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Tag: Policy/Politics

POLICY/POLITICS/PHARMA: Is Part D the begining of the end for Big Pharma? by The Industry Veteran

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THCB’s favorite vituperative contributor, The Industry Veteran, is back with some New Year thoughts. He got what I was up to on NY Eve a little wrong, but may have a closer idea about what the long term effects of the New Year will bring to Big Pharma. The Veteran writes:

A healthy and prosperous New Year to you!! For some reason I have a picture in my mind’s eye of you sitting in a pub, raising many pints to toast in the New Year. At 2:00 a.m. I see you wearing a thick turtleneck sweater beneath a Harris Tweed sport-coat as the proprietor gives his inevitable call, “glasses, gentlemen.”

 

The following article from Tuesday’s Financial Times says some interesting things about plausible effects of Medicare Part D. The author maintains it will push the US closer to the rest of the world in terms of a national payer system, greater transparency in drug pricing and cost constraints. To advance that last objective, he sees the feds pushing IT and more rational provider management patterns, a sort of revenge-of-the-nerds that should delight you and a segment of your readership. I suppose since neither a Republican or a Democratic administration is likely to enact the sort of changes I would prefer (e.g., tumbrels, guillotines and iron maidens for the Hank McKinnells of the world), the sort of temporized-neuterized change from the back office is better than nothing.

 

The thing that strikes me as amusingly ironic about Medicare Part D is that it shows the folly of leaving economic planning to the monopolistic corporations.  The US throughout its history has disdained strategic economic planning by government because of the secular faith in the market among the country’s business leaders. So here we have the Medicare Modernization Act as developed by Big Pharma’s Pfizers, Mercks and their PhRMA lobby. They fashioned the MMA, with its confusing, competing PDPs, specifically to prevent Medicare from acting as a single payer that could make volume discount purchases. After all, if they could elect George by manipulating an electoral system to create the illusion that 3,000 elderly Jews in Florida voted for Pat Buchanan, a Rube Goldberg MMA could certainly boost their earnings at taxpayers’ expense. Now here we have consultants, journalists and equity analysts forecasting that by decade’s end, the MMA will do precisely what the CEO malefactors wanted to avoid. I dread to think what would happen if Big Pharma’s CEOs were half as bright as their sycophants in Pharmaceutical Executive and the other vanity rags claim.

 

Although as the Veteran has pointed out before, the crew running big Pharma in 2003 will be long gone counting their millions by the time those chickens come home to their successors’ roosts.

POLICY/POLITICS/PHARMA: Inserting the DEA into End-of-Life Care

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The NEJM has an article and an interview about the Oregon assisted suicide ruling that is coming up before the Supreme Court. Because theocratic fascist John Ashcroft was unable to overturn the will of the Oregon voters legally he tried to get around it by using the controlled substance act. If the Supreme Court rules in the Administration’s favor, it has very serious consequences for palliative care. Basically doctors will be even more in fear than they are now of prescribing opiates, and patients will suffer.

The interview is pretty interesting. Despite both wanting the Supremes to rule against Ashcroft, one of the authors is in favor of the assisted suicide law, one against it. Diane Meier opposes it because she feels (rightly) that the average physician doesn’t have the training or the time to properly evaluate requests for assisted suicide.  Funnily enough America’s leading and crazed advocate of assisted suicide agreed with her, which is why Kevorkian advocated creating a medical specialty for helping patients who wanted it. The other author, Timothy Quill does approve of the Oregon law, citing that as an experiment it gives data showing that the law is working and that patients and their families are using it as the entrance to a discussion about what they actually need. And of course palliative care with opiates is one type of help those critically ill patients, who are often in tremendous pain, need. And of course the authors are terrified that the DEA will not understand that the line between proper palliative care and going slightly over that line to hasten a coming death is very fuzzy and one that often cannot be identified.

