Drug Makers and Drug Access are Out of Control

indexNew Orleans   In the fight against the Affordable Care Act much was made of so-called “death panels,” as many may remember. Years go by and now we have something in place a lot like that now, and there’s not much never mind. When it comes to money or life, pretty much everyone has become resigned to the realization that money will win almost every time in such a contest.

Nonetheless, recent news that there were as many as 150 different drugs in critically short supply was not sobering, but shocking. The rationales were across the board, and they included production and manufacturing problems, abandonment by companies of drugs because of puny sales, supply line problems, and probably hoarding, though I don’t remember that being on the list. Some of it also had to do with predatory pricing on some drug therapies by companies charging exorbitantly for new treatments, like Hepatitis C, where almost $90,000 per year was standard, based on the companies’ argument that the cost was cheaper than transplants. The stories of hospitals unable to get enough chemo and other cancer drugs so they were having to lower dosages, deny access, try something else, or choose between the old and young in a deadly triage based on these shortages were horrible.

Having recently interviewed James Lieber about similar issues, many of which he had researched in his book, Medical Error, I reached out for him to give me a better understanding on whether the problem was the way I was looking or what I was seeing. Lieber’s finger pointed right at the drug companies:

 

Yes, these shortages and triaging are highly conducive to medication errors. Big Pharma plays a lot of games with pricing, and shortages which are often artificial is a main one. Another, which is related, is for hospitals to get kickbacks when they order high priced drugs, especially chemo agents, which can be in short supply. The dangers are real when physicians can’t order and nurses can’t administer the right medicine. It’s unethical practice in both professions. For people to sit in hospitals compounding by hand basic medicine is a crude throwback. Modern medicine requires adequate supplies of pre-measured drugs in the correct dosages. And where is the FDA which should be guarding our safety in this space? In bed with Pharma that’s where.

Yeah, good point! Where the heck is the Federal Drug Administration, supposedly a watchdog and regulatory agency of the US Government? Shouldn’t they be watching over this and both talking and swinging a big stick? How about some executive orders on this, President Obama?

Lieber has a recommendation, though it’s in the “pay me now or pay me later” vein. He says, let’s put clinical pharmacists in the mix right at the point of care:

I’m a big fan of clinical pharmacists who should round with doctors in hospitals and long term care making sure that patients get the right meds from the start. This cuts way down on errors, but is often considered an unnecessary expense.

Lieber also pointed me in the direction of my brothers and sisters at ACORN Canada, where they don’t have this problem. As Lieber says,

Truth to tell we’ll probably always lose this battle as long as all providers have to compete for and in formularies that rarely have complete stocks, a byproduct of our dysfunctional multi-payer system.

 

Maybe that’s not much comfort to us now, but it’s worth remembering that we don’t have to live – or die – this way.

Congress is the Undercard, the Real Fight for Healthcare is Still Corporate

imrs.phpNew Orleans   Recently the House of Representatives voted to repeal the Affordable Care Act for something like the 62nd time. They have now almost banned Obamacare from being funded as many times as they have barred ACORN! The more you understand about the continued tug of war behind the scene with employers, hospitals, drug companies, doctors, and insurance companies, the more you realize the political machinations on the front pages are window dressing, just part of the puppet show as the pols are pulled back and forth, up and down by the big players. Not to mix too many metaphors, but they are the weak under-card in this fight, while the heavyweights are the companies punching back and forth for advantage.

Of course we have the scandalous way that some drug companies are trying to play arbitrage with people’s health and hike the prices of rare drugs through the roof, regardless of the body count, not caring about anything other than making Wall Street happy. This situation is so grotesque that Congress may be forced to do something about it. We also have 800 pound gorilla setting on the examining table and continuing to pose the most serious problem, increasingly noticed, but left unattended, and that is the persistent problem that employers did not play fair on Obamacare and have largely squeezed through the loopholes, providing coverage in name only with deductibles, co-payments, and monthly bills all collectively so high that millions of lower waged workers are having to embrace the fines, because actual health coverage on offer is financially out of their reach and unreasonable.

