By JIM PURCELL

I wrote earlier here about the exchanges, how they are failing, and why.  It is unsurprising that what I wrote is coming true, not because I am some clairvoyant, but because I’ve lived in the insurance world and understand it.  The causes are very, very obvious.

The most recent whipping boy is Aetna, which announced that it is exiting most of its exchange markets, citing losses of $200 Million in the second quarter. From correspondence, it is clear that Aetna was willing to be a good citizen and accept such losses if its proposed acquisition of Humana were not opposed by the feds.  Well, the feds are opposing.  And predictably, Aetna is sending back a message that it’s willing to be a good citizen, but only up to a point.

Might we wonder what the Obama Administration is thinking regarding the exchanges?  All of this is so predictable.  The exchanges were designed to fail economically.  Fundamentally, insurance is a financial matter.  Money in, money out.  If the exchanges were designed to be something else (a socially-conscious program to afford (so to speak) coverage to everyone that would require tax subsidies), it might be time to admit to that.

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By MICHAEL BANKS, MD

We decided that if MACRA is good for physicians, then the same thinking is probably a pretty good idea for the US government. We need Value-Based Government. It’s clear that past methods of paying for US Government services have been terribly inefficient. Costs keep going up. Quality keeps going down. We thought about doing this nationwide, with all US government personnel, but we will just do CMS leaders for now. Let’s call it a demonstration, we’re calling it  GACRA, Government Access and CMS Revaluation Act.

Eventually we want all US government employees to be value- based, no more salaries. This is an obvious improvement on how we will pay you,  The way you are paid now does not seem to work. Everyone agrees our government is too expensive to run and nothing gets done.

Here’s how value-based government works:

Every CMS leader will send in a code for every 10 or so minutes of work and exactly what they did. Yes, Andy Slavitt and Sylvia Burwell, you will not be paid as you were previously.

You will now be paid for value.

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BY LAURIE LEONARD

I am very glad the AMA is studying the issue of aid in dying. Opponents to the legalization of aid in dying put quotes around the term, apparently to indicate that it is a euphemism for what they believe is physician-assisted suicide. But aid in dying is not suicide.

On 9/11 witnesses saw a number of people trapped in the World Trade Center intentionally jump to their deaths. None of those deaths were ruled suicides by the medical examiner. The death certificates for the jumpers list the cause of death as homicide.

Similarly, in the states in which aid in dying is legal, the death certificates do not list “suicide” as the cause of death; instead, they list the underlying terminal disease as the cause. Just as the 9/11 jumpers chose death by falling over death by burning, those terminally ill people fortunate enough to live in an aid in dying state can choose a peaceful, quick death at the time and place of their choosing over a drawn-out, miserable death that may end alone, intubated in an ICU rather than at home with loved ones present.

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By DEVON HERRICK

Politicians are concerned about your drug costs. Unfortunately, their proposals could actually raise drug prices and force you to pay more, albeit indirectly. For instance, presidential candidate Hillary Clinton proposes to cap your prescription drug co-pays at no more than $250 per month. Rising drug costs are now a political issue because the number of diseases and conditions that can be treated using drug therapy has grown tremendously over the past 25 years. Arguably, one of the main reasons patients visit their doctors is to obtain or renew prescriptions. When they visit their doctors’ offices, Americans leave with a prescription in hand about three-fourths of the time. This is hardly a travesty; and few patients are drowning under the cost of prescriptions drugs. Most prescription costs are paid for by prescription drug plans sponsored by insurers and health plans.

Insurers and health plans use multiple techniques to make drugs affordable. One of the ways employers, insurers and pharmacy benefit managers (PBMs) hold down costs is through drug formularies with multiple tiers. The purpose of tiered formularies is to steer enrollees to lower-cost alternatives when appropriate, using differing levels of cost-sharing and co-pays. Drug plans typically encourage generic use by requiring little if any cost-sharing when a generic drug is dispensed. Prescriptions are dispensed in generic form about 88 percent of the time. Generic drugs are cheap compared to brand drugs — accounting for less than three percent of national health care expenditures.

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By RONALD PIES, MD

Physician-assisted suicide. Physician-assisted dying. Physician Aid in Dying. All these terms have been used to describe a terminally ill patient’s use of a lethal, prescribed medication. Sometimes the medication is used to end the patient’s life; sometimes, it is held “in reserve” to provide a sense of control over the timing of death. Historically, the American Medical Association has stood squarely against physician-assisted suicide (PAS). But recently, in approving “Resolution 015”, the organization has resolved to study the issue of “aid in dying”, with an eye toward reconsidering the AMA’s longstanding policy. As a medical ethicist, I find this resolution deeply troubling.

Consider this scenario from an ethical perspective. Your loved one is facing a terminal illness, and is expected to live only another month or two. He is sitting in his doctor’s office, and knows that the doctor owns a gun, which she keeps locked up and loaded in her office. The patient, who is mentally competent, requests use of the physician’s gun, in order to end his life. Would it be ethical for the physician to grant the patient’s request? I suspect most of us would be horrified at the thought. Indeed, most U.S. states have laws that prohibit someone from “knowingly and willfully assisting” another person in the commission of suicide.

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By STEVEN FINDLAY

Since we are in a political season, I’ll begin with one of the candidate’s positions on a facet of healthcare: Hillary wants to double funding for Community Health Centers (CHCs) over the next decade.

Is that a good or bad thing?  If you’re inclined to think that’s good, please read on; I’ll reinforce your views.  If your impulses are in the opposite direction….well, I hope you’ll still read on; I’ll hope to convince you.

By the way, I could find no mention by Trump of CHCs—no surprise there.

The role CHCs play in healthcare has gone largely unheralded for years, eclipsed by sexier health policy topics and debates.  But that role has expanded in recent years and become more important than you might think.  And not incidentally, CHCs have had broad bipartisan support for many years.

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By JIRKA TAYLOR and ELTA SMITH

Antimicrobial resistance (AMR) is a major threat to public health and the global economy. Indeed, a RAND Europe study found that failure to address AMR could result in worldwide economic losses of $3 trillion and annual population decreases of 10 million people every year until 2050.

In May 2016, the UK’s Review on AMR, headed by economist Jim O’Neill, delivered its final report, which stressed the need to find global and cooperative international solutions. It is good news then that the United States and European Union (EU) are among the most important international actors in this area committed to making an effort to tackle AMR, both domestically and in collaboration with their international partners.

The United States adopted a National Action Plan to tackle AMR in 2015, and the Obama administration nearly doubled federal funding for 2016 to more than $1.2 billion. Similarly, the EU’s activities in the area are guided by an EU Action Plan on AMR, which RAND Europe is evaluating, with the EU dedicating substantial resources to AMR-related efforts, including about €2 billion on AMR-related research from 2012-2015.

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