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.

California Names Former Google Scientist as the State’s ‘Mental Health Czar’

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Source: Stat

Noted psychiatrist and former Verily leader Dr. Tom Insel is going to be the “mental health czar” for the state of California, Democratic Gov. Gavin Newsom announced Tuesday.

Insel, the former National Institute of Mental Health director, will also continue his work with Mindstrong, a startup that is working on a mental health app, a company spokesperson confirmed. Insel joined the company in 2017 after leaving Verily, Google’s life sciences arm.

Insel’s new job will be to “inform the state’s work as California builds the mental health system of tomorrow, serving people whether they are living in the community, on the streets or if they are in jails, schools or shelters,” according to a press release from the governor’s office.

In a press conference, Newsom said Insel was “volunteering” his time as an adviser. “I’m calling him the mental health czar in the state of California,” he said.

Mindstrong, which is focused on using data on how people use their smartphone to detect trends in their mental health, already has a relationship with public officials in California. One of Mindstrong’s first large-scale rollouts was slated to happen in the state through county-level public mental health systems, STAT reported in October.

A spokesperson for Mindstrong said that Insel would recuse himself from conversations about the company, and noted that he will have “no fiscal or regulatory authority and will have no oversight of current programs in this voluntary role.”

The spokespeople for Newsom and for California Health and Human Services Secretary Mark Ghaly, with whom Insel will be working, did not immediately reply to a request for comment.

Mindstrong raised $31 million in an expanded Series B round in January led by General Catalyst, bringing the company’s total funding to about than $60 million.

“Our excitement over Mindstrong’s technology is bolstered by our inspiration in the core founding team,” an associate and the managing partner of General Catalyst wrote in a blog post in January about the investment.

In Its Fight to Keep Drug Prices High, Big Pharma Leans on Charities

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Source: Los Angeles Times

The U.S. Rural Health Network has a slogan on its website that seems obvious: “We’re fighting for rural health.” But it’s not that simple.

The 2-year-old nonprofit organization hasn’t had much impact in rural health circles, where experts say they’ve never heard of it. It’s also active in a different area: fighting proposals that would cut the cost of prescription drugs. This year, it joined scores of other groups to oppose letting Medicare negotiate prices with drugmakers.

The network, which declines to disclose who funds its work, is part of a gaggle of self-styled patient-advocacy groups with murky origins or hidden funders that have cropped up since 2017. With names like the Doctor-Patient Rights Project or the Defenders Coalition, such groups pursue various policy aims that include effectively aiding pharmaceutical companies’ efforts to defeat drug-price proposals.

The nonprofits take public positions in newspaper op-eds and letters to Congress while drugmakers — beset by years of negative publicity over price hikes — tend to remain in the background. The groups say they’re independent.

That’s not true for all of them, said Marc Boutin, the chief executive of the National Health Council, which has more than 50 patient groups and dozens of drugmakers as members.

“There are a number of groups created by pharma companies that look and act like patient organizations, but they’re 100 percent funded by industry,” said Boutin, who didn’t name any specific examples. “They sound and look like patient organizations, but they take positions that industry wants.”

Boutin said he’s trying to dissuade pharma companies from getting involved in such efforts.

These newer nonprofits often join issue-oriented coalitions alongside established, bona fide patient groups, amplifying their message. Some experts fear they provide a way for drugmakers to influence policy without any disclosure of such efforts.

Typically, the newer groups are created and operated by public-relations or marketing firms with extensive ties to the pharmaceutical industry. They generally refuse to discuss their funding, but Bloomberg News documented that at least one got its seed money from Amgen Inc., whose most lucrative drug, the arthritis medicine Enbrel, has tripled in price since 2010, according to data from IBM Watson Health.

While its funding is unclear, the U.S. Rural Health Network has an illustrative origin story.

