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Matthew’s health care tidbits: Oh, the DEA makes me sigh….

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

I have always thought that the dual role of the Drug Enforcement Agency (DEA) was an anachronism that severely hampers America’s complex relationship with pharmaceuticals. Congress deems some medicines legal and regulates them via the FDA, and deems others illegal and tells the DEA and other law enforcement agencies to attempt to control their supply. Leaving aside the basic futility of this task, somehow DEA was also given the task of regulating the prescribers of legal prescription (and non-prescription) drugs–in particular those around controlled substances.

This has led to decades of DEA-led persecution of doctors, patients and even convenience store clerks in the name of reducing the diversion of opiates and methamphetamines. Of course going after any of these folks is much easier and less risky than hunting a Mexican cartel or busting real criminals, so it’s easy to see why the DEA has taken that approach. Has it worked in reducing the supply of opiates? Maybe. Has it had any impact on the opiate crisis? Not really. Have a whole lot of patients been caught in the crossfire? Yup.

Now the DEA is moving onto the next phase–re-regulating the online prescribing of controlled substances that was liberalized at the start of the public health emergency in 2020. As you can imagine, their proposals are not exactly bursting with reason.

The DEA is essentially banning all controlled prescribing without a face to face visit first. This is despite the fact that the demand for those mental health medications increased dramatically during the pandemic as rates of depression and anxiety went up by a factor of three. While you can argue that in 2021 and 2022 some online services (notably Cerebral) may–and I stress may–have crossed the over-prescribing line for ADHD and other conditions, there’s no evidence that what happened is any worse than the in-person care that the DEA has been inadequately overseeing for decades. More importantly, those online services have already pulled out of those exact therapeutic markets the DEA is alarmed about. Who is left providing online ADHD care? Local clinicians and reputable services. And of course DEA knows full well, and is doing nothing about, the lack of access to mental health professionals that existed long before the increase in demand.

Is there any reason to suspect DEA will improve the quality of the system dealing with these medications? Highly doubtful. There are two current examples suggesting why not. First, due to the increased demand from the pandemic induced mental-health crisis and production problems at pharma company Teva, there’s a massive shortage of ADHD medication already. The DEA could help patients out here, but have declined to increase production quotas–sending millions of patients and their parents on a wild goose chase hunting down pharmacies with actual supply of Adderall and related meds.

Secondly, the DEA wants to also ban the the online prescribing of another drug, buprenorphine, which is used to help wean patients with substance use disorder off opiates and other substances. OK, so there’s a one month grace period here but essentially this is a short-sighted ban that will directly lead to patients going to the black market to acquire opiates, leading to more addiction and death.

My conclusion is that the DEA should be removed from its oversight of licensed clinicians and that role be given to FDA or HHS. At the least these proposed  regulations should be abandoned and rolled back to what we have now. The only good news is that there is still time to comment on the regulations. I went and did so and I hope you will too. Patients have suffered enough already.

Matthew’s health care tidbits: Medicare Advantage is now a provider fracking contest

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Yes it’s time to talk Medicare Advantage (MA). It’s been a huge couple of weeks for the world of MA. On the commercial side, CVS bought the biggest pure play MA provider, Oak Street Health for $10bn. This pissed me off as if they paid $2 a share more I’d have made a profit on the stock I foolishly bought “on a dip” in 2021.

But this amazed many of us on THCB Gang, as they paid a huge premium and it works out to some $60k per patient. Now health care organizations have been overpaying for patient “lives” as long as I can remember–going at least as far back as Aetna nearly going out of business when it bought US Healthcare in 1996. So why is today’s incarnation of Aetna buying providers?

Well that’s to do with the regulatory side of MA. I have been on record since the very first post of THCB that Medicare FFS is an inefficient and expensive program–even if 80% of American hospitals say they lose money on it and have to charge commercial insurers more to make up for it. But while it’s possible to agree with George Halvorson that MA delivers better care at a lower cost than FFS Medicare, it is simultaneously possible to believe that MA costs more than it should. That’s because of aggressive RAF upcoding that’s been built both into home visits from companies like Signify and also into the EMRs doctors have been using to code MA members’ health status.

There are lots of proposals on how to fix this–including this one from Chenmed on how to change MA from paying for inputs (i.e how sick people are when they join MA) to outputs (how much better they got while in MA). But it’s clear that CMS is now officially coming after upcoding including full cross plan audits back to 2018. Even if not back to 2011. The MA plans will grumble about those past audits and tie CMS up in court but they know going forward the game is up

To make more money in MA they need to get hold and shake loose or frack some of the 85% of the premium that goes to provider organizations. Hence they are all getting into bed with them or buying them outright. UHG, Humana & now Aetna/CVS have been buying physician groups that serve MA populations at a quickening rate, and their goal is to put more of the 50% of seniors already into MA into those groups.

