The Eight Big Problems with Warren’s Medicare-for-All Plan

Image result for The Eight Big Problems with Warren’s Medicare-for-All Plan images

Source: The Washington Post

Sen. Elizabeth Warren (D-Mass.) released her spending plan to finance Medicare-for-all, a single-payer health-care scheme that would eliminate private insurance. The Post reports:

—The plan is designed to hit corporations and the wealthy, including a provision requiring companies to send most of the funds they currently spend on employee health contributions to the federal government. It also expands Warren’s signature wealth tax proposal, cuts military spending and takes advantage of what she says would be significant savings from eliminating private insurance’s vast bureaucracy….

—The proposal comes on top of roughly $5 trillion in new taxes that Warren had already advocated to cover a range of new programs, including through a levy on those with more than $50 million in assets. It doubles down on Warren’s strategy of winning the Democratic nomination by consolidating support from the party’s liberal wing, rather than reaching out to more centrist Democrats.

The plan, as one would expect, was roundly criticized by former vice president Joe Biden’s campaign, which put out a statement that said it “hinges not just on a giant middle class tax hike and the elimination of all private health insurance, but also on a complete revamping of defense, immigration, and overall tax policy all at once in order to pay for it — a hard truth that underscores why candidates need to be straight with the American people about what they’re proposing.”

About the only thing all the Democratic candidates might agree upon is that this is the most sweeping proposal we have seen from any major-party candidate, one which would revamp the entire federal budget and the health care of every American.

There are (at least) eight problems she will have to contend with:

First, her plan raises a purported $20.5 trillion, around $10 trillion less than independent cost estimates for the plan from progressive groups such as the Urban Institute. Even Sen. Bernie Sanders (I-Vt.) concedes it would cost $30 trillion or more. Perhaps voters’ eyes will glaze over, and they will decide that everyone can find an economist to justify anything, but others might see the sort of standard sleight of hand — trillions in administrative savings! stronger tax enforcement! — as confirmation that it really is impossible to come up with a plan this extensive and not further burden the middle class.

Moderate Sen. Michael Bennet (D-Colo.) blasted Warren’s plan in a written statement. “Voters are sick and tired of politicians promising them things that they know they can’t deliver,” he said. “Warren’s new numbers are simply not believable, and have been contradicted by experts. Regardless of whether it’s $21 trillion or $31 trillion, this isn’t going to happen, and the American people need health care.”

Second, there is not much of a justification as to why we need this when Affordable Care Act premiums are decreasing and other issues (e.g. extending coverage, premium costs) can be addressed through much cheaper proposals, such as the public option. (As Biden’s campaign put it, “Most voters want to protect and strengthen the Affordable Care Act.”)

Third, it is pretty clear to all but the horribly naive that this is never going to happen. An $800 billion cut in defense? What’s the justification for that, and what national security concerns does it raise? What moderate Democrat is going to sign on to this? The bigger and more complicated it is, the more obvious it becomes a fantasy — one that could prevent more modest and achievable ends such as prescription drug cost containment. Warren is relying, for example, on a wholesale immigration reform plan (something that frankly does not seem politically attainable) to generate hundreds of billions of dollars (above and beyond revenue going to state and local governments). At some point, this fails the straight-face test.

Fourth, eliminating all private insurance has real-world impacts on health-care providers. The New York Times reports: “Ms. Warren’s plan would put substantial downward pressure on payments to hospitals, doctors and pharmaceutical companies. … Payments to hospitals would be 10 percent higher on average than what Medicare pays now, a rate that would make some hospitals whole but would lead to big reductions for others. She would reduce doctors’ pay to the prices Medicare pays now, with additional reductions for specialists, and small increases to doctors who provide primary care.” Do rural hospitals survive by protecting against the uninsured or go bust without the much higher reimbursement rates that private insurers provide? If doctors’ salaries get chopped, how will this affect time with patients and the availability of specialists?

Fifth, her proposal tests the limits of her electability argument. The Times observes: “Although she is not proposing broad tax increases on individuals, her proposal will still allow Republicans to portray her as a tax-and-spend liberal who wants to dramatically expand the role of the federal government while abolishing private health insurance. Her plan’s $20.5 trillion price tag is equal to roughly one-third of what the federal government is currently projected to spend over the next decade in total.” Simply put, this really is the sort of plan President Trump would use to scare voters into sticking with him rather than plunging into a “socialist” abyss.

Sixth, Warren winds up handing the health-care issue right back to the Republicans. Andy Slavitt, who headed the Medicare and Medicaid trust funds under President Barack Obama, tells me: “In my view, 90 percent of the Democratic focus on health care should be on Trump’s lawsuit and his other plans to get rid of the ACA and pre-existing condition protections.” He suggests, “The other 10 percent can be on policy differences between the candidates on how they would ideally make universal coverage happen.” He warns, “Doing the reverse is like spending 90 percent of the time on environmental issues debating the Paris Accord vs. the Green New Deal instead of spending 90 percent of the time remembering they are running against a climate denier.”

Seventh, Warren doesn’t seem to consider the downsides from slashed reimbursement (nurses pay?), elimination of private insurance companies (jobs for all those white-collar workers?) and/or mammoth tax hikes (growth? jobs?). This embodies one of the major criticisms of the super-progressive wing of the Democratic Party: blind faith in centralized federal government with little or no regard for unintended consequences.

Eighth, the plan does damage to her brand. Warren’s plan is a reminder of how far to the left of the rest of the field she really is. The notion that she is a “compromise” between Sanders and center-left candidates will be harder to sustain. Moreover, she was supposed to be the straight-shooter, the candid progressive who could tip the scales in favor of working-class Americans. There are plenty of voters (including more moderate African American voters with whom she has struggled to connect) who might regard this as akin to Trump’s magical health-care plan (better! cheaper!) or other snake oil peddled by politicians. People have become a bit too savvy to think you can have everything for nothing.

Warren will have ample opportunity to defend her plan at the next debate. In the meantime, Democratic voters can mull over whether this makes it easier or harder to defeat Trump.

Elizabeth Warren’s ‘Medicare for All’ Math

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Source: The New York Times

She thinks a single-payer health care system can save more than other analysts think. Here’s where she says she’ll get the money to pay for it.

Elizabeth Warren’s “Medicare for all” proposal would make substantial shifts to how the United States pays for its health care system. She would eliminate most other forms of coverage, including private insurance, and provide all Americans with a generous government-run plan.

To calculate its cost, she has modified estimates from the Urban Institute, a Washington research group that has assessed the legislative proposal she is endorsing.

To pay for it, she has proposed large new taxes, transfer payments and some cuts to government spending. Altogether, her campaign believes health spending under Medicare for all will cost $52 trillion over the next decade, with about half shifting from other sources onto the federal budget.