It was registered in 2017 by the general counsel of Moore Communications, a Tallahassee, Fla.-based marketing firm. Moore Communications has worked for the drugmakers’ industry group, Pharmaceutical Research and Manufacturers of America, or PhRMA, since at least 2001, including on a national ad campaign in 2014. The firm has also built websites for at least three other patient-focused groups with opaque industry connections.

The rural-health network is a family affair. Its executive director is the sister of Karen Moore, Moore Communications’ chief executive. One of the group’s directors is the mother of a Moore Communications vice president. And the lawyer who registered it is Richard Moore, Karen’s husband and the marketing firm’s general counsel.

The charity’s headquarters, located behind an unmarked door in a building owned by Richard and Karen Moore, was locked on a recent weekday morning.

Across a parking lot, in Moore Communications’ corporate office, Richard Moore described the nonprofit as separate from the marketing company and said he helped launch the organization because “we saw a particular need regarding health issues with rural areas of the country.”

(Four directors of other rural health centers say they’ve never heard of the group. “I don’t know anything about them,” said Alan Morgan, CEO of the 21,000-member National Rural Health Assn., which holds the nation’s largest annual conference on rural health issues.)

Asked to name the nonprofit’s funders, Richard Moore said he’d have to ask some colleagues for the information. Neither the nonprofit nor the marketing firm responded to follow-up requests, but Cheryl Elias, the Rural Health Network’s executive director, said in a written statement that the group takes its positions “independent of outside influence.”

A spokesman for PhRMA, the drugmakers’ industry group, declined to say whether it has funded the nonprofit.

Nonprofits aren’t required to publicly disclose their donors. Some pharmaceutical companies voluntarily disclose at least some of their funding for patient groups, but the full scope of their giving is far from transparent.

Even among long-established patient organizations — founded years ago to address specific diseases or conditions — disclosure is spotty. Matthew McCoy, a University of Pennsylvania professor who teaches medical ethics, found in a 2017 study of 104 patient-advocacy groups that 83% reported receiving money from drugmakers, but only 5% disclosed the exact dollar amounts.

Kaiser Health News reported last year that 14 major drug companies gave a combined $116 million to patient groups in 2015, far more than the $63 million they spent on federal lobbying.

Much of that money benefits disease sufferers or society at large. Patient groups run support networks for those who’ve received life-altering diagnoses. Some support research to develop new treatments for particular diseases. They also create communities of patients from whom drug companies can learn more about particular ailments and how treatments affect people.

But those communities are also stocked with potential policy advocates. And with no disclosure requirements, it’s often impossible to know whether drugmakers’ contributions are shaping the patient groups’ policy stances, said Susannah Rose, associate chief of patient experience at the Cleveland Clinic.

“We need much greater transparency, not only in funding, but also how the money is used,” Rose said.

Long-established groups bristle at the suggestion that the drug industry sways their positions. “There are times when what’s best for the patient aligns with what industry wants,” said Claire Gill, chief mission officer for the 35-year-old National Osteoporosis Foundation. “And there are times when it doesn’t.”

With regard to Medicare and drug prices, the foundation recently aligned with the industry in an unusual way.

In 2017, the group began running an informal coalition called the Protect Medicare Part D Working Group. It organized a January letter that called on Congress to reject plans for letting Medicare negotiate on drug prices; some 200 organizations signed it, including the U.S. Rural Health Network.

The negotiation issue has a tortuous history. When Medicare was expanded to cover prescription drugs in 2003, it became the single-biggest buyer of medicines in the U.S. But while other federal agencies, such as the Department of Veterans Affairs, can use their market clout to seek better deals on drug prices, Congress prohibited Medicare from doing so. Instead, the scores of private insurance providers that offer Medicare plans are left to negotiate individually with drugmakers, with significantly less power.

Now several Democrats, including Sen. Amy Klobuchar of Minnesota, have proposed legislation to let the sprawling health program bargain on behalf of its 43 million beneficiaries.

Gill said the osteoporosis foundation took a leadership role in opposing that plan—not because of any drugmakers’ contributions, but rather the fear that such legislation would eventually force Medicare to cut its coverage of certain high-priced drugs, including some needed by osteoporosis patients. (The foundation gets about $1 million a year, or 20% of its budget, from drugmakers.)

