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Above the Fold

Measuring MACRA

Apr 15, 2017• 4

By STEVEN FINDLAY

With all the machinations over ACA repeal and replace, the new law that makes big changes in the way the federal government pays doctors—the Medicare Access and CHIP Reauthorization Act, or MACRA—hasn’t garnered much attention lately.

But doctors nationwide are sure thinking about it. That includes many of the regular commentators on THCB. I think it’s accurate to say that most of them have been highly critical of MACRA since the law was enacted in April 2015, and even after it was significantly amended late last year to address physician complaints. (See, for example, Kip Sullivan’s most recent post here.)

The law’s main provisions kicked in on Jan. 1, 2017, with 2017 being the first performance-reporting year, affecting payment in 2019.

In a policy brief on MACRA for Health Affairs published late last month, I raised a host of questions about MACRA.

As Kip and many others have noted, some parts of MACRA are weakly designed and both the law and regulations implementing it make some big assumptions. Excerpts from one section of the policy brief are below. The whole brief can be had at the link above. If you are well versed in MACRA, you can skip to the section titled “What’s the Debate?

Is the overall design coherent and workable?

Major special-interest groups, including those representing physicians, industry, and consumers and patients, supported MACRA’s intent and the general framework of the regulations through three comment periods.

However, almost all groups sought changes and raised questions. CMS’s final revisions were most responsive to physician groups, which were insistent on an easier path and more flexibility for doctors in the initial years of the program.

Yes, Mr. President. Health Care is Complicated. And Also Hard.

Apr 14, 2017• 3

By ASEEM SHUKLA, MD

“Nobody knew that health care could be so complicated,” President Donald Trump told us a few weeks ago. As the failure of the House Republican bill shows: Healthcare is hard.

The American Healthcare Act failed to clear the House of Representatives despite catering to longstanding conservative demands: rid the ‘individual mandate’ (designed to force able-bodied people to pay insurance so it’s cheaper for sick people), subsidies to individuals, and revamping Medicaid into block grants to states.

Even with the claim it could be deficit-neutral, the act failed to win enough moderate or conservative Republicans.

While Obamacare stays, the progressive wing of the Democrat party still calls for a single-payer Medicare-for-all health care system.

They would offer a dual catharsis: the moral certitude of declaring health care as a right; and the beguiling simplicity that one only need expand an existing entitlement and simply include the 264 million Americans not currently covered.

But leave aside questions of practicality and which option balloons the national debt further (both actually would), no proposed alternative delivers a cure-all.

Protection? Fairness? Hardly.

Apr 14, 2017

By ART CAPLAN and ZACHARY CAPLAN

The American Health Care Act (aka Trumpcare or Ryancare) failed because it was patched together and would have imperiled insurance benefits for millions of the neediest Americans. Two other health care related bills – the Protecting Access to Care Act and the Fairness in Class Action Litigation Act – have made it out of the U.S. House and are currently pending in the U.S. Senate. If passed they will produce the same abysmal result. Like the American Health Care Act, they should be rejected.

Protection and fairness? How could anyone be against that? Unfortunately, the titles hide the motive of these bills: maybe cost savings and damn the public good. These bills appear to have been written by lobbyists to protect corporate bottom lines. Both bills will add to the substantial roadblocks injured patients already face in attempting to vindicate their rights against powerful entities and corporations in the legal system.

The Protecting Access to Care Act (H.R. 1215) is being touted as a way to control the cost of frivolous medical malpractice lawsuits. The Act would limit medical malpractice victims’ ability to have their day in court by making certain providers immune from lawsuits and imposing strict caps on damages for victims of medical malpractice regardless of the degree of injury or the extent of negligence involved. Some variation of this bill has been floating around Republican circles for decades. There is no question this bill would likely reduce costs for medical providers and insurance companies, but there is every reason to believe it will do so by harming ordinary Americans.