But in dealing with this issue, there are two massive problems faced by rational people in the US. First, the opponents of this type of care — including leading bloggers — are happy to start labeling any doctor thinking about this as a genocidal Nazi. Secondly, the DEA is already intervening with no regard to patient care in its insane prosecutions of doctors who are treating patients according to acceptable guidelines. Meier can claim that the DEA is good at intercepting illegal diversion of prescriptions, but it’s clear that the DEA couldn’t give a rats arse about diversions, they’re just out to impose themselves on anyone they don’t like. Consequently patients all over America are suffering already. The imposition of the DEA into end of life care won’t make much difference, other than the pain of those at the end of life will last less time than those living with chronic pain who can’t get the care they need because of the DEA’s appalling behavior. If you don’t believe me, read the comments on my last post on this subject.

I sincerely hope that the AMA looks past its nose and gets involved in this travesty of a public policy. Maybe this article is a start, but it may well be too late. The only hope is that this case will be decided by O’Connor, before the theocratic fascist that Alito appears to be gets on the court.

POLICY/POLITICS: Let them eat cake

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Remember pre-election 2000 when Bush said that we shouldn’t balance the budget on the backs of the poor? He was of course joking (and not just about the balancing part), as Bob Herbert points out in his article — The Machete Budget.

Contrast the cuts in Medicaid that are in the latest budget with the $10m spent on a bahmitzvah party by a defense contractor who made $70m last year supplying apparently faulty flak-jackets to our troops. And they claim that there’s no war profiteering. Of course in WWII a real American hero, Harry Truman stopped that stuff dead in its tracks.

PHYSICIANS/POLICY/POLITICS: Is cutting Medicare Part B fees a good thing? by Eric Novack

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THCB’s favorite orthopedic surgeon Eric Novack is grumpy about Medicare’s proposed cuts in physician reimbursement, which are still up in the air as I write. Not sure how much support he’ll get over here on THCB, but it’s ironic that $10 billion is being set aside for health plans and PBMs to reimburse them for possible losses for their role in Medicare Part D, and hospitals are getting a raise. If we are going to cut Medicare, wouldn’t an across the board cut be fairer? Here’s Eric’s thoughts:
Unless Congress acts in the next week, reimbursement to physicians for services provided to Medicare recipients will be cut by 4.4%. The government’s formula for determining the payment rate does not take into account the increasing costs of healthcare delivery. Rather it is based upon such factors as the cost of prescription drugs and general economic factors over which doctors have no control. The reduction is not merely a reduction in the rate of growth of spending. Payments of $100 will become $95.50. And if the Congress’s inaction continues, payment will be less than $75 by 2011. No adjustments for inflation or cost of living are included.
Is all Medicare spending being cut? No, only payments for outpatient services- Medicare Part B- are affected.
Hospital care, paid under Medicare Part A, will get a pay increase of about 4.8%. Managed care plans that get paid by Medicare for managing Medicare HMOs will also get a raise. In both cases, the government’s formula for payment is based upon the medical economic index, which takes into account the costs of health care delivery.
Other than doctors, why should anyone care that reimbursement is going down? What options do patients and physicians have? Doesn’t more affordable mean more accessible?
Nearly 97% of US doctors participate in Medicare. This means that the doctor has signed a contract to accept the rates that the government says it is willing to pay for services. Doctors cannot be selective. They must accept the rate for any and all services that Medicare offers. They cannot tell patients that they will accept the contracted rate for one service, but not another. For example, doctors are not allowed to accept the Medicare rate for knee replacements, but not for hip replacements. This is especially an issue when it comes to the care of very complex conditions, as the level of expertise, time necessary, and potential liability is significantly increased, whereas payment is often only minimally higher than for the care of much simpler cases.
Physicians have several ways to deal with the Medicare cuts. They can retire and stop practicing medicine. Some will. They can see more patients each day, spending less time with each patient. Some will. They can stop practicing medicine and pursue other careers. Some will. They can limit the number of new Medicare patients they will see. Some will. They can drop out of Medicare altogether, requiring Medicare patients to pay completely out of pocket for healthcare services. Some will.
Patients have few, if any, options under the current structure of Medicare. Seniors cannot opt out of Medicare and find private insurance to cover care.
Government fixing of healthcare prices below reasonable market rates will create the medical equivalent of the gasoline crisis of a generation ago. The planned and projected Medicare cuts will have exactly the opposite of the intended effect: seniors throughout the United States will have less access to doctors and healthcare services.