“We support lower prices, but we want to make sure that whatever is proposed actually makes the system better,” Gill said.

Klobuchar’s proposal doesn’t get to that level of detail, but the group’s concern stems from previous research: The Congressional Budget Office has said that Medicare negotiations would yield significant savings only if the program is given the authority to restrict coverage of certain medicines.

Lobbyists with pharmaceutical industry ties have worked behind the scenes with the Medicare Part D Working Group as it attempts to transition to a new, catchier name: the Defenders Coalition. The osteoporosis foundation won’t be running the new version. Instead, initial work on the changeover was done by a Washington-based lobbying firm called NVG Group, which has worked recently for drugmakers such as Merck & Co. Inc., Sanofi and Pfizer Inc., as well as the trade group PhRMA.

The transition also got an assist from lobbyist and former Democratic Sen. Blanche Lincoln. According to a written summary of a January conference call, Lincoln urged members to stick with the coalition and keep fighting “drastic changes” to Medicare. Her company, Lincoln Policy Group, has worked for drugmakers, including AbbVie Inc. and Pfizer, as well as insurers such as Aetna Inc.

Were the lobbying firms paid to help organize the coalition?

“You’d have to ask them,” Gill said of the osteoporosis foundation.

Irene Bueno, a co-founder of NVG, said in an email that her firm is no longer involved in the effort; she didn’t answer questions about who funded her work. Lincoln Policy Group didn’t respond to several telephone calls and emails seeking comment.

The coalition’s January letter against Medicare negotiations appears to have benefited in part from a bandwagon effect. One patient group that signed it was the National LGBT Cancer Project — though its director said in an interview that he really doesn’t know enough about the issue to form an opinion on it. Darryl Mitteldorf, who runs the cancer-patient support group under an umbrella organization called Malecare, said he gets an avalanche of requests to sign policy letters, so he’ll sometimes sign on if he sees other groups he trusts.

Drug companies supply about half of Malecare’s annual operating budget of $209,000, and Mitteldorf calls them “heroes” — “they make the molecules that save lives” — but he’s wary of their influence all the same. He said he turns down drugmakers’ money when their agenda doesn’t fit his organization’s mission, but not every group does that.

“It’s no surprise who’s going to get a favorable response to a grant proposal,” Mitteldorf said, “if you’re licking the boot of pharma.”

Another patient group that popped up in 2017 shows how one pharmaceutical company tried to downplay its involvement.

The Doctor-Patient Rights Project lists 18 members — including the U.S. Rural Health Network and the drugmaker Amgen — and describes itself as a “nonprofit coalition of doctors, patients, caregivers, companies and advocates.” It publishes detailed policy papers and places scores of op-eds in newspapers around the country, mostly criticizing insurance companies for interjecting themselves into medical decisions and steering patients to cheaper therapies.

The group’s website provides scant clues about who operates and funds the coalition — no names or addresses — but there is a phone number. It goes to a voicemail account that doesn’t give a name. After Bloomberg News left a message, a person who called himself “Eli” responded via email and said the group is funded by “private companies, grants, educational institutions and non-profit organizations.” He didn’t reply to a request for actual names.

“DPRP was founded on the idea that medical decision-making should be based on science, not economics,” said Dr. Theresa Rohr-Kirchgraber, a member of the group, in an emailed statement. “The idea that any single entity unduly influences our agenda is categorically false,” said Rohr-Kirchgraber, a past president of the American Medical Women’s Assn.

An Amgen spokeswoman described an organic beginning for the group. The company heard from physicians and patient groups about people who were unable to get the medicines their doctors prescribed, she said.

“As a result, Amgen and other founding members … came together to address the importance of the physician and patient relationship,” she said in a written statement. These founding members, Amgen said, agreed to select a public-relations agency to run the coalition.