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Insurers: Getting To Know The New B In B2B2C

Apr 13, 2017• 1

By PASCAL LARDIER PARTNER CONTENT

Startups are increasingly counting on partnerships with payers and insurers to accelerate the commercialization of their solutions.

Health 2.0 was recently invited by AXA and the International Federation of Health Plans (IHFP) to be part of a meeting in Paris with 15+ European/global health insurers. On March 14th, we took this opportunity to organize a Health 2.0 Paris meetup and present several solutions designed to be implemented or reimbursed by health insurers.

The presentations generated a strong interest and fueled a lively discussion. Insurers had a lot of questions for our panel of presenters… but, not necessarily the ones you would expect. We often think of insurers as payer organizations that only care about saving costs. However, the ROI question was not raised once.

This Doctor Says #BoycottUnitedAirlines

Apr 13, 2017• 25

NIRAN AL-AGBA, MD

Watching events unfold at United Airlines over the last few days have filled me with shock, awe, and horror. As a result of this public relations disaster, their motto “flying the friendly skies” has turned into “not enough seating, prepare for a beating.” America stands as a beacon of freedom from oppression. In my opinion, United Airlines was an iconic American company until last Sunday.

That ended Sunday.

Much of the backlash was initially a result of the lackluster attempt at an apology from the CEO of United Airlines, Oscar Munoz. Despite three attempts, he still appears rather oblivious to the real suffering of Dr. Dao. Physicians have been taught that the best thing to do in the face of a medical error is to be honest, forthcoming, and apologize; it must be genuine and from the heart — acknowledge our blunder, take responsibility for our mistake, and convey our sincere regret. Executives at United Airlines would do well to heed these words.

Who’s to Blame For the Shortage of Doctors? Doctors and Politicians

Apr 12, 2017• 10

By CHARLES SILVER and DAVID HYMAN

After missing an appointment with a physician recently, one of us was tongue-lashed by a medical assistant who explained that the practice has a months-long waiting list for new patients. The dressing-down included a threat. Another no-show and the miscreant would be discharged from the doctor’s practice and have all medications cut off.

Wondering if patients really wait months to see this doctor, the delinquent called back, pretended to be a new patient, and asked how quickly he could get in. The first available appointment at the closest location was, in fact, 2 months out. (The wait could have been cut in half by driving to an office that was farther away.)

Two months is a long time to wait to see a doctor. If your auto mechanic or air conditioner repairman told you that it would take a week to fit you in, you’d find someone else to take care of the problem and you’d never go back to the person who told you to wait. Given the transcendent importance of health, why do patients who need medical assistance routinely wait far longer? And if patients with good insurance wait for two months, how long is the queue for those who rely on Medicaid or who have no insurance at all?Continue reading…

Evidence-Based Diagnosis and Faith-Based Solutions

Apr 11, 2017• 6

By KIP SULLIVAN, JD

It’s official: the Medicare Payment Advisory Commission (MedPAC) has at long last decided that MACRA’s MIPS (Merit-based Incentive Payment System) can’t work.
MedPAC reached this decision at its January 12 and March 2, 2017 meetings.

Its principle rationale was that measuring “merit” (quality and cost) at the individual physician level, which is what MIPS requires CMS to do, is not possible. As one MedPAC staff person put it at the January meeting, “A redesign of the MIPS program should build off a clear-eyed assessment of the limit of the national Medicare program’s ability to assess clinician performance” (pp. 235-236 of the transcript of the morning session of the January 12, 2017 meeting).

“Value-Pricing” of Drugs and Pharmaceutical Innovation

Apr 10, 2017• 26

By UWE REINHARDT

In a fascinating paper on drug pricing, Ana D. Vega and her five co-authors trace increases in the price of brand-name and generic drugs in the U.S. during the period 2012-15, using the national average drug acquisition costs (NADAC) data made public by the Centers for Medicare and Medicaid Services (CMS). These acquisition costs are the prices that retail community pharmacies pay to acquire medicines, usually from a wholesaler.