The Warren plan includes several key assumptions, including starkly lower prescription drug prices, minimal administrative spending and health care costs that grow at a significantly slower pace.

Warren backers describe these cuts as ambitious and assertive, contending that the American health system — which has the highest prices in the developed world — could weather the change. Other health care experts call the ideas unrealistic, given the revenue that American doctors, hospitals and drug companies have become accustomed to earning.

The key question in this debate is, how quickly can the United States tamp down its sky-high health care prices?

“The whole point of this analysis, which took weeks and was done with real discipline, was to come up with, what is realistic?” said Don Berwick, a co-author of an economic analysis of the Warren plan, and former administrator of the Centers for Medicare and Medicaid under President Barack Obama. “I think they’re achievable and, for those who are critical, please show me yours.”

Here’s a summary of what Ms. Warren has proposed on either side of the ledger.

To reduce the plan’s costs:

• Change the way Medicare pays for certain types of hospital stays, such as paying a package rate rather than different fees for surgical services, and paying doctors in hospital-owned practices the lower prices paid to those in private practices. ($2.3 trillion)

• Assume that the Medicare for all program itself can operate very leanly. The Urban Institute estimated that Medicare would devote about 6 percent of its health budget on administrators to decide what and how Medicare would pay for things, and to prevent fraud. In Ms. Warren’s plan, that rate is 2.3 percent. ($1.8 trillion)

• Assume very aggressive drug discounts. Ms. Warren believes a government system will be able to reduce spending on drugs substantially, including lowering the prices of branded prescription drugs by 70 percent. ($1.7 trillion)

• Assume slower growth in health spending over time. The federal government now thinks health spending will increase by 5.5 percent a year; the Warren campaign assumes 3.9 percent growth under Medicare for all, closer to the rate of growth in gross domestic product. ($1.1 trillion)

• Assume lower payments to hospitals. The campaign believes hospitals can be paid around 110 percent of what they are currently paid by Medicare, a number that would cause some hospitals to operate at a loss. Currently, private health insurers often pay a lot more to hospitals than Medicare for similar procedures. ($600 billion)

To pay for the plan:

• Employers would be required to pay fees to the federal government, equivalent to 98 percent of what they now spend on their employees’ health care. Some companies would be exempt, and companies with unionized work forces would be able to lower this payment if they increased workers’ wages. Currently, companies vary greatly in the cost and generosity of their health benefits, so this fee would vary substantially by firm. ($8.8 trillion)

• States and local governments would be required to make payments to the federal government, similar to what they currently spend on government employee benefits and their share of Medicaid expenses. ($6.1 trillion)

• Corporate taxation would be increased. ($2.9 trillion)

• Tax collections would increase through improvements to I.R.S. enforcement, which Ms. Warren believes could raise a lot of money. ($2.3 trillion)

• The top 1 percent of individual earners would pay new taxes on their capital gains; they would pay taxes on increases in investment value annually, instead of waiting until assets are sold. ($2 trillion)

• Income tax collections would increase, since workers would no longer pay part of their salaries for insurance premiums, which are not taxed now. ($1.4 trillion)

• Billionaires would pay a higher wealth tax than the rate Ms. Warren has previously proposed: 6 percent, up from 3 percent. ($1 trillion)

• A new financial transactions tax would be imposed on stock trades. ($800 billion)

• Pentagon spending from an overseas contingency fund, often criticized as a slush fund, would be eliminated. ($800 billion)

• Income earned by immigrants, following the passage of her immigration overhaul plan, would provide new tax revenues. ($400 billion)

• A risk fee on the liabilities of banks with more than $50 billion in assets would be introduced. ($100 billion)

Physician Groups Play Hardball Opposition Against Surprise Billing Fixes

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Source: BenefitsPRO

Congress may be attempting to take action against surprise bills that prove to be the financial undoing of so many consumers, but not if physician groups have anything to say about it.

And they’re saying as much as they can, as loudly as they can, according to a report in Modern Healthcare. In fact, according to congressional staff, physician groups are willing to make the entire effort against surprise billing go down in flames rather than find themselves on the receiving end of efforts to curtail how much money they can make.

According to Modern Healthcare, it’s not just physician groups’ public relations and advertising that’s pushing back hard against any sort of action. There’s also lobbying and the influx of dark money, too, to ads against lawmakers, particularly vulnerable senators, in their home districts. And the American Hospital Association is asking members to “go directly to their representatives and senators to lobby against the benchmark proposal.”

According to one congressional aide close to the negotiations, “it’s not a matter of tweaks to get providers to stand down, it’s that provider groups don’t want to see a solution here. They want the status quo. They’ve charted out where Congress could end up, and they are ready for the whole thing to come down. For them, surprise billing can stay in the mix.”

Another staffer said that the massive effort is causing policy aides to doubt whether providers actually want any action at all. That staffer is quoted saying, “Our question is, what happened to their commitment to protecting the patients? It shows just how big of a cash cow this practice is, that they’re willing to pour millions of dollars into fighting these bills.”

Provider groups deny that, with Chip Kahn, CEO of the Federation of American Hospitals, which represents for-profit hospitals, quoted saying, “We want to see legislation. It’s a problem we can’t solve ourselves—I wish we could—and we need legislation to ensure patients don’t suffer from sticker shock, that their copayments are reasonable and within the bounds of their coverage.”

But neither the proposed “benchmark” solutions proposed by Senate and House health committee leaders, nor a limited arbitration proposal, are making much headway at present, with efforts focused in apparent ploy to keep votes from occurring at all. The benchmarking proposals are being characterized in ads and other campaigns as “rate-setting,” and efforts focused on Democrats say that benchmarking could “undercut the health safety net.”

Even lobbyists are somewhat concerned about the turn the battle is taking, with the report quoting one who said, “The fact that industry on both sides could scare Congress into inaction on an issue that is financially ruining Americans through no fault of their own is unconscionable.” That provider lobbyist, the report adds, “wants a ‘split the baby’ policy that ‘doesn’t destabilize the relationship between providers and payers.’”

“What we’ve seen (from industry) is, ‘First, protect me financially. And to the extent we can then take patients out of the middle, that’s great,” Shawn Gremminger, senior director of federal relations for the consumer advocacy group Families USA told Modern Healthcare.

Millions and millions are being spent on this August push against surprise billing legislation. The losers are sure to be consumers.

Paging More Doctors: California’s Worsening Physician Shortage

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Source: CalMatters

In a northern California valley stretching under miles of bright blue sky between two snowy volcanic peaks, Mt. Lassen and Mt. Shasta, Daniel Dahle is known as a godsend, a friend, a lifesaver, a companion until the end.

For more than three decades, “Doc” Dahle has been the physician in Bieber, serving a region about the size of five smaller U.S. states. When he started, he was one of five doctors in the region.  Today he is joined by only one other full-time physician.

At 71, Dahle has delayed retirement for years — waiting for someone to take his place.