But that’s not exactly how it happened. In reality, the Doctor-Patient Rights Project began after a New York-based public-affairs firm called Marathon Strategies pitched the idea to Amgen, according to two people familiar with the group’s beginnings.

Amgen put up the initial money, while Marathon helped recruit other members, built the website, wrote the reports and placed the op-eds in newspapers. The marketing company declined to comment.

Questioned about this timeline, Amgen provided an updated statement, saying the company — and not the coalition’s member groups — selected Marathon based on their past relationship. It added that while Amgen provided the “seed money” to launch the group, other groups and companies have contributed since.

It declined to name them.

Did Your Doctor ‘Ghost’ You? An Employment Contract May Be To Blame

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Source: Kaiser Health News

When Don Cue developed a bladder infection last fall, he called his longtime urologist’s office for a urine culture and antibiotics. It was a familiar routine for the two-time prostate cancer survivor; infections were not uncommon since he began using a catheter that connects to his bladder through an incision in his abdomen.

When Cue called this time, a receptionist told him that his physician, Dr. Mark Kellerman, no longer worked at the Iowa Clinic in Des Moines, a large multi-specialty group. She refused to divulge where he’d gone.

“As a patient, ‘scared’ is too strong a word, but my feeling is, ‘What do I do now?’” said Cue, 58.

Flummoxed, he solved his immediate problem by taking leftover antibiotics he had in his medicine cabinet.

It was only later that he learned his doctor had been fired by the Iowa Clinic and planned to start a urology practice with clinic colleagues. And, under the terms of their contract with their former employer, the doctors were banned for a year from practicing within 35 miles of the clinic and from recruiting former patients to follow them.

Contracts with so-called restrictive covenants are now common in medicine, although some states limit their use. Noncompete clauses — common in many commercial sectors — aim to stop physicians or other health care professionals from taking patients with them if they move to a competing practice nearby or start their own. But what may be good for business is bad for patient care — and certainly disquieting for those whose doctors simply disappear.

One survey of nearly 2,000 primary care physicians in five states found that roughly 45 percent were bound by such clauses.

Continuity of care is important, doctors say, especially for patients with ongoing medical issues. Cutting off access to a doctor is different from disrupting someone’s relationship with a favorite hairstylist or money manager, they say.

“When doctors want to move from one practice to another, if they’ve got good therapeutic relationships with their patients, you’d think that public policy would want them to continue to treat these patients that trust them,” said Judy Conti, government affairs director at the National Employment Law Project.

Charlie Wittmack, a lawyer at Hartung Schroeder in Des Moines, is representing Kellerman and the two other urologists who were also fired in a lawsuit against the Iowa Clinic. The wrongful termination suit asks the court to declare the physicians’ restrictive covenant provisions unenforceable. Wittmack said the controversy there was “tragic” for patients. “These are people who have prostate cancer or are in extreme pain because of kidney stones or have blood in their urine.”

Ed Brown, the clinic’s CEO, said the noncompete agreements are not just about business but also help ensure that the Iowa Clinic can provide reliable services.

“Noncompetes are good for the patients because they help to provide stability within a practice and ensure continuity of care,” Brown said recently in an email. Further, he added, noncompetes protect physicians by ensuring that other physicians in the practice are committed to the same agreement and can’t abandon it without proper notice.

The urologists “believe they can make more money elsewhere, and they don’t want to be held to any contractual responsibilities,” he said.

Even when longtime patients go sleuthing to find their doctors’ new offices, they may not be accepted into those practices. Hospitals and clinics say they have little choice but to respect the terms of business agreements that others have negotiated.

UW Health, the health care system for the University of Wisconsin-Madison, recently hired three primary care doctors who had worked across town, said Dr. Sandra Kamnetz, vice chairwoman of clinical care for the Department of Family Medicine and Community Health at the University of Wisconsin’s School of Medicine and Public Health. They are taking great pains not to treat any of the new doctors’ former patients because the terms of the doctors’ contracts with their old employer prohibit them from taking care of former patients for two years.