A story in Modern Healthcare about the insurance companies’ tug of war was also depressing and enlightening particularly because the companies continue to play such a huge, daunting role in the exchanges, pricing, and coverage. CMS, the Obamacare administrator, is trying to nail down regulations for 2017, understanding that they need to lock as many backdoors as possible before the Obamas pack out of the White House. They proposed a rule that would require any health insurers to require all insurer networks “to include hospitals and doctors within certain travel times or distances from members. There would also be minimum provider-to-member ratios for some medical specialties. The CMS wanted to make sure consumers had access to enough healthcare providers as more insurers moved to narrow-network products.”

And, that’s when everything hit the fan. The CMS is basically trying to make sure that those who buy into care get a standard package across the country to meet their health needs. The insurers and some of their buddies in the state insurance commission offices, who are most frequently their captive audiences, in some states are crying like stuck pigs. They claim they want to tailor the networks to each state rather than have a federal cookie cutter approach, but the real deal is likely just making a deal that makes the big insurers they are used to currying happier to do business with them. Many hospitals and doctor groups line up with CMS on this one rather than being hammered even harder by the insurance bullies. According to Modern Healthcare some of them even advocate that “the CMS…go a step further and build network standards for appointment wait times.”

Meanwhile hospitals and doctors have their own issues. Doctors employed by hospitals in Oregon have even organized a union because of rough handling by the hospitals. Hospitals are being scored by CMS for service, recovery, and billing and some of the outfits that can’t make the mark are squealing about the scores rather than trying to do better on the tests. Meanwhile hospital requirements for providing affordable care to justify their tax exemptions, enjoyed by many, are still resisting and avoiding any accountability.

My best advice is to not take your eye off of the healthcare fight. It’s a long way from over yet, and any notion that we won, has been gone since the early rounds.

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Please enjoy Since You Been Gone by The Heavy.  Thanks to KABF.

Affordable Care is Simply Not Affordable

HealthCareGovSiteNew Orleans    The more studies that are done, the more time that passes, the more it seems impossible to get around the core issue embedded in the compromises of the Affordable Care Act: it’s just not affordable for lower income families.

The government’s projections for the current signup period are frankly modest at about nine million signups, rather than the twenty million projected several years ago for this period. Given the number of states that continue to boycott the expansion of Medicaid, which is where a lot of the gap for the uninsured continues, the budget offices are finding the predicted costs of Obamacare are about 20% lower than originally expected.

Furthermore, the mandate is not pushing enough people into insurance who don’t have it, particularly among lower waged workers. Studies are finding that at about $40,000 the maximum participation is achieved. Lower income families are simply paying the penalty, because it’s cheaper than the insurance bite.

Reports from employers are very depressing, though not surprising. Having represented big health care employers with sorry health plans for decades and seen the abysmal participation figures, we were hardly shocked, but still reading figures for huge food service companies with tens of thousands of employees and their reports of only 500 workers out of 25,000 actually signing up for employer insurance is ridiculous. The workers are blocked from access to ACA marketplace subsidies and cost sharing because they have opted out of corporate insurance, but they have opted out because the costs are too high and the benefits are too crummy with essentially catastrophic coverage and deductibles as high as $6000. Who can afford any of that on $10 or $15 per hour?

Increasingly, it seems clear we have a little bit of something for health insurance, but it’s only a bit better than nothing, and under the private company and corporate-centered regime, it’s too pricey and too paltry. We need real national health insurance, but that means a more significant governmental investment, and that is a bridge way past the level of political consensus.

It is also way past the level of public support, which fuels the continued opposition to Obamacare. When even the primary beneficiaries of the program among low-and-moderate income families are still priced out of the market, who is left to show the program the love it needs and deserves?

Half-stepping clearly has only gotten us halfway to where we need to be. We shouldn’t be surprised, but that doesn’t make it any easier to live with the disappointment or the continued perilous state of national health protection in the United States for low-and-moderate income families.