Will this save any money?  Well probably not, at least not yet. Humana has been reporting on the costs in its full risk capitated MA groups versus its FFS ones for a couple of years, and the difference is a rounding error. But the point is that the next war in Medicare Advantage is going to be what happens inside these plan-owned medical groups. So expect a lot more scrutiny of both costs, outcomes and patient experience within MA focused medical groups starting about now. 

Elia Stupka, Angelini Ventures

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I’ve been friends with Roberto Ascione for many years. Roberto is a keen Napoli fan who on the side runs the Healthware Group and also the Frontiers Health Conference that I’ve been going to for many years (and where Jess DaMassa is co-MC). Recently Healthware acquired the media company pharmaphorum and hired star reporter (and another friend) Jonah Comstock, ex MobiHealthNews and HIMSS Media. THCB will be doing some occasional cross-posting with pharmaphorum starting with this interview of the boss of a new and well heeled Italian health tech VC fund!–Matthew Holt

Elia Stupka, Managing Director at Angelini Ventures, talks to Paul Tunnah, pharmaphorum founder, about his career, life passions and the exciting launch of Angelini Ventures – a €300 million fund paving the way for healthcare transformation across digital health and life sciences

With access to my records, I took my business elsewhere

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By EPATIENT DAVE DEBRONKART

Not our usual headshot but it is Dave!

I had a skin cancer diagnosed in November. It’s my third, and I researched the last one heavily, so I knew what I wanted (Mohs on the nose). But the hospital that did the diagnosis insisted I wait and have a consult visit in January, and *then* they’d let me schedule the procedure, probably in March.

I said I know what treatment I want – can’t I schedule the surgery now? They said, “That’s not how we do it.”

So I went home and called around. Beth Israel Deaconess Medical Center said if I could get them the information they would book me for January, right then and there.

How long did it take me to get them the data? 15 minutes. I went back to the first place’s portal and downloaded my visit note and pathology report and emailed it all to BIDMC. An hour after I dialed the phone I had the appointment I wanted.

Patient power. I took my records – and my business – elsewhere.

This is of course a nightmare for providers who think they can lock us in. And it’s a dream come true for providers who have been longing to win us away by providing better service.

(I would have had the surgery before now, within January, but COVID struck so we postponed.)

Medical record access is empowering! Thank you to those who worked so long and hard to create these policies!

It’s also great news for providers who are trying hard to be #patientcentric: now we can easily reward them with our business!

It’ll be even better in the coming years because data #interoperability via FHIR will let apps and hospitals go GET the data … or, even better, let consumers already have their data in their own app, to do anything they want with it. True patient autonomy.

Dave deBronkart is a patient activist, speaker and author. This was originally published on his LinkedIn page

Expanding Real World Datasets

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How are you working to advance research and improve patient outcomes? Are you precisely matching records across disparate datasets? Find out at a Webinar TODAY Feb 1st 1pm ET Sponsored by LexisNexis Risk Solutions Health Care

Healthcare’s fragmented data silos and strict but necessary privacy restrictions make it difficult to link real-world datasets. Legacy tokenization technology has helped link records across disparate data sources, but it lacks the accuracy required to uncover actionable insights that can truly improve patient outcomes. Next-generation tokenization technology leveraging a Referential Data Layer is needed to match de-identified records with precision. Hear from Solis Mammography’s CMO on how they are leveraging referential tokenization technology to link their longitudinal imaging data with complementary clinical and genomics data, enabling in-depth breast cancer research to champion women’s long-term health and wellness.

If you care about healthcare improvement, and want to continue to make an impact, join us to learn more about:
• What is referential tokenization and why it matters in healthcare
• Challenges and limitations of legacy tokenization technology
• The power of linking real-world data sets through a network of curated partners
• How Solis Mammography is leveraging referential tokenization to advance women’s health
• Actionable use cases demonstrating referential tokenization further empowering your organization to improve patient outcomes.