Staff at the UW clinics ask prospective patients if they’ve ever been seen by one of the doctors. They then check the patient’s electronic health record to confirm there are no messages, prescription refills or other recent contact with the new UW Health doctors and that patient at the previous job, said Kamnetz.

“Patients get frustrated, but what they may not understand is that this is a legal thing that we have to abide by,” she said.

Whether noncompete clauses are binding in health care — especially when patient care is disrupted — is a point legal scholars debate. In general, to be enforceable, the agreements must be reasonable and narrowly drawn so that they protect an employer’s legitimate business interest but don’t unduly restrict a doctor’s ability to make a living.

Courts may weigh whether enforcing a noncompete clause would create a physician shortage in a particular region or specialty. The guiding principle is patient choice, said David J. Clark, a partner in the New York office of the law firm Epstein Becker Green who has analyzed state noncompete statutes in health care.

“No court is going to deny a patient who wants to go see a doctor of her choice,” Clark said.

Most disputes are settled before they make it to court, however.

A recent report by the Trump administration evaluating how to promote choice and competition in health care recommended that states examine noncompete agreements for their effect on patients’ access to care and the supply of providers.

Several states, including Massachusetts and Colorado, that allow noncompete clauses in employment contracts generally won’t enforce them against doctors, according to Clark’s analysis.

Other states, such as Texas and Tennessee, place limits on the agreements. In Texas, for example, a noncompete pact must allow doctors to have access to a list of their patients in the past year and access to their medical records, among other things, Clark found.

Medical board rules take it a step further. “In Texas, when a physician leaves, the practice is required to cooperate with a physician who wants to put up a notice that says this is where that physician can now be contacted,” said Kathy Poppitt, a partner in the health care and government and internal investigations practices at the Austin, Texas, office of King & Spalding.

The American Medical Association, which represents doctors, doesn’t oppose restrictive covenants outright, although its policy notes they can limit patients’ choices. “To the extent that these agreements disrupt continuity of care and disrupt patient choice, this is of great concern to the AMA,” said Dr. Patrice Harris, the organization’s president-elect.

For patients in central Iowa, the departures of longtime urologists at the Iowa Clinic is dizzying. After Kellerman and his colleagues left, five of the clinic’s remaining seven urologists submitted their resignations. They are also subject to noncompete restrictions. They left the practice in mid-February.

Brown, the clinic CEO, said the urology department has replaced four of the eight urologists and has nine nurse practitioners or physician assistants to treat patients. The clinic is continuing to recruit physicians and advanced practice providers like nurse practitioners.

Susan Murphy, 72, has seen a number of doctors in the urology department. Dr. Richard Glowacki, one of the urologists who left with Kellerman, performed surgery to remove her kidney stones more than a decade ago. Another, Dr. Stephanie Pothoven, did surgery to repair her prolapsed uterus a few years ago.

Murphy said she got a letter from Pothoven announcing her departure. It didn’t provide details about where she would be going.

“I’ve got it etched in my brain to find out where they went,” she said. She has no plans to return to the Iowa Clinic. “Somehow they lost sight of patient care and were more concerned about the bottom line,” she said.

Health System Consolidation: Can Employer Groups, Brokers Survive It?

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Source: Benefits Pro

Health care systems have been buying up one another, and physician practices, at an alarming rate. The 115 announced health care system deals in 2017 was a record, with 2018’s 90 close behind.

This level of consolidation activity 2017 “shook the health care landscape,” said consulting firm Kaufman Hall, which produces an annual mergers and acquisitions review. “These tremors continued into 2018 and are beginning to fundamentally reshape the health care landscape,” KH said in its 2018 review.

The consolidation within the physician practice sector was no less titanic. Hospital systems acquired more than 5,000 standalone practices in 2015 and 2016 alone. Meantime, practices are also being swallowed up by UnitedHealthcare and other non-hospital enterprises.