The tables in the paper show that the top 50 increases in the price of generic drugs over the three-year period ranged from a “low” of 448% to a high of 18,808%. For branded drugs the increases over the period ranged from a “low” of 63% to a high of 391%.

The paper also presents data on the wholesale acquisition costs (WAC) differences between first-in-class drugs and subsequent me-too-drugs, the latter usually costing much more than the first-in-class drugs, although they typically involve only small molecular changes. Here the price differentials varied from a low of -2.3% (the sole case me-too-drug actually being cheaper than the first-in-class drug) to a high of 61,259%.

It is rare to find such transparency on drug prices in this country, presumably because the data are in possession of a public agency, the CMS. By contrast, the private sector usually confronts both patients and researchers with contemptuous opacity. The pharmaceutical benefit management industry (PBMs) is particularly opaque on drug pricing, and private insurers and employers have gone along with it.

Price increases of the sort reported by Vera et al. usually are defended on two distinct grounds.

The first is what has come to be called “value pricing’ the idea that the price of a drug should be pegged on the value that drug has to patients or to society at large, in their eyes. For life-saving drugs or pain-killing drugs, that value can be very high.
Another defense of the ever rising prices of drugs is that they are needed to provide the incentives for new drug development.

Value Pricing

In my presentations on drug pricing, I often use the following metaphor to convey the central point of this concept.
Picture, then, a man somewhere in the Sahara desert close to dying of thirst.

Along comes a camel caravan for tourists, loaded with bottles of water. Assume the chap on the first camel is a private equity manager who knows a thing or two about “value creation” through “value pricing.” Assume the lady on the camel behind the first is a corporate lawyer.

Jumping off the camel, the private-equity chap approaches the dying man and, water bottle in hand, queries the dying man thus:

“How much would you pay me for this fresh bottle of water?”

When the Patient is a Racist

Apr 8, 2017• 10

By JULIE KIM, MD

Something has changed.

In my first 16 years in practice, I received exactly one insensitive comment from a young child who had never seen an Asian in person. But in the last year, I have received a hateful, bigoted comment approximately every other month. (That includes the remarks by a person who tried to reassure me that the comments were not directed to me personally, but to the “other illegals.”)

My colleagues are experiencing an increase in bigoted comments too. A fellow physician, a southeast Asian man, says he has been called “Dr. Bin Laden” on several occasions recently.

Last September, one of my students was on the receiving end. A patient’s father requested another doctor when he saw the medical student assigned to his son’s case was black. My student and I went to see the patient’s family together. I acknowledged the father’s anxiety and reassured him that we could treat his son. I asked the surgeon-on-call to see the patient.

Is Healthcare a Right? A Privilege? Something Entirely Different?

Apr 8, 2017• 24

By BRIAN JOONDEPH, MD

Election Day 2016 should have been Christmas morning for Republicans. Long awaited control of the White House and both houses of Congress. A chance to deliver on an every two-year election cycle promise to repeal and replace Obamacare. In 2010 Republicans needed the House. They got it. In 2014, it was the Senate. Delivered. But we still need the White House they said. Asked and answered with President Donald Trump.

So, what happened a few weeks ago when the House bill fizzled like a North Korean missile launch? Disparate factions within the House couldn’t unify behind Speaker Paul Ryan’s plan, despite pressure from the White House. For some it wasn’t a repeal, only a rearranging of the deck chairs on the sinking Obamacare ship. Others in the GOP were happy with the status quo, preferring to rail against Obamacare in campaign speeches rather delivering on empty campaign promises. Still others, #NeverTrumpers, knowing that President Trump was behind the House bill, preferred to see the bill, and Trump, fail.

Kudos to the Democrats. When they ran the show in 2008, they herded their cats and passed Obamacare. No Statist Caucus on one side or a Tuesday (or Thursday or Friday) group on the other side, each wanting their own version of healthcare reform.