POLICY: Ignorance is not bliss

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Young punk Kate Steadman has a very interesting post about the uninsured over at Health Policy

The current display of ignorance was on the subject of being uninsured. The woman I talked with didn’t really understand what it meant to be uninsured until her housekeeper had a health problem and couldn’t get seen by a doctor.

Look down in the comments for a combination of ignorance and desperation, and you’ll see why this will end up the political topic of the next two decades, as I said in my Spot-on piece last week.

And a big Hat-tip to Derek Lowe who’s doing Grand Rounds this week.

PHARMA/POLICY/POLITICS: Medicare Part D–A mess that will need fixing when the grown-ups get back into power

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Last week the most convoluted program in the history of Medicare began. I’ve heard comments from friends, neighbors and people in the press saying that they can’t make heads or tails of the new drug benefit. The Washington Post piled in on Saturday with yet more about how confused seniors are.

Whether you like it or loathe it, there are some interesting parts of the Medicare Modernization Act, including the HSA provision and the disease management provisions. But the main event–drug coverage–is neither rational nor ideologically consistent. It’s a dog’s breakfast put together to ensure that the PBMs and some private health plans have something extra to sell, and so that the pharmaceutical companies don’t have to deal directly with the government on pricing.

Now seniors are going to have to deal with a donut hole, out-of-pocket costs, in-network and out-of-network pharmacies, and deciding whether their employer-sponsored coverage is going to stay around. No wonder they’re confused.

And despite all this, the cost to taxpayers is going to be double what Congress was told it would be. Drug coverage for everyone (especially seniors) is needed. But the only prediction I can make is that a more fiscally and socially responsible government–should we get one–will be forced to re-sort this mess in the very near future.

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POLICY: Yet more Dartmouth proof about doing too much

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We’re almost at the point that you know exactly what any study from the Dartmouth group is going to find before it’s published. Following the assessment last year that showed that the nations “Top 100” hospitals show a wide variety of difference in procedures in their ICUs, for no apparent difference in outcomes, the same result comes up again.  This time (with Stanford’s Lauren Baker playing a starring cameo) Wennberg, Fisher et al looked at Medicare spending on patients in the last two years of life in hospitals in California and once again geography is destiny. (Health Affairs article here)

The study found that reimbursements ranged from $19,745 per Medicare patient at Redwood Memorial Hospital in Humboldt County’s Fortuna to $88,661 at Garfield Medical Center in Monterey Park in the San Gabriel Valley

Sacramento was cheaper than the Bay Area which was in turn cheaper than Los Angeles.  And of course the outcomes were similar in all places and had little relation to the costs. Interestingly, hospital chain is also a predictor. Sutter, which isn’t exactly known by California’s health plans as being a low cost operator, did way less than Tenet. (although I don’t know if Redding Medical Center skewed the data by itself!)

Medicare spending was also higher in some large hospital systems. Sutter Health, which operates 27 hospitals in Northern California, spent $30,814 on average per Medicare patient in the last two years of life, compared with $46,323 at Tenet Healthcare Corp.

Given that these are the most expensive patients (the 10% that cost 50% of all dollars), and moreover “it’s my money dammit”, you’d think that our so-called conservative leaders would be seizing on this to try to do something about the practice variation problem. But it just seems to be accepted as some type of unintelligent design.

 

POLICY/POLITICS: Health Reform may be back on the national agenda

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Here’s my editorial from FierceHealthcare this morning.

This week may or may not have been a political harbinger for the coming years. Following a disastrous year for the Administration, Democrats have been claiming victory following wins in Virginia, New Jersey and California. Meanwhile, voters in California and Washington rejected measures that would have limited the activities (and incomes) of drug companies and trial lawyers. In Massachusetts, there may be the start of a compromise designed to get universal insurance (of a sort) for the state, and several other states are looking at the issue. Of course, nationally this will only mean something if the Democrats really carry their (so far modest) victories into the Congress next year and the White House in three years. That of course is a long time away. But health care is fast becoming the number one domestic issue and a Democratic majority will feel compelled to have another crack at it.