Analysts tend to focus on two major outcomes of this consolidation craze: financial and quality of care. So far, evidence suggests that consolidation among health care systems leads to higher prices for services and thus costs to users, and stable or lower quality of care.

These trends are not the friends of two very specific groups: health insurance brokers, and employer groups created to negotiate better terms for their members with hospitals.
“It is frustrating,” admits Brian Marcotte, CEO, The National Business Group on Health. “Scale for the sake of scale leads to higher costs, and that’s what we are seeing. When we look at what actually happens when hospitals buy hospitals or physician groups, we see higher cost and price.”

One of the primary objectives of NBGH’s 435 enterprise level members–all of which are self insured–has been to negotiate better terms with medical providers. As consolidation creates ever larger health care systems, its members report that “consolidation has not led to the efficiencies you’d see in other industries. … Most report that costs went up or were unchanged. Very few saw them go down.”

Employer groups are promoting Centers of Excellence and encouraging plan members to seek care from top performing practitioners. But consolidation among hospitals can erode quality of care for employer plan members by bringing into an existing system underperforming hospitals and physicians, Marcotte says.

“Let’s say you have a 12-hospital system that dominates a market or several markets,” he says. “The health plan is looking to contract with eight higher performing hospitals, but not all 12. The hospital system’s negotiating position is, ‘You take the whole system or you don’t get any of our system.’ These are the tactics that go on when providers are dominating a particular market.”

The decline of bargaining power
Smaller employers that band together into health care purchasing groups lose negotiating power when consolidation sweeps through a market. Employer groups negotiate locally or regionally for terms for their members with hospital systems. Their cache is numbers: They guarantee a large number of patients in exchange for favorable terms.

But, says Den Bishop, president, Holmes Murphy, an insurance advisor, as the systems expand, the group’s bargaining power diminishes.

Meantime, consolidation among physician practices is driving costs up for plan members. Physicians are highly incentivized to merge practices and then sell to a health care system. “They want to get out from under the administrative burden and just practice medicine,” Bishop says. “As soon as they buy the practice, the hospital system goes to the insurance company and says, ‘Our contract rate is much higher than the physicians, so you will now pay us this rate.’ That rate gets passed on to the employer. By paying higher prices for physician services, employers are paying the acquisition price for the hospital.”

In Atlanta not long ago, a major health system purchased a large physician practice–and employer plan costs for those physicians increased 40 percent, says Suzannah Gill, benefits strategy consultant with EPIC in Atlanta. “Sadly, when hospitals buys practices, the hospital wins and the member loses,” she says.

The national movement toward greater price and cost transparency among providers faces a threat from consolidation, Marcotte and others say. As systems expand, “you see a reluctance to have a price listed in transparency tools,” Marcotte says. “They refuse to list their prices, effectively eliminating any real ability for a consumer to choose a cost effective site of service.”

Josh Luke, MD, a former hospital CEO who now writes and lectures on hospital system strategies, believes the transparency issue may prove to be a turning point battleground for hospitals.

“There’s a transparency movement uprising coming with overall health and cost,” he says. “That momentum will be tough for any market to turn away from. Pricing transparency may outweigh a monopoly’s ability to gouge employers.”

Broker adaptation
On the broker side, a major threat to traditional brokers comes from the hospitals themselves. As they expand, many are moving into the health insurance business.

“The hospital systems are moving quickly, while they still have the most money, to compete with insurers. They are becoming insurers,” says Luke. “The bottom line is that is the [hospital] model of the future is an insurance model.”

To adapt to this new model, brokers need to become advisors and consultants to their clients. Their role may revolve more around transparency, advising clients on negotiating specific terms with health care systems, guiding them through the opaque pricing lens hospitals have thrown up.

Longer term, the health care system as insurer could have a positive effect on plan design and cost, several experts agree. The insurance component of a hospital system benefits from a healthier patient population, on more efficient use of services and facilities, and on a leaner brick-and-mortar footprint. These systems will focus more on convenience for patients and on value-based cost structures, and will be more responsive to negotiating with large employer groups.

