150,000/ year, and our health insurance was through my employer. My wife and I worked, which meant that we had the flexibility for one of us to stop working, and still maintain our benefits.

If Your Premiums Go Down but Coverage Gets Worse, Does Your Healthcare Matter?

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Picture this. Amy becomes pregnant while working as a high school teacher. Her employer’s health insurance plan pays the maternity bills and she happily raises her twins.

Fast-forward a few years. She’s decided to become an entrepreneur and runs a small business. She becomes pregnant again but, this time, finds that her $400 a month individual health insurance policy won’t cover the expenses. In fine print, she discovers that she needed to purchase a special rider to activate maternity care benefits. She’ll have to pay $10,000+ out of pocket now, putting her burgeoning business at risk.

Angry at this, Amy decides to switch insurers but, to her dismay, she finds that the four largest insurers in her area don’t cover most expenses associated with a normal delivery. Amy has nowhere to go. Also, since pregnancy is a pre-existing condition, Amy is advised by her doctor to “not become pregnant again” if she wants to get quote reasonable health insurance rates during her search.

This is not an exaggerated or dystopian situation, it’s a real example from 2010.

Whether or Not Republicans Are Able to Replace Obamacare …

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… There is a far more fundamental issue affecting the overall success of our healthcare system.  Doctors and patients need more transparency when it comes to health care costs.

Healthcare is becoming more expensive by the year. In 1960, healthcare costs accounted for 5% of the gross domestic product. In 2015, they made up 17.8 percent. Although the rates of spending growth actually decreased since 2010 when the Affordable Care Act was enacted, a recent study demonstrated that for employees under 65 with employer sponsored health insurance, the proportion of income consumed by health insurance premiums has increased from 6.5% in 2006 to 10.1% in 2015.

Why does this matter? Health care costs, often from an unexpected medical emergency are the #1 cause of personal bankruptcy in the US. There are 1.7 million Americans live in households that declared bankruptcy due to unpaid medical bills. Also, while more subtle, the rising incremental costs of routine medical care are wearing on the financial stability of many families leaving less funds for essentials such as housing and food, let alone other needs and hobbies.

Healthcare’s Fake News Epidemic

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Fake news has replaced responsible journalism. It’s hard to know what to believe. It wasn’t long ago that supermarket tabloids like National Enquirer were considered fake news. Now it seems the Enquirer and TMZ may be more reliable sources of accurate news than the New York Times or Washington Post.

Government agencies aren’t immune from the fake news trend either. The Congressional Budget Office describes itself as, “Strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence without regard to political affiliation.”

I’ll bet most newspapers and television news networks say the same about their own objectivity.

The CBO analyzed the American Health Care Act of 2017, a lame effort by Republicans to repeal and replace Obamacare.  Passed by the House, it’s now on to “the greatest deliberative body in the world.”

Will Senate Republicans Get 50 Votes to Repeal the ACA?

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THCB readers are well aware this coming week Senate Republicans plan to begin debate on passing their amended version of the House-passed American Health Care Act (AHCA), titled the Better Care Reconciliation Act.   As of today, June 23rd, immediate reactions by Republican senators to the June 22nd released discussion draft have been limited largely because members immediately left town after the draft’s release. The Congressional Budget Office’s (CBO’s) score, that will again be influential, is expected this Monday or Tuesday. Senate debate on the legislation will likely begin next Wednesday with a vote expected late Friday or early Saturday morning, or just prior to their week-long July 4th recess.   Here is an assessment of the legislation’s prospects:

A Primer For Conservatives: Health Insurance is not Really Insurance

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Is health insurance a plan to help healthy people mitigate against an unexpected illness, or an income subsidy to help the sick pay for medical care?

Conservatives ought to have a clear answer to that question. Not long ago Congressman Morris Brooks from Alabama did not and found himself on the receiving end of liberal ridicule.

By suggesting that those who take better care of themselves should pay lower health insurance premiums, Brooks implied that health insurance is indeed a type of insurance arrangement. After all, the risk adjustment of premiums is a practice proper to all other kinds of insurance services. A prudent driver pays less for auto insurance than one with a negative driving record. A homeowner pays more for home insurance if the property is on muddy terrain rather than on sturdy ground. A smoker pays more for life insurance than a non-smoker, as does anyone whose risk of dying prematurely is high, even if that predisposition is inherited genetically.

Brooks’s conception of health insurance, however, intuitive as it may be, is wrong. Health insurance is not insurance even if, on the surface, health insurance policies meet the dictionary definition of insurance as contractual arrangements “in which one party agrees to indemnify or reimburse another for loss that occurs under the terms of the contract.”

Examining How Senate Republicans Frame Their Health Care Bill

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You can find the full text of the Senate Bill here.

Following is the Senate Republicans summary of their Obamacare replacement bill, with comments by NYU’s Jason Chung.

Seven years ago, Democrats imposed a risky health care experiment on Americans that led to skyrocketing costs and collapsing insurance markets.  Senate Republicans are working to fix the mess Democrats made by acting to rescue the millions trapped by Obamacare.

Jason Chung: While Obamacare has been largely successful in its aims to get millions of uninsured Americans medical coverage, including low-income and those with pre-existing conditions, it has also thus far failed to rein in premiums.  Some of that can be attributed to Obamacare failing to institute a public option, which would charge premium lower by 7% to 8% according to the Congressional Budget Office.

This is a nuanced position.  One can support former President Obama for extending coverage for up to 17.7 million more people and criticize him for failing to account for or communicate the possibility of rising premiums in an unchecked for-profit health insurance model.