“I was going to retire November 8th of last year; it was going to be a third of a century,” he said. “It’s tough to recruit young new vibrant family practitioners or internists or pediatricians to come up here.”

Unfortunately, Dahle’s situation is not unique.

California is facing a growing shortage of primary care physicians, one that is already afflicting  rural areas and low-income inner city areas, and is forecasted to impact millions of people within ten years. Not enough newly minted doctors are going into primary care, and a third of the doctors in the state are over 55 and looking to retire soon, according to a study by the Healthforce Center at UC-San Francisco.

That means by 2030, the state is going to be in dire need of physicians. Studies show the state could be down by as many as 10,000 primary care clinicians, including nurse practitioners and physician assistants. Some areas — the Central Valley, Central Coast and Southern Border region — will be hit especially hard. So too will be remote rural and inner-city residents, communities of color, the elderly, those with mental illness or addiction, and those without health coverage.

Many people will be forced to wait longer for doctor visits, travel longer distances to see someone, and may become so discouraged they forego preventative care and even care for chronic, serious disease until emergency treatment is necessary.

The federal government’s Council on Graduate Medical Education recommends 60 to 80 primary care doctors per 100,000 people. Statewide in California, the number already is down to just 50 per 100,000 — and in some places it’s even lower:  down to 35 in the Inland Empire and 39 in the San Joaquin Valley, according to a report from The Future Health Workforce Commision.

Among the causes of the physician shortage:

  • High student loan debt induces medical students to go into specialty care, which pays more than primary care — currently only 36 percent of doctors provide primary care.
  • Low Medi-Cal reimbursement rates for primary care drive doctors away from low-income areas and primary care.
  • Even primary care physicians often shy away from rural areas, opting instead to practice in big cities near medical centers and specialists.
  • Medical school students don’t reflect the diversity of the state, which also influences where new doctors practice — and where they don’t.

UC Davis Medical School Dean of Admissions and Outreach Mark Henderson said his medical school is focused on trying to eliminate the shortage between Davis and the Oregon border.

At Davis, where there is a focus on primary and rural care, about half of graduates go into primary care. But at most other medical schools, that percentage is 20 to 30 percent and it’s not enough.

“We still don’t take enough students from (rural and underserved) communities that will have a deep desire to want to go back to the community,” Henderson said. “You have to take a different type of a student, you can’t take the same old usual suspect.”

New doctors “take these specialty areas that pay higher, and that leaves us with a shortage of primary care physicians including pediatricians, internists, family practice physicians and OB/GYNs,” said John Baackes, CEO of LA Care Health Plan, which has the largest number of Medi-Cal members in the state.

He said in rural areas, veteran doctors who are solo practitioners are having a hard time bringing in new doctors to take over.

“Young doctors are increasingly going to salaried positions” at institutions such as Kaiser, said Baackes.

In low-income areas, a different deterrent comes into play. Dismal Medi-Cal reimbursement rates  keep some students out of primary care and repels some primary medical graduates, said Elaine Batchlor, CEO of MLK Jr. Community Hospital in South Los Angeles.

“It’s difficult for physicians to support a practice in that environment and organized medical groups are not attracted to the community because of low (Medi-Cal) reimbursements,” she said.

The California Future Health Workforce Commission — made up of business, elected and health care leaders — released a report earlier this year warning of the looming shortage of health workers to meet the needs of the “growing, aging and increasingly diverse population.”

“If we’re looking to the future in a state where we have everyone covered, we can’t do it with the workforce we have and we are not doing it well now in many places,” said Assemblyman Jim Wood, a Santa Rosa Democrat who was part of the commission.

The commission found that already 7 million Californians live in federally designated Health Professional Shortage Areas because they lack primary care physicians, dentists and mental health professionals. Most are in the Inland Empire, part of Los Angeles, the San Joaquin Valley and in remote parts of the state, like where Dahle practices.

He tries to assist the next generation of providers: He takes physician-assistant trainees nearly year-round from the University of Iowa, where one of his former physician assistants runs a program.

“These guys are smarter than me already,” Dahle said. “Actually, we teach each other. We teach them the art of medicine and they teach me all the new science of medicine. It works out really good.”

The trainees live with Dahle in his log cabin on 160 acres just outside of town, down a 5-mile dirt road. His dog Clint, a Pyrenees he rescued, eagerly awaits him each afternoon.

Over the course of two recent days, Dahle treated patients with hyperthyroidism, migraines, diabetes, swollen lymph nodes, chronic ear infections, knee pain and constant nausea, and performed a skin biopsy to test for cancer.

Inevitably, country doctors have to be able to do more with less — and be willing to live far from urbanity.

“The younger generation of providers, they don’t have the clinical skills or know-how. They’re not trained the same as Dr. Dahle,” said Shannon Gerig, CEO of Mountain Valleys Health Centers, which operates seven centers across 6,000 square miles in the northern part of California including in Bieber, where Dahle is the lone doctor at that center. “It’s a scary thing for them to come out and be so remote, and know that they are going to be solo a lot, and they are going to be depended on by the mid-level staff…and they don’t have specialty (doctors) around them.”

Dahle has birthed thousands of babies, diagnosed cancers, done skin biopsies, assisted in minor surgeries, attended to patients on their deathbeds and occasionally rushed out into the forest or to a ranch to treat those whacked by a falling hay bale, a downed tree or a stubborn horse. He once finished a pelvic exam by flashflight because the power went out, did minor toe surgery in his office while taking direction from a surgeon on the phone, and jumped in a helicopter transport to accompany a patient with a broken neck enroute to a far-away trauma center.

He also works in the Fall River Mills’ emergency room one 24-hour shift a week, and makes hospital rounds first thing most days.

One recent morning, he greeted and joked with Wilma Chesbro, 88, who used to be an operating room scrub nurse with Dahle, and now is a patient in long-term care.

She grasped his hand, reminding him that when they first met decades ago she thought he was a “yokel” because he’s from a local town. But Chesbroe cried and lost her breath every time she tried to express just how much Dahle meant to her.

“He’s brilliant,” she said through her tears. “But he doesn’t show it. I have so much respect for him.”

Earlier this year he was named Country Doctor of the Year by AMN Healthcare, the largest health staffing agency in the country. The welcome sign to Bieber announces it has 510 residents; the health centers there cater to about 17,000 residents across several towns.

Much of the area is designated “frontier” by the federal government because so few people live there. Beiber has one motel, and passersby who blink might miss the Big Valley Market, where Dahle gets a maple bar for breakfast most days. Fields and ranches dot the wide-open valley, giving way to forests and rising peaks. The nearest Safeway grocery store is in Burney, 40 miles away. The isolation has made some prospective physicians make a U-turn and drive away, without ever stepping foot in the clinic for their scheduled interview. Many have told Dahle their spouse or partner saw the town and said “no way.”