“If the hospital system becomes big enough, it can negotiate directly with employers,” Bishop says. “They don’t need the insurance broker. The great hope [for employers] is that the hospital companies become insurers and have an incentive to provide better quality at a lower cost. It is still a ways off. We are in the cocoon period right now.”

EPIC’s Gill agrees that hospital systems that branch out into insurance will seek to contain the costs of medical care. “Health care providers have an incentive to increase costs. Insurance carriers have incentives to reduce or maintain costs. So when a health system develops an insurance business, there are incentives for them to do things efficiently,” she says.

The broker/advisor can play a crucial role in a consolidating market, Gill and others say.

“Employers need advisors to guide them today. They are focused on running their business, so you are seeing more advisors introducing interesting, cutting edge practices to meet their needs,” she says. “Sometimes when you tell a provider or facility, ‘My client will pay on the spot and you won’t have to worry about collections later,’ [the health care provider] will take it. I see all of the changes as very good for the broker/advisor market. The market is evolving, becoming more complex, and that’s where employers turn to brokers for guidance.”

The overall effects of hospital consolidation in a major market “are probably indifferent to most forward-thinking brokers,” says Allison De Paoili, founder and owner, De Paoli Professional Services, San Antonio. “But in the smaller markets, where you have two health systems that merge, then you have a problem,” she says. “With no competition, there is no incentive to negotiate price.”

In the end, the final chapters on health system consolidation have yet to be written. The merger frenzy of the past two years is still working itself out. As hospital systems seek market domination, creative brokers, concerned large employers, and national organizations like NBGH are still developing their responses.

Pockets of positive physician practice and hospital system consolidation do exist, NBGH’s Marcotte says. The hospital-as-insurer places the parent company in a position to accept some of the risks, he says, and that’s where innovation and efficiencies will emerge. It’s mostly happening on the Medicare Advantage side, but could translate to commercial insurance, he says.

“What I worry about with provider consolidation is when I have the whole market, I have no incentive to move to a value based direction, unless I have to do it to get paid differently,” he says.

Total market domination may be the goal of health systems. But it could also be their undoing.

“When there’s a monopoly, people will walk away,” says Josh Luke. “People are getting fed up. The public pressure is starting to rival the doctor and hospital lobby. Major employers, like Disney and Amazon, are saying ‘We are gonna blow it up and start over.’ Hospitals haven’t started feeling the pain yet. But it’s coming.”

Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’

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Source: New York Times

Even before Democrats finish drafting bills to create a single-payer health care system, the health care and insurance industries have assembled a small army of lobbyists to kill “Medicare for all,” an idea that is mocked publicly but is being greeted privately with increasing seriousness.

Doctors, hospitals, drug companies and insurers are intent on strangling Medicare for all before it advances from an aspirational slogan to a legislative agenda item. They have hired a top lieutenant in Hillary Clinton’s 2016 presidential campaign to spearhead the effort. And their tactics will show Democrats what they are up against as the party drifts to the left on health care.

They also demonstrate how entrenched the Democrats’ last big health care victory, the Affordable Care Act, has become in the nation’s health care system.

The lobbyists’ message is simple: The Affordable Care Act is working reasonably well and should be improved, not repealed by Republicans or replaced by Democrats with a big new public program. More than 155 million Americans have employer-sponsored health coverage. They like it, by and large, and should be allowed to keep it.

“We have a structure that frankly works for most Americans,” said Charles N. Kahn III, the president of the Federation of American Hospitals, which represents investor-owned hospitals. “Let’s make it work for all Americans. We reject the notion that we need to turn the whole apple cart over and start all over again.”

The Democrats’ proposals could radically change the way health care providers do business and could drastically shrink the role and the revenues of insurers, depending on how a single-payer system is devised.

The hospital federation and two powerful lobbies, America’s Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America, created a coalition last June to pre-empt what they saw as an alarming groundswell of interest in proposals to expand the federal role in health care.