Join Us | February 1 @ 1pm ET/10am PT | Register Today

Speakers are: Camille Cook, MPH, Sr. Director, Healthcare Strategy, RWD @LexisNexis® Risk Solutions

Camille has 15 years of experience in healthcare with a focus on leveraging big-data to improve clinical care outcomes. Throughout her career, Camille successfully implemented innovative practices for healthcare IT, healthcare organizations, and life sciences companies utilizing health informatics, big-data, epidemiology, and human behavior patterns to create actionable insights that guide healthcare policy and meaningful use practices. Camille has spent the last 7 years evaluating syndromic infectious disease trends, healthcare operations, health economic outcomes research, and social determinants of health.

Matt Veatch, Real World Data Consultant, Founder and Managing Director @Revesight Consulting

Leveraging over 25 years of experience in biopharmaceutical product and medical device development, Matt advises life science companies on global RWD access and RWE strategic planning, execution, and M&A investments. Prior to establishing Revesight Consulting in 2017, Matt served in various corporate leadership positions, most recently as Vice-president of Strategic Operations at Syneos Health, leading initiatives in RWD access and decentralized study management. Prior to Syneos, Matt rose through various levels to become the Global Head of RWD-Driven Research for Quintiles, founding and leading the landscape-changing strategic collaboration with IMS Health in 2015, directly seeding the $19 billion merger of the firms in 2016 to form IQVIA. Additionally, Matt is a Founding Board Member of the Decentralized Trials & Research Alliance.

Chirag Parghi, MD, MBA, Chief Medical Officer @Solis Mammography

Dr. Chirag Parghi is a board-certified radiologist with fellowship (subspecialty) training in breast imaging and the Chief Medical Officer of Solis Mammography where he oversees clinical quality across more than 100 breast centers. As CMO, he also leads the clinical research endeavors where he is the principal investigator on several trials and manages relationships with the various radiologist practices.  Dr Parghi is still a practicing radiologist with an academic appointment at Albert Einstein medical center in Philadelphia.  Dr. Parghi’s clinical interests are rooted in the use of emerging technologies (including AI) to facilitate the early diagnosis, individualized risk modeling, and treatment of breast cancer.

Matthew’s health care tidbits: How do you tell the price of a drug?

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

As the average THCB reader is probably all too well aware I live in Marin County, California and therefore my kids are on amphetamine-based medication for ADHD. This is annoying as all get out because, as a controlled substance, this medication needs to be re-prescribed every month (no automatic refills allowed). In addition no 90 day supplies are allowed, and the kids must have checkups with their prescribing physician every 3 months (which are not cheap).

It’s not just prescribing which is complicated. Supply is an issue too and frequently pharmacies run out. This is furtherly frustrating because if one pharmacy is out it can’t move the Rx to another, even in the same chain like Walgreens or CVS. The new pharmacy requires a whole new prescription. I discovered last year that Alto Pharmacy, a VC backed home delivery pharmacy, will deliver controlled medications. This has saved me 12-24 visits to CVS in the past year.

But with a new year there are new problems. The “allowed” price, i.e. the price my insurer Blue Cross of Massachusetts had agreed with Alto Pharmacy (and other pharmacies) for the specific generic for one of my kids somehow went from $29 a month to $107. That’s the amount I actually pay until we hit our $4,500 family deductible. Incidentally because it’s a medication we still pay $10 a month after we hit the deductible.

Alto kept telling me that the cash price was around $50. But of course if we pay the lower cash price (either there or elsewhere using GoodRx) that doesn’t count against the deductible. So if we hit the deductible we are out the $50 (which works out to roughly $1200 per year for 2 kids). I kept asking Alto what had changed that made the cost go up? They kept not telling me an answer, other than it cost $107. I asked the good people at Health Tech Nerds slack group if they could guess what was going on. Their consensus was that the formulary tier had been changed. “But it’s a generic”, (I foolishly thought).

Finally I called the pharmacy number on BCBS Massachusetts website, and ended up talking to someone at CVS Caremark– their PBM. In the course of the 30 minute call they ran a dummy claim with several other pharmacies. All came back at the $107 number. They then looked up the formulary to see if it had changed. Meanwhile I looked at the formulary on the BCBS Mass website while this was going on. The medication was still tier 1. So why has the cost to me and perhaps to the Blues plan gone up from $29 a month to $107? (Yes that’s more than a factor of 3!)

While she was talking to me the Caremark rep was also able to Slack with several other colleagues–relatively advanced for an old world PBM I thought. Eventually the answer came back. The med was indeed tier one. But until we spent our deductible the med was tier 2. In other words if we were paying for the drug the price is $107. As soon as BCBS Massachusetts starts paying for it the price goes back to $29 (of which they only pay $19) as we have a $10 copay.