Using Telemedicine to Lower Cost and Expand Healthcare

01_philips_eICU_fullNew Orleans   Recently I had my annual physical. I’ve used the same doctor for a dozen years. She chatted and asked me about other family members that I’ve sent her way. She asked me a series of basic, rote questions, checked my pulse, pulled out the stethoscope to take a listen, and then sent me on back for blood and urine samples. All of these were simple procedures that frankly could have been done anywhere and with basic training by a whole range of people, and certainly by nurses or nurses’ aides. The clinic was part of the giant nonprofit Ochsner in Louisiana. They no longer have an x-ray machine there or the capacity for EKG’s so that’s another trip to a larger location, if I’m willing to take it. A doctor or other health professional could as easily review the tests and pronounce me “good to go” or “come back in.” I’m not whining, but once I step back and think about the process my own experience starts to outline part of the problem of the “volume” provision model for healthcare versus the “value” model touted for the future. It also brings to mind the crisis in rural health care facilities that cannot sustain the volume and are challenged to provide the value. Are there some other fixes for this problem?

One might entail a significant expansion of telemedicine. Extensive US-based pilots have established at the least that using telemedicine can link specialists in larger hospitals and cities with patients in rural areas. With equipment and training there are widely reported cases establishing success in matching health needs in other countries, like Latin America, with doctors and specialists in the USA. The Georgia-based Global Partnership for Telehealth touts on its website not only an extensive telemedicine network in that state but a project begun in Africa in 2014 that they claim is the first on the continent. Telemedicine embraces the full range of technical tools from smartphones to computers, and in some developed country experiments, even robots.

In the current clinic-hospital model in the USA where costs continue to be out of control and access continues to be frustratingly difficult, breaking the bricks-and-sticks model of healthcare and embracing access, tools, and outreach could be revolutionary. A telemedicine primer offer this insight:

Globally, the tipping point will be the care model realignment under healthcare reform, where payment is value-driven, not volume-driven. Care providers (hospitals, physicians, and ancillary caregivers — all part of the overall care team) are paid for results, and whether the venue is the office or a virtual visit at home will no longer matter. Quality is measured and payments made for meeting targets. Finally, there are incentives for preventive care — for keeping citizens healthy so there is a decrease in the number of physician’s office visits and hospital admissions.

“The ACO shall define processes to promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring and other such enabling technologies.”
(Federal Register, Vol. 76, No. 67, p. 19531, 4/7/11)

They are talking about the call and promise of the Affordable Care Act as the herald to reform and a different model of healthcare. The more you think about it, the more you wonder “Why not?” and “When?” I also start to wonder if the real opposition to Obamacare in the United States by some is their persistent toadying to all of the vested interests of industrial medicine and healthcare delivery systems that have been the standard for decades and need to have voices to protect their old models rather than embracing the change people deserve for universal quality care? The more we deal with the intransigence of hospitals providing even their required financial assistance plans, the clearer we have become about their unified resistance to change.

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Please enjoy a new arrangement of Natalie Merchant’s Carnival. 

The Problem of Obamacare Dropouts: Cost, Confusion, and Language

indexNew Orleans   We’re knocking on the door of another Affordable Care Act enrollment period beginning November 1st. There are ten million eligible people who have not yet received coverage of whom 40% or 4 million are lower income. Reports indicate that there are improvements in the website, but there is no indication that there is improvement in the outreach.

Having labored in the vineyards of the enrollment process, it is hard not to take note of the fact that as difficult as it is to enroll families in the program initially, it is also difficult to keep them enrolled. In 2015 after an announcement that 11.7 million had selected plan in the 2015 enrollment year, latest information from the end of June is that 9.9 million continue to be enrolled for a dropout rate of 15% and almost 2 million people. That hurts! Experts are saying the obvious culprits are costs, especially in all of the states that have not extended coverage and expanded Medicaid services, and confusion, which is part and parcel of the continuing fragmentation of the insurance marketplace and the myriad array of choices that confront families inexperienced with the already opaque health insurance industry.