Doc Dahle grew up in nearby Tulelake, the son of a potato farmer. He was drafted from college to Vietnam. Later he finished college at Oregon State, then was turned down for medical school there four times before he was accepted at the University of Rochester. When he graduated he returned to northern California to practice. His cousin is Brian Dahle, a GOP state senator who represents the area.

But Doc Dahle may just be the better known of the two. Thousands of  residents in these parts go out of their way to see him.

“Patients are fine waiting, because they know when they see Dr. Dahle he will take whatever amount of time he needs to talk with them, to get the care they need. I guess you’d call it old school,” said Gerig, who was Dahle’s patient before becoming his boss.

She began working as a registered nurse with Dahle 25 years ago, and he delivered her three babies via C-section. It seems everyone has a connection like that. At a local bar, a group of guys ticked off what Dahle has done for them — one called him a “lifesaver” for diagnosing a 99 percent carotid artery blockage.

This is why Dahle is fired up about finding his replacement. This is his “family,” he said.

He’s got his eye on a young doctor couple out of Davis. But there is one hitch. The local hospital in Fall River Mills, just about 25 miles up the road, closed its obstetrics unit, forcing pregnant women go at least a hundred miles to Redding or Shasta to deliver.

Unless the hospital reopens that wing, Dahle may not be able to land the couple despite their interest. The husband is in primary care and has already filled in at Dahle’s clinic, but the wife, who is from Fall River Mills, is training to be an OB-GYN.

“We’re not going to be able to recruit these homegrown kids to come back here without something changing,” said Dahle. “We have got to do this for our community.”

That’s the reason he’s sticking around, for the community and to work on bringing the couple back home.

“I love my job,” said Dahle, who is twice divorced, acknowledging it was always hard to stay married because he is wedded to medicine. “I have never regretted ever being a doctor.  Everyday I go to work and say that I help somebody.”

If he ever does retire, he plans to scuba dive, hunt rocks and travel.

But he’ll still probably have lunch on Tuesdays at the Roundup Bar, just like he does now for the hot dog special. Sometimes, if someone sees Dahle heading over, they’ll call the bar and buy Dahle’s beer.

“He’s a staple in our community. He holds us all together,” said bar owner Scott Johnson. “This is like his second office. He comes here and everyone gathers round and asks him questions to avoid a doctor visit.”

GOP, Dems Offer Compromise to Reduce Drug Costs for Seniors

Image result for GOP, Dems Offer Compromise to Reduce Drug Costs for Seniors imagesSource: The New York Times

Two veteran senators — a Republican and a Democrat — unveiled compromise legislation Tuesday to reduce prescription drug costs for millions of Medicare recipients, while saving money for federal and state health care programs serving seniors and low-income people.

Iowa Republican Chuck Grassley and Oregon Democrat Ron Wyden said the bill would for the first time limit drug copays for people with Medicare’s “Part D” prescription plan , by capping patients’ out-of-pocket costs at $3,100 a year starting in 2022. They’re hoping to have it ready soon for votes on the Senate floor.

The legislation would also require drugmakers to pay a price-hike penalty to Medicare if the cost of their medications goes up faster than inflation. Drugs purchased through a pharmacy as well as those administered in doctors’ offices would be covered by the new inflation rebates.

Political compromises over health care are rare these days. The bill reflects efforts by lawmakers of both parties to move beyond the rancorous debates over the Obama-era Affordable Care Act and focus on ways to lower costs for people with health insurance. Separate legislation to address “surprise medical bills” has already cleared the Senate Health, Education, Labor and Pensions committee.

The senators said preliminary estimates from the Congressional Budget Office show that the Medicare program would save $85 billion over 10 years, while seniors would save $27 billion in out-of-pocket costs over the same period, and $5 billion from slightly lower premiums. The government would save $15 billion from projected Medicaid costs.

CBO also projected that Medicare’s inflation rebate would have ripple effects, leading to prescription drug savings for private insurance plans sponsored by employers or purchased directly by consumers.

The senators announced a Thursday vote on the package by the Finance Committee, which oversees Medicare and Medicaid. Grassley is the panel’s chairman, while Wyden serves as the senior Democrat.

“Pharmaceutical companies play a vital role in creating new and innovative medicines that save and improve the quality of millions of American lives, but that doesn’t help Americans who can’t afford them,” Grassley and Wyden said in a joint statement. “This legislation shows that no industry is above accountability.”

The White House encouraged the Senate negotiations, and spokesman Judd Deere said the Trump administration stands ready to “work with senators to ensure this proposal moves forward and advances the president’s priority of lowering drug prices.”

Democrats controlling the House want to go farther by granting Medicare legal authority to directly negotiate prices with pharmaceutical companies. Direct negotiations are seen as a nonstarter in the Republican-controlled Senate, but the bill’s drug price inflation penalty may yet find support among Democrats in the House.

Grassley’s office said the bill will force drugmakers and insurers to take greater responsibility for keeping Medicare prescription prices in line, instead of foisting increases on taxpayers and beneficiaries.

The lack of a cap on out-of-pocket costs for Medicare’s popular prescription benefit has left some beneficiaries with bills rivaling a mortgage payment. That’s because with Medicare’s current protection for catastrophic costs, patients taking very expensive drugs are still responsible for 5% of the cost, with no dollar limit on what they pay. For example, 5% of a drug that costs $200,000 a year works out to $10,000.

The Grassley-Wyden bill does not directly address the problem of high launch prices for new medications, but its inflation rebates could put the brakes on price hikes for mainstay drugs such as insulin.

The bill drew a rebuke from the pharmaceutical industry, while AARP praised Grassley and Wyden.

Other provisions of the legislation would:

— Change an arcane Medicaid payment formula through which drugmakers can avoid paying rebates on certain drugs, depending on fluctuations in prices.

— Allow state Medicaid programs to pay for expensive gene therapy treatments on the installment plan, spreading out the costs over several years.

— Require drugmakers to provide public justification for new high cost drugs or steep hikes in the prices of existing medications.

— Require middlemen known as pharmacy benefit managers to disclose details of the discounts they are negotiating and how much they are passing on to consumers. The benefit managers negotiate with pharmaceutical companies on behalf of insurers and consumers.

— Provide doctors with new computer tools they can use to estimate out-of-pocket medication costs for patients with Medicare.

Doctor Alexa Will See You Now: Is Amazon Primed To Come To Your Rescue?

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Source: Kaiser Health News

Now that it’s upending the way you play music, cook, shop, hear the news and check the weather, the friendly voice emanating from your Amazon Alexa-enabled smart speaker is poised to wriggle its way into all things health care.

Amazon has big ambitions for its devices. It thinks Alexa, the virtual assistant inside them, could help doctors diagnose mental illness, autism, concussions and Parkinson’s disease. It even hopes Alexa will detect when you’re having a heart attack.