Why this has happened is beyond me? Is Caremark or BCBS Massachusetts suggesting another cheaper drug? I haven’t heard from them. Are they trying to discourage patients from getting to their deductibles? My cynical conclusion is that Caremark is trying to increase the revenue for CVS– its corporate pharmacy–which that accounts for 1/3 of all outpatient Rx.

Otherwise this pricing strategy makes no sense to me. Of course this is just another example of a completely opaque process. And that appears typical for American health care.

Return to McAllen: A Father-Son Interview

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By IAN ROBERTSON KIBBE

You are going to hear a little more about McAllen, TX on THCB Shortly. And before we dive into what’s happened there lately, I thought those of you who weren’t here back in the day might want to read an article on THCB from July 2009. Where then THCB editor Ian Kibbe interviewed his dad David Kibbe about what he was doing as a primary care doc in McAllen–Matthew Holt

By now, Dr. Atul Gawande’s article on McAllen’s high cost of health care has been widely read.  The article spawned a number of responses and catalyzed a national discussion on cost controls and the business of medicine.  It even made it’s way into the President’s address to the AMA.

Almost overnight, McAllen and the Rio Grande Valley were thrust into the national health care spotlight – the once sleepy border town became, not a beacon on a hill, but a balefire in the valley, representing much of what is wrong with the current medical culture.

But, McAllen wasn’t always like something from an old Western, where doctors run wild and hospital CEO’s compete like town bosses.  I remember McAllen quite differently.  I remember it, because as it turns out, it was where I was born.

It’s also where my father, Dr. David Kibbe, practiced medicine from 1980 to 1990. In order to find out how McAllen earned the dubious reputation it now has, I sat down with my Dad, and asked him what he remembers about that little border town on the Rio Grande.

Ian Kibbe: So Dad, what was your first reaction to reading Atul Gawande’s article?

David Kibbe: Well, Ian, it was sort of “oh-my-gosh, he nailed it.”   And, of course, a flood of memories, good and bad, came back to me about our time there.  My medical career began there, you and your sisters were born there, small town 4th of July parades, etc.  But I left after great disappointment and frustration.

IK: What were you doing in McAllen practicing medicine anyway?

DK: The National Health Service Corps sent me there to work in a clinic for migrant farm workers.  The NHSC had provided me three years of medical school scholarship, and so I owed three years of service in an under-doctored area of the country.  I speak Spanish, and so working as a family doctor in the Rio Grande Valley of Texas, which is the home of many of the country’s Hispanic migrant farm workers, was a good fit.  Hidalgo County, where McAllen is located, was the poorest county in the country, and there was a real physician shortage there in 1980.

Continue reading…

Matthew’s health care tidbits: My retina & what it tells us about primary care

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

I had a little scare the other night. I was driving home from a weekend in the mountains and I asked my wife if she saw that flashing light. No it wasn’t the cops, and no she hadn’t seen it. Turns out that I had a bright flash if I moved my eye a certain way. Oh, well I assumed I was tired and a good night’s sleep would fix it.

Next morning the flash was still there when I looked quickly to the left and a few weird floaters had appeared. I headed to the Mayo Clinic website and it looked to me like I had a detaching retina. I got on the urgent visit video with One Medical. The NP who answered said it sounded like I might have retina problems and I should get it checked by my ophthalmologist. But my eyesight has always been great (other than me needing reading glasses in my old age) and I haven’t got one. So who, I asked, do you recommend?

Here we fall into the crux of the problem. One Medical is an excellent primary care service. So good that Amazon bought it for $3bn. But it’s not a multi-specialty group nor is it a system like Kaiser. The answer was, “we don’t really recommend anyone–that’s not how it works.” The NP ended up looking up ophthalmologists near me & sent me a name as a referral in their app. But that’s not a link to anything and it wasn’t one chosen through some analytical process of seeking quality excellence.

I looked up MarinHealth (my local hospital)’s website and searched ophthalmology. That referred name was on it. I called. The doctor was out this week. They gave me another name. That doctor’s office gave me another name and that third office could see me that same day. I felt some pressure to see them right away as in the case of a detached retina Mayo says “ Contacting an eye specialist (ophthalmologist) right away can help save your vision”. The good news is having spent a couple of hours at the ophthalmologist’s my retina needs watchful waiting not surgery.

But the bad news is that for me, like 90% of Americans, there’s no easy way to get referred into a trustworthy system for specialty care. This can be even worse. My friend Sarah McDonald explains in her book The Cancer Channel how, after being diagnosed with a rare incurable cancer by a head & neck surgeon, the all encompassing support she received was to be given the number of a specialist at UCSF who couldn’t even talk to her for 3 weeks.