One element of the confusion that may not be on everyone’s radar may be language and the foot dragging, half-hearted compliance with Title VI of the Civil Rights Act and its requirement that there be no discrimination in this area. Recently we participated in a conference call organized by the Seattle-based Alliance for a Just Society, and listening to the work from various groups around the United States, it is hard not to believe that inability to access the website and documents based on language has to be counted as part of the problem, and one that should be easy to correct. Of course seeming easy and being easy are different things, since many of us no doubt can remember that in the initial enrollment year the government was chronically unable to even make the enrollment website accessible in Spanish, much less other languages that are less ubiquitous in modern America.

The Civil Rights Act requires accommodation, either through accessible printed and on-line materials or by providing – and paying for – translation services. A fair number of languages are seen as the major dozen or so in the United States, but where there is sufficient density in a geographical area, ranging to more than 1000 individuals, the requirements stiffen. The proposed semi-official languages are based on a national grid not local issues, so local community organizations are having to step up to advocate and ensure that underserved populations facing language barriers get needed translation services to navigate the complexities of the health insurance mandate. There was talk of a new rule making process so that will have to be kept on the radar as well.

It is unlikely in the current climate of contention that the huge issues of costs and program expansion are going to get a quick fix, but lowering language barriers would seem to be a straight forward objective easily within our reach. What the heck, it’s already the law!

North Carolina is Showing the Way in Fighting for Rural Hospitals

Republican mayor of Belhaven, NC walks to Washington, DC to save Pungo Hospital and becomes a national voice for Medicaid expansion.

Republican mayor of Belhaven, NC walks to Washington, DC to save Pungo Hospital and becomes a national voice for Medicaid expansion.

New Orleans   For all of the continuing polarization in Congress over Obama’s Affordable Care Act and the “last stand in the hospital door” strategy of one Republican governor after another, there are realities in the heartland of the Republican base that some of the politicians are continuing to miss from their sky high perches as they survey the battleground. A fight in North Carolina by a Republican mayor, Adam O’Neal, in small town Bellhaven in the eastern part of the state, to save his town’s rural hospital should be sending a message about the political price the resistors will pay with their base voters, even if they are missing the life-and-death message that adequate and accessible health care represents. As the Mayor has made clear, health care is an issue that defines bipartisanship because both Republicans and Democrats get sick.

The private healthcare corporation Vident closed the local hospital, Pungo that served Bellhaven. Since the viability of so many hospitals was based on expanding health care coverage not restricting it, Pungo is just one of many early warning signs of what could become a widespread calamity. As noted in the Daily Kos, the Rural Health Association counts 283 rural hospitals as on their own kind of deathwatch to survive.

To save the hospital, Mayor O’Neal pulled pages from the history of the civil rights struggle and joined hands with contemporary activists. They hit the streets and marched to the state capitol in Raleigh to ask for a modification of the certification to allow the hospital to reopen. They also marched to Washington totaling hundreds of miles. They were joined by Rev. William Barber and his Moral Majority who have been central in recent struggles in North Carolina and beyond. They were also joined by former civil rights activists, like the legendary Bob Zellner from early SNCC and Freedom Rides fame. I can remember reaching out for Zellner in 1976 when we opened ACORN’s office in New Orleans and asking for help then. He was “retired” he said and working for an industrial plant, Godcheaux’s sugar refinery, while living in New Orleans and trying to find some calm after his years of activism. I doubt if he had really retired then, but there’s no doubt that he is back in action now. It was good to read that Zellner had joined this fight in North Carolina and walked with Mayor O’Neal every step of the 238-mile trek to Washington.

Does this kind of bipartisanship work even in the rock-ribbed rural communities of the South that have become the bastion of the Republican voting strength? Can these dusted off tactics still make a difference?

It seems so as Mayor O’Neal tweeted at the end of September:

Great news!!! NC Legislature changes Cert. Of Need law to allow our hospital to reopen. Votes..House 102-8 and Senate 44-0. #savepungo

Seems like part of the message from North Carolina is that we may need to build a movement on health care access for all to finally get the job done here.