At present, Alexa can perform a handful of health care-related tasks: “She” can track blood glucose levels, describe symptoms, access post-surgical care instructions, monitor home prescription deliveries and make same-day appointments at the nearest urgent care center.

Amazon has partnered with numerous health care companies, including several in California, to let consumers and employees use Alexa for health care purposes. Workers at Cigna Corp. can manage their health improvement goals and earn wellness incentives with Alexa. And Alexa helps people who use Omron Healthcare’s blood pressure monitor, HeartGuide, track their readings.

But a flood of new opportunities are emerging since Alexa won permission to use protected patient health records controlled under the U.S. privacy law known as the Health Insurance Portability and Accountability Act (HIPAA).

Before, Alexa had been limited to providing generic responses about medical conditions. Now that it can transmit private patient information, Amazon has extended its Alexa Skills Kit, the software development tools used to add functions. Soon, the virtual assistant will be able to send and receive individualized patient records, allowing health care companies to create services for consumers to use at home.

Amazon’s efforts in this domain are important because, with its 100 million smart devices in use worldwide, it could radically change the way consumers get health information and even treatment — and not just tech-savvy consumers. Analysts expect 55% of U.S. households will have smart speakers by 2022.

Some of Alexa’s new skills depend on a little-understood feature of the devices: They listen to every sound around them. They have to in order to be ready to respond to a request, like “Alexa, how many tablespoons in a half-pint?” or “Put carrots on the shopping list.”

University of Washington researchers recently published a study in which they taught Alexa and two other devices — an iPhone 5s and a Samsung Galaxy S4 — to listen for so-called agonal breathing, the distinct gasping sounds that are an early warning sign in about half of all cardiac arrests. These devices correctly identified agonal breathing in 97% of instances, while registering a false positive only 0.2% of the time.

Earlier research had shown that a machine learning system could recognize cardiac arrest during 911 emergency calls more accurately and far faster than human dispatchers could.

Amazon, which declined to comment for this article, holds a patent on an acoustic technology that recognizes and could act on significant audio interruptions. Combined with patented technology from the University of Washington that differentiates coughs and sneezes from other background noises, for example, Alexa could discern when someone is ill and suggest solutions.

Because Amazon also holds patents on monitoring blood flow and heart ratethrough an Alexa-enabled camera, Alexa could send vitals to a doctor’s office before you head to your appointment and continue to monitor your condition after you get home.

“It opens possibilities to deliver care at a distance,” said Dr. Sandhya Pruthi, lead investigator for several breast cancer prevention trials at the Mayo Clinic, which has been on the front lines of using voice assistants in health care. “Think about people living in small towns who aren’t always getting access to care and knowing when to get health care,” she said. “Could this be an opportunity, if someone had symptoms, to say, ‘It’s time for this to get checked out’?”

A growing number of clinics, hospitals, home health care providers and insurers have begun experimenting with products using Alexa:

  • Livongo, a Mountain View, Calif.-based startup focused on managing chronic diseases, sells an Alexa-connected blood glucose monitor that can help diabetes patients track their condition.
  • Home health care provider Libertana Home Health, based in Sherman Oaks, Calif., created an Alexa skill that lets elderly or frail residents connect with caregivers, set up reminders about medications, report their weight and blood pressure, and schedule appointments.
  • Cedars-Sinai Medical Center in Los Angeles put Amazon devices loaded with a plug-in called Aiva into more than 100 rooms to connect patients with staff and to provide hands-free television controls. Unlike a static call button, the voice-controlled device can tell nurses why a patient needs help and can then tell the patient the status of their request.
  • Boston Children’s Hospital, which offered the first Alexa health care software with an educational tool called Kids MD, now uses Alexa to share post-surgical recovery data between a patient’s home and the hospital.

Many medical technology companies are tantalized by the possibilities offered by Alexa and similar technologies for an aging population. A wearable device could transmit information about falls or an uneven gait. Alexa could potentially combat loneliness. It is learning how to make conversation.

“Alexa can couple a practical interaction around health care with an interaction that can engage the patient, even delight the patient,” said elder care advocate Laurie Orlov.

It and other voice assistants might also help bring some relief to doctors and other medical practitioners who commonly complain that entering medical information into electronic health records is too time-consuming and detracts from effective interactions with patients.

This technology could work in the background to take notes on doctor-patient meetings, even suggesting possible treatments. Several startup companies are working on such applications.

One such company is Suki, based in Redwood City, Calif., which bills itself as “Alexa for doctors.” Its artificial intelligence software listens in on interactions between doctors and patients to write up medical notes automatically.

Amazon devices will need to excel at conversational artificial intelligence, capable of relating an earlier phrase to a subsequent one, if it is to remain dominant in homes.

In a 2018 interview on Amazon’s corporate blog, Rohit Prasad, a company vice president who is head scientist for Amazon Alexa, described Alexa’s anticipated evolution using “federated learning” that lets algorithms make themselves smarter by incorporating input from a wide variety of sources.

“With these advances, we will see Alexa become more contextually aware in how she recognizes, understands and responds to requests from users,” Prasad said.

Medical Group Deals Face Growing Antitrust Scrutiny as Price Worries Rise

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Source:

Recent actions by antitrust enforcers and courts to block or regulate purchases of physician practices by hospitals and insurers may signal increasing scrutiny for such deals as policymakers intensify their focus on boosting competition to reduce healthcare prices.

Last month, the Federal Trade Commission announced a settlement with UnitedHealth Group and DaVita unwinding United’s acquisition of DaVita Medical Group’s Las Vegas operations.

At the same time, Colorado Attorney General Phil Weiser separately reached a deal imposing conditions on UnitedHealth’s acquisition of DaVita’s physician groups in Colorado Springs.

Also in June, the 8th U.S. Circuit Court of Appeals upheld a District Court ruling blocking Sanford Health’s proposed 2015 acquisition of the multispecialty Mid Dakota Clinic in the Bismarck, N.D., area. That antitrust case originally was filed by the FTC and North Dakota Attorney General Wayne Stenehjem in 2017.

And in May, Washington Attorney General Bob Ferguson settled an antitrust lawsuit with CHI Franciscan setting conditions on the health system’s 2016 affiliation with the Doctors Clinic, a multispecialty group, and its purchase of WestSound Orthopaedics, both in Kitsap County. CHI Franciscan will pay up to $2.5 million, distributed to other healthcare organizations to increase access to care.

The cases represent the most significant antitrust developments involving physician acquisitions since federal and state antitrust enforcers won a 9th U.S. Circuit Court of Appeals ruling in 2015 upholding a lower-court decision forcing Idaho’s St. Luke’s Health System to unwind its 2012 acquisition of Saltzer Medical Group.