Mike Magee talks about the role of the health care system being to reduce patients’ “fear and worry”. Our lack of a specialty care referral system, especially when potentially serious and urgent care is on the line, is a big reason why there is so much fear and worry. I wish I had a concierge advocacy system like Included Health or Transcarent which could get me to the right place and work with me through the experience. But like most Americans at the time I need reassurance the most I’m calling a list of phone numbers hoping someone can see me.

We have primary care, we have specialty care. But we don’t have a system that cares.

Medicare Advantage UpCoding Has Been Eliminated by CMS Effective 2022

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By GEORGE HALVORSON

Medicare Advantage now enrolls almost exactly half the people enrolled in Medicare — and has both significant fans and hardline opponents in the health care policy circles who disagree about its performance.

The biggest attack point that comes from the critics deals with the issues of coding accuracy by the plans. The payment model for the program is capitation — and that capitation is based on the average cost of fee-for-service Medicare in every county. The people who designed the model believed that the country should use the average cost of fee-for-service Medicare in every county as the baseline number and should have the plans paid less than that average Medicare cost going forward every year in their capitation cash flow.

Medicare fee-for-service has a strict and consistent payment level based on a list of approved Medicare services — and they add up the cost of those services in every county and let the plans bid a lower number than that fee for service Medicare cost, if the plans believe they can offer all of the basic benefits and possibly add more benefits and additional services for that amount.

The fee-for-service Medicare cash flow and costs in each county tend to be very stable over time, with a continuous and steady increase in the actual functional cost for taking care of those fee-for-service patients for each year that they receive care. That total cost of fee-for-service Medicare care is a visible and clear baseline number that we can use each year with confidence and knowledge that it is what we are spending now on those Medicare members in the counties.

The direct capitation amount that is then paid to each of the plans is based on the age, gender, health status, and diagnosis profile of the Medicare Advantage members who enroll in the plans. The plans have been reporting those patient profile numbers to the government through the Risk Adjustment Processing System (RAPS) over a couple of decades to set up their payment levels and to create the monthly cash flow for each plan.

That’s where the upcoding accusations relative to the plans arise.

The plans get paid more if the patients have more expensive diagnoses — so the plans have had a strong and direct incentive to make sure that every diabetic enrollee is recorded and reported as being diabetic for their RAPS filings.

They also have a strong incentive to be sure that every congestive heart failure patient has their diagnosis recorded in their RAPS report.

Continue reading…

Fighting the Wrong (Culture) War

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By KIM BELLARD

News flash from the culture wars: they’re coming to take our gas stoves!

Well, actually, “they” are not, but the kind of people who got alarmed about it are a threat to our health, and to theirs.

The gas stove furor started with a Bloomberg News interview that Richard Trumka, Jr, a Consumer Product Safety Commission commissioner. “This is a hidden hazard,” he said. “Any option is on the table. Products that can’t be made safe can be banned.”

He was referring to the well known but little acknowledged fact that gas stoves emit various pollutants, especially nitrogen dioxide. Last year the AMA adopted resolutions about the risks of gas stoves, and urged migration efforts to electric stoves. Shelly Miller, a University of Colorado, Boulder, environmental engineer has said:

Cooking is the No. 1 way you’re polluting your home. It is causing respiratory and cardiovascular health problems; it can exacerbate flu and asthma and chronic obstructive pulmonary disease in children…you’re basically living in this toxic soup.

So one can see why the CPSC might be concerned. But the outcry about Mr. Trumka’s comments were immediate and vociferous. “I’ll NEVER give up my gas stove. If the maniacs in the White House come for my stove, they can pry it from my cold dead hands. COME AND TAKE IT!!” Rep. Ronny Jackson (R-TX) tweeted. The Atlantic further reported:

Governor Ron DeSantis tweeted a cartoon of two autographed—yes autographed—gas stoves. Representative Jim Jordan of Ohio declared simply, “God. Guns. Gas stoves.” Naturally, Tucker Carlson got involved. “I would counsel mass disobedience in the face of tyranny in this case,” he told a guest on his Fox News show.

Almost as immediately, Mr. Trumka clarified: “To be clear, CPSC isn’t coming for anyone’s gas stoves. Regulations apply to new products.” CPSC Chair Alexander Hoehn-Saric issued a statement making it clear that, while “emissions from gas stoves can be hazardous…I am not looking to ban gas stoves and the CPSC has no proceeding to do so.” The White House issued its own denial. Case closed, right?

Continue reading…

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