By STEVEN FINDLAY

The white hot EpiPen controversy is the latest signal—and it should be loud and clear at this point—that the pharmaceutical marketplace is dysfunctional.

To be sure, drug companies make medicines that save and prolong lives and ease suffering. And many drugs save money compared to alternative treatments, and yield productivity gains by keeping people alive, well, and working.

But over the past two decades, the industry has become the poster child for poor business ethics, flaunting the law, and profiteering. Just one example: Since 1990 drug companies have paid $15 billion in civil and criminal fines to the federal government for promoting the use of their products “off-label” – that is, for unapproved uses.

They have also been caught red-handed (a) testing drugs in illegal and unethical ways in third world countries, and (b) hiding study results from authorities worldwide that undermine claims for their drugs’ effectiveness and/or safety.

Most recently, they have been vilified for startling increases in the prices of both brand-name and generic drugs.

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BY LEONARD KISH

“The system only changes if we empower the one person who cares about their health the most – the patient. Over the next decade, I believe people will become the CEOs of their own health.” Vinod Khosla

Self care is the future for the simple reason that nobody wants to be a patient. Of course we want care when we need it. We want to be well. We want a good life. We want independence. We want control, and we certainly don’t want to need care nor to lose control.

And becoming a patient, for better or for worse, implies giving up control. Being a patient implies there are gatekeepers, there are limits, there are constraints, there are decisions we can’t make for ourselves. We can’t always get the access we want. Talk to patient advocates and you’ll find people fed up with the lack of control, lack of ownership and the lack of help from the health care system.

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KIP SULLIVAN, JD

Dear President Obama,

If I were to tell you that alligators and southern accents are correlated and that alligators cause southern accents, what would you say? You’d say, “Yes, Kip, there is a correlation, but it’s weak. But more importantly, even if the correlation were strong, there is no plausible mechanism by which alligators could influence accents. Therefore I reject your conclusion.”

I offer the same rejoinder to your argument in your August 2 JAMA article  that the Affordable Care Act has reduced health care inflation. In that paper, you claimed the ACA has “contributed to a sustained period of slow growth in per-enrollee health care spending,” and you cited the low average inflation rate of the five-year period 2010 to 2014. But that period correlates only loosely with the period of very low inflation that began in 2008 and ended in 2014. The fit is even worse if we define the “sustained period of slow growth” as 2004 or 2005 to 2014 as some do. To give you the benefit of the doubt, I’ll assume you were referring to the 2008-2013 inflation lull.

Of far more importance, even if the correlation were strong, there is no plausible mechanism in the ACA that could have caused more than a tiny fraction of the 2008-2013 slowdown.

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By CARE LOGISTICS

In the latest installment of the Who Cares: Hospital Talk podcast we chat with Kristin Colby, a specialist with Children’s Hospital of Atlanta about the challenges of preparing kids for the uncertainty and trauma of hospital care. Could working with kids just maybe teach something to the rest of us? Maybe. Just maybe ..

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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