The agreements with UnitedHealth in Nevada and Colorado show a new willingness by federal and state antitrust enforcers to use seldom-cited vertical merger theory. Under that theory, acquisitions of physician groups by insurers or hospitals may foreclose competition by making it more difficult or costly for rivals to obtain physician services.

“I am concerned about the state of consolidation,” Weiser said in an interview. “Healthcare costs in Colorado have risen at an alarming rate. Protecting competition needs to be a central part of our strategy to provide affordable and quality healthcare.”

These recent antitrust actions come as concerns mount over the growing consolidation of hospitals and physician practices and the impact on prices and total health spending. Sixty-five percent of metropolitan statistical areas are highly concentrated for specialist physicians, while 39% are highly concentrated for primary-care doctors, according to Martin Gaynor, a health economist at Carnegie Mellon University.

Hospital acquisitions of physician practices have led to higher prices and health spending, researchers have found. Average outpatient physician prices in 2014 ranged from 35% to 63% higher, depending on physician specialty, in highly concentrated California markets compared with less-concentrated markets, according to a 2018 study by researchers at the University of California at Berkeley. The link between physician market concentration and prices is similar across the country, experts say.

That’s why some elected officials and antitrust attorneys say it’s past time to step up oversight of physician practice acquisitions by hospitals, insurers and private-equity firms. These deals traditionally have received less scrutiny than hospital and insurance mergers, partly because they are smaller transactions that federal and state antitrust enforcement agencies may not have known about beforehand.

The recent cases suggest state attorneys general may play a growing role in policing physician acquisition deals by hospitals and insurers, given that they are in a better position than the feds to find out about brewing local deals. Most of the growth in physician group size has come from piecemeal acquisitions of small group practices, a Health Affairs study found last year.

Washington and at least two other states have passed laws requiring healthcare providers to give state officials advance notice before finalizing a merger or acquisition. That gives state AGs another advantage over the FTC, which under federal rules only must receive advance notice of deals exceeding $78.2 million in value. Few physician acquisitions meet that threshold.

Others worry, however, that the absence of clear federal guidelines for challenging vertical mergers between hospitals and physicians has made the FTC and the courts overly cautious, and that it now may be too late because many physician markets are already highly concentrated. In March, the FTC and the Justice Department said they were working on new vertical merger guidelines, which were last updated in 1984.

“The horse may be out of the barn in a number of markets where there have been very large acquisitions of physician practices,” said Tim Greaney, a visiting professor at the University of California Hastings College of Law. “It’s not clear what you can do about that.”

But hospitals, insurers and other physician aggregators argue that making it harder to buy physician groups would hamper their ability to establish cost-saving, high-quality delivery models emphasizing care coordination.

That’s how Sanford Bismarck President Dr. Michael LeBeau responded to last month’s 8th Circuit ruling against his organization’s merger with Mid Dakota Clinic. “Sanford continues to believe that combining with Mid Dakota Clinic would lead to the enhanced provision of and access to healthcare for patients in central and western North Dakota,” he said in a written statement.

Researchers have raised doubts, however, about whether hospital acquisitions of medical practices have truly achieved efficiencies and cost savings, and whether any cost savings have been passed on to payers and patients.

Going forward, hospitals, insurers and other healthcare organizations need to prepare themselves for an era of closer state and federal examination of physician acquisition deals, antitrust experts agree. That also may apply to private-equity firms, which have accelerated their investment in physician groups and have sought to build market power in particular specialties.

The FTC did not respond to requests for an interview.

Healthcare organizations pursuing physician deals must be ready to cite circumstances where competition continues to thrive following a merger. But that may not be easy, conceded Lisa Gingerich, an antitrust attorney at Michael Best & Friedrich.

“The challenge now is there has been so much consolidation that it’s harder and harder to find those circumstances,” she said.

Scaling back integration in Nevada and Colorado

The UnitedHealth Group-DaVita case may present the clearest warning shot to organizations contemplating large physician acquisitions, attracting both federal and state attention.

The FTC argued that the proposed acquisition by United’s OptumCare of DaVita’s HealthCare Partners of Nevada would result in a near-monopoly controlling more than 80% of the market for services delivered by managed-care provider organizations to Medicare Advantage plans.

The merger would be both horizontal—combining OptumCare’s and DaVita’s competing physician groups—and vertical, as it would combine a Medicare Advantage insurer and a physician group. That, the FTC said, would increase costs and decrease competition on quality, services and amenities by forcing rival Medicare Advantage plans to pay more for physician services.

Under the FTC settlement, UnitedHealth agreed to sell DaVita’s Nevada medical group to Intermountain Healthcare, which offers a Medicare Advantage product in Las Vegas through its SelectHealth insurance arm.

Colorado’s terms

Meanwhile, under a separate consent judgment with Attorney General Phil Weiser in Colorado, UnitedHealth will lift its exclusive contract with Centura Health for at least 31/2 years, expanding the provider network available to other Medicare Advantage plans. In addition, DaVita Medical Group’s agreement with Humana, United’s main competitor in Colorado Springs, will be extended through at least 2020.

All four FTC commissioners approved the enforcement action in Nevada. But the two Republican-appointed commissioners and the two Democratic-appointed commissioners disagreed on whether to ask a judge to block United’s acquisition of DaVita’s medical group in Colorado, a purely vertical merger. The 2-2 split meant no federal action was taken.

The Democratic commissioners. Rebecca Kelly Slaughter and Rohit Chopra, said the merger would harm competition and consumers, and welcomed the Colorado attorney general’s remedial conditions. “We hope all state attorneys general actively enforce the antitrust laws to protect their residents from harmful mergers and anticompetitive practices,” they wrote.

But the Republican commissioners, Noah Joshua Phillips and Christine Wilson, opposed action in Colorado on the grounds that the law on vertical mergers is “relatively underdeveloped” and that there was mixed evidence on whether the Colorado merger was pro- or anti-competitive.

Weiser said his office had to intervene to protect the ability of Humana and other Medicare Advantage insurers to compete with United by having access to physicians and hospitals. “State attorneys general will be a critical part of protecting competition, both because we’re close to our citizens and because of a lack of action by the federal government,” he said.

To other observers, the Nevada and Colorado agreements were notable because they invoked seldom-used vertical merger theory, which the FTC has been reluctant to use because it generally saw vertical mergers as helping reduce costs and increase competition.

“This shows that in the proper case, the FTC won’t hesitate to pursue vertical theory to reverse the course of” a physician group acquisition, said Douglas Ross, a veteran antitrust attorney at Davis Wright Tremaine in Seattle.

 

A muddier outcome in Washington state

Washington Attorney General Bob Ferguson’s settlement of his antitrust case against CHI Franciscan was less definitive than the outcomes in the other recent cases.

He had accused the hospital system of engineering the purchase of WestSound Orthopaedics and the affiliation with the Doctors Clinic to capture a large share of orthopedists and other physicians in Kitsap County, fix prices at a higher level, and shift more services to its Harrison Medical Center in Bremerton. But the settlement left in place CHI Franciscan’s purchase of WestSound and its tight professional services agreement with the Doctors Clinic, while placing relatively modest conditions on joint contracting by the hospital system and the clinic.

Ferguson’s bargaining position was weakened by a federal District Court decision in March granting CHI Franciscan’s motion to summarily dismiss his allegation that the acquisition of WestSound reduced competition and violated antitrust law. That may be the first time since the 1990s that a defendant won summary judgment on a horizontal merger claim in an antitrust case, one expert said.

In addition, the judge required the parties to go to trial on whether the transaction between CHI Franciscan and the Doctors Clinic was a true merger, as the two organizations claimed, or whether they remained two competing provider groups. If Ferguson lost on that issue, his antitrust case would be dead because a merged entity cannot be cited for price-fixing.

The attorney general settled that claim with CHI Franciscan and the clinic by requiring a $2.5 million payment to other healthcare providers and expanding the types of value-based contracts they could participate in. But the two sides differed sharply in their characterization of the settlement.

“This was a matter where we identified anticompetitive effects and ongoing harm to consumers and saw a need to act quickly,” said Jonathan Mark, senior assistant attorney general in Washington. “We believe the remedies in the consent decree are sufficient to address the anticompetitive effects we alleged.”

For its part, CHI Franciscan said there never was any court judgment or admission that it engaged in anticompetitive conduct, noting that the settlement preserved its deals with WestSound and the Doctors Clinic. It was particularly important for hospitals all over the country that Ferguson failed to establish that a professional services agreement with a physician group constituted price-fixing, an attorney for the hospital system said.

“The AG lost this lawsuit and is now twisting the facts to match his baseless allegations,” said Cary Evans, the hospital system’s vice president for government affairs. “Had we not affiliated, the closing of the Doctors Clinic and WestSound would have resulted in less choice, decreased access, and high costs for residents.”

A classic example in North Dakota

The outcome in the North Dakota case was more conventional than the others.

There, the 8th U.S. Circuit Court of Appeals affirmed the District Court’s preliminary injunction blocking Sanford Health’s acquisition of Mid Dakota Clinic as a horizontal merger.

That was fairly predictable because of the huge physician market share Sanford—whose physician group competed with the clinic—would capture if it completed the deal, experts said.

Sanford would control 99.8% of general surgeon services, 98.6% of pediatric services, 85.7% of adult primary-care services, and 84.6% of OB-GYN services in the Bismarck-Mandan market, the 8th Circuit panel found.

The appeals court also upheld the lower court’s finding that a competitor, Catholic Health Initiatives’ St. Alexius Health, would not be able to enter the market quickly after the merger, at least partly because it faced difficulty recruiting physicians in the Bismarck-Mandan area.

“That case really seemed like a no-brainer to me,” said Tim Greaney, a visiting professor at the University of California Hastings College of Law.

A key takeaway was the 8th Circuit’s rejection of Sanford’s “powerful buyer” defense. Sanford had argued that Blue Cross and Blue Shield of North Dakota, the state’s dominant insurer, had enough market power to resist any price increases sought by the newly merged entity.

But analysis of claims data and testimony by a Blues plan representative demonstrated that the merged provider would have the market power to force the insurer to raise prices or leave the market, the 8th Circuit panel wrote.

“If antitrust authorities see someone getting more bargaining power and being able to charge higher prices, that’s something they’ll worry about, even if the (payer) has significant bargaining power as well,” said Debbie Feinstein, a former top Federal Trade Commission official who heads Arnold & Porter’s global antitrust group.

Sanford didn’t say whether it planned to abandon the deal.

Broker Comp Disclosure Bill Flies Through Senate CommitteeBroker Comp Disclosure Bill Flies Through Senate Committee

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Source: BenefitsPRO

Members of the U.S. Senate Health, Education, Labor and Pensions (HELP) Committee voted 20-3 to support S. 1895 — a health care cost bill that includes a health insurance producer compensation disclosure provision.

The provision, Section 308, would require agents, brokers and consultants in the group market to send detailed compensation disclosure statements to plan sponsors. The provision would require health insurers to take charge of sending policyholders producer compensation statements in the individual market.

S. 1895 includes many provisions that would affect drug price disclosures and health care services price disclosure, especially for patients who are seeking emergency care, or ordinary care at in-network hospitals, and may be at risk of having to pay out-of-network prices.

The most visible opposition to the bill from parties other than health insurance producers and producer groups has come from providers of emergency medical services.

The only committee members to vote against the bill today were Sen. Rand Paul, a Kentucky Republican, and Elizabeth Warren and Bernie Sanders.

Warren is a Democrat from Massachusetts who is running for president.

Sanders is an independent from Vermont who’s running for president.

Rand — a board-certified ophthalmologist — blasted many provisions, and especially provisions that were included in an effort to keep insured patients seeking medical services from getting “surprise medical bills.”

The current version of the bill could, in some situations, require providers at a hospital that’s in an insured patient’s provider network to provide care at an in-network rate, even if the provider is not in the patient’s health plan network.

Rand said the provision would have a much broader effect than drafters expect.

“This is going to affect hundreds and hundreds of thousands of transactions,” Paul said.

Rand called the provision a form of cost control.

“If you fix the price that emergency room doctors work at, you will get a shortage,” Rand said.

Rand said drafters should replace the provision with efforts to improve health savings accounts and to give patients new ways to join together to negotiate for lower prices.

Health Agents for America (HAFA), a group that’s been fighting S. 1895, said in an alert sent to members that the committee vote in favor of the bill is “a bump in the road.”

“Don’t give up,” HAFA told its members.

HAFA said Sen. Lamar Alexander, R-Tenn., the chairman of the Senate HELP Committee, wants to have S. 1985 on the Senate floor by the end of July.

“Time to lobby the entire Senate and look for friends of our industry,” HAFA said in the alert. “Please ask other associations to step up.”

New Trump Order May Make More Health Care Prices Public

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Source: New York Times

The White House released an executive order Monday afternoon intended to require insurance companies, doctors and hospitals to give patients more information about precisely what their care will cost before they get it.

President Trump announced the new policy at a signing event, flanked by doctors and patients who had been hit by unexpected medical bills. The event came a week after the official launch of his re-election campaign, and it allows the president to make a claim that he is pursuing a far-reaching health reform plan, his answer to voter concerns about the high costs of care.

“We’re taking power away from bureaucrats, we’re taking it away from insurance companies and away from special interests, we’re giving that power back to patients,” he said, adding that the proposal would bring health care costs “way, way down.”

“We’re taking one more giant step towards a heath care system that is really fantastic.”

Mr. Trump was elected on a promise to repeal the Affordable Care Act, and he has continued to suggest that a plan to repeal the 2010 health law is around the corner, even after Republicans failed to pass several replacement bills in 2017. His attorney general is arguing in court that the entire law should be invalidated. But at Monday’s event, he sounded a more conciliatory note and said he had instructed the Health and Human Services secretary, Alex M. Azar II, to do “a great job” administering the Affordable Care Act.

The transparency order could upend the traditional business practices of major players in the health care industry by revealing price negotiations that have typically been kept secret. Insurers and medical providers negotiate discounted prices in private, and neither party wants competitors to know the details of the deals they’ve struck. The result is a market that can be opaque, with consumers frequently shocked at the prices of their care. President Trump and Mr. Azar say patients could avoid such unpleasant surprises if they could find out the cost of medical services in advance.

But the wording of the order, which delegates the details to regulators, also leaves ample room for modest forms of transparency that might rankle industry officials less.

There had already been strong pushback by industry groups over any proposal that would have forced them to detail all of their negotiated prices. Exactly what information hospitals and insurers will have to disclose is not specified in the executive order, which has no force of law on its own. White House officials said the details would be worked out during the rule-making process.

“It could have been much more aggressive,” said Paul Keckley, a health policy analyst and managing editor of the Keckley Report. “This reflects a lot of behind-the-scenes work by the trade groups.”

Hospitals and insurers have both argued that forcing them to disclose negotiated prices could distort rather than improve existing markets for health care. Many economists have raised similar concerns. “We would be very much opposed to disclosure of privately negotiated rates,” said Tom Nickels, an executive vice president at the American Hospital Association, in an interview before the executive order was issued.

Forcing the hospitals and insurers to disclose their agreements “has a chilling effect on negotiation — it could create a race to the top,” he said.

In an interview after the president issued the order, Mr. Nickels said the decision to go through rule making was “a positive move,” indicating that the administration was listening to concerns from the industry and others. “They have clearly invited or encouraged stakeholders to weigh in,” he said

I

The president became interested in the issue after hearing stories from patients whose finances were upended by high medical bills. And he sold the idea in populist terms, saying that increased transparency could help protect patients from a predatory health industry. He has also called for legislation to ban so-called surprise medical bills, when patients receive care from a doctor in the hospital who is not covered by their insurance; Congress is moving to answer that call.

Administration officials say they believe the order could result in substantial decreases in the cost of medical care. “Prices will go down, and patients will win,” Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, said in an interview. Ms. Verma emphasized that the order “specifically mentions negotiated rates,” rejecting criticism that the order was watered down.

The executive order will follow earlier administration actions to improve the transparency of health pricing data, including new requirements that drug companies disclose their list prices in consumer advertisements and that hospitals publish on their websites the prices they charge uninsured patients. (The drug companies are fighting the advertising rule in court.)

The data described in the executive order is different from hospital list prices made public earlier this year. Currently, hospitals must disclose what they charge, which represents the price they would like to receive.

But the executive order asks for disclosure of the actual prices insurance companies have agreed to pay health care providers for care. In many cases, patients themselves don’t pay that amount directly. But as health plans with high deductibles have become more common, more patients must pay these negotiated prices until their insurance kicks in.

Hospital executives say making information about how much the insurer pays for the care will not help people figure out how much they may owe. Requiring hospitals to disclose what they are paid by individual insurers would require an “incredible lift,” said Chip Kahn, the chief executive of the Federation of American Hospitals, which represents investor-owned systems. The executive order calls for patients to also get an estimate of their out-of-pocket costs before they get care.

It remains unclear how far the administration will go in making negotiated prices public. A senior administration official said that whether patients would have access to a full database of specific prices or something closer to a range of prices would be decided during the regulatory process. But both insurers and hospitals have objected to having what they describe as proprietary information made public, and they are expected to mount legal challenges to any mandated disclosure. In Ohio, a state law requiring price transparency remains mired in the courts two years after its passage.

How successful the administration will be may depend on what legal authority it can claim to make the changes. “No one should get credit for doing this until it gets done,” said Frederick Isasi, the executive director for Families USA, a consumer group.

The order will also ask government agencies to simplify the system of measuring and publicly reporting the quality of care provided by hospitals, doctors and others, enabling patients to more easily compare the performance of different doctors and hospitals alongside their prices.

Enthusiasts for greater price transparency say that making cost information public could increase market — and social — pressure on health care providers to lower prices. Some patients might be able to use the information to shop for their own care, when seeking a blood test or an X-ray, for example.

“I really firmly believe that once we get this transparency in place, the dominoes will fall for better quality, better price and better access,” said Cynthia Fisher, a health care entrepreneur and the founder of the group Patient Rights Advocate, who became interested in the issue after learning about friends and acquaintances who were harmed by high medical bills. Her group has produced videos of their stories, which the president has watched.

But others are more skeptical about whether pricing information alone will drive down overall costs. “Despite the tremendous bipartisan enthusiasm for the idea, price transparency has unfortunately not achieved the promise of helping patients price-shop or save money,” said Dr. Ateev Mehrotra, an associate professor at Harvard Medical School, who has studied earlier experiments.

Government officials also hope the data will be useful to employers, who typically rely on insurance companies to arrange their benefits without knowing all the details of the deals those insurance companies have cut. Even large employers with many workers have said that their insurance contracts have made it hard for them to see detailed pricing information or to be able to steer their workers to doctors and hospitals that are of high quality but cost less.

“The purchaser community has been pushing for transparency for years,” said Michael Thompson, the chief executive of the National Alliance of Healthcare Purchaser Coalitions, who praised the president’s actions. “The lack of transparency is a root cause of higher health care costs.”

Poll: 1 in 4 Americans Say Cost Led to Skipping Medical Care

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Source: The Hill

More than 1 in 4 Americans say they or a family member went without needed health care in the past two years because they felt they could not afford it, according to a new poll.

The survey from Monmouth University released Monday finds that 27 percent of adults say they or a member of their household have avoided necessary medical care in the past two years because of cost. That figure is down slightly from 2017, when 31 percent said they had skipped care.

In addition, 45 percent of the public says it is difficult to pay their deductibles and other out-of-pocket health care expenses.

Relieving the burden of health care costs has been a major driver of the debate over “Medicare for All,” with proponents saying that generous government-run insurance is needed to make health care affordable for more people, while opponents argue there are other, more market-based ways to bring down health costs while building on the current system.

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) are currently working on a bipartisan package aimed at lowering health care costs, including protecting patients from surprise medical bills that they get when a doctor is outside their insurance network.

The poll finds that 20 percent of adults say they have thought about getting a new job or starting a business in the past 10 years but did not pursue it because of the need to maintain their health coverage.

Proponents of Medicare for All say that reducing this “job lock,” or the need to stay in a job to keep the employer-provided health insurance, is a benefit of government-run insurance. Opponents say people often like their employer-sponsored coverage and do not want to be forced to give it up.

Last Updated 11/13/2019

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