In a daily fusillade of digital advertising, videos and Twitter posts, the coalition, the Partnership for America’s Health Care Future, says that Medicare for all will require tax increases and give politicians and bureaucrats control of medical decisions now made by doctors and patients — arguments that echo those made to stop Medicare in the 1960s, Mrs. Clinton’s health plan in 1993 and the Affordable Care Act a decade ago.

The coalition will step up the tempo in the coming week as Democrats in the House and the Senate plan to introduce bills to establish a single-payer system.

The name of the coalition is intentionally nondescript, and its executive director, Lauren Crawford Shaver, who led Mrs. Clinton’s efforts in 2016 to put marginal states into play, is cagey when asked for details. She says only that the group is planning “a big nationwide effort” with grass-roots allies.

But its reach is undeniable. The coalition has picked up more than 25 members, including the American Medical Association, the American Hospital Association and the nation’s Blue Cross and Blue Shield plans.

And it has already sprung into action.

When Senator Bernie Sanders, the author of the Medicare for All Act, announced on Tuesday that he was again running for president, the coalition immediately attacked him as “a leading advocate for upending our nation’s health care system in favor of starting from scratch with Medicare for all.”

Mr. Sanders, independent of Vermont, fired back at the insurance and drug companies. “They make tens of billions of dollars a year in profits from this dysfunctional health care system and pay their C.E.O.s outrageous compensation packages,” Mr. Sanders said. “We’ve expected their opposition all along.”

When members of Congress unveiled legislation to let people age 50 to 64 buy into Medicare, the coalition conflated it with proposals to put all Americans into Medicare.

“This is a slippery slope to government-run health care for every American,” said David Merritt, an executive vice president of America’s Health Insurance Plans, a lobby for insurers.

The buy-in proposal for older Americans dates back to Bill Clinton’s presidency, and many of its advocates have put it forward as a moderate alternative to Medicare for all.

But the coalition said the proposal was wrong for America, “whether you call it Medicare for all, Medicare buy-in, single payer or a public option.”

The chief sponsor of the House buy-in bill, Representative Brian Higgins, Democrat of New York, said: “The critics lump our bill with the bigger Medicare-for-all proposal. That’s strategic, and I think it’s deliberate.”

Mr. Higgins said the option of Medicare at age 50 would create “a countervailing force to private insurance.”

“Insurance companies are fighting it because they are afraid of the prospect of a potent new competitor that will cut into their profits,” Mr. Higgins said. “Medicare has lower administrative costs and lower executive salaries and could use its bargaining power to get better deals from hospitals and other health care providers.”

Senator Debbie Stabenow, Democrat of Michigan and the sponsor of the buy-in bill in the Senate, said she was not surprised at the criticism. “It’s a knee-jerk reaction to anything that expands Medicare,” she said.

But, she said, people 50 to 64 need the option.

“We see the auto industry laying people off, encouraging people to retire early,” Ms. Stabenow said. “Many people are holding their breath until they turn 65. They put off preventive screenings, so they come into Medicare at 65 with more health problems.”

Under the Affordable Care Act, insurers can increase premiums with a person’s age, and older people who do not qualify for subsidies face the highest premiums on the insurance exchange. For a 60-year-old in Charlotte, N.C., the average premium for a midlevel silver plan is more than $1,100 a month; in Phoenix, it is nearly $1,000 a month.

The mission of the industry partnership includes advocacy, advertising, lobbying and public education, but it has not registered under federal lobbying laws. Forbes Tate, a public affairs company that lobbies for many health care and drug companies, coordinates the work of the partnership, but is not registered to lobby on its behalf.

“There are no direct lobbyists for the partnership,” Ms. Shaver said. “We work through all of our different groups. They have their own lobbyists who do obviously lobby on Medicare for all. But there are no registered lobbyists for the partnership because we are not doing that directly at this time.”

The coalition, like President Trump, attacks any proposals that smack of socialized medicine. But it also has a positive agenda. It wants to expand Medicaid under the Affordable Care Act in Texas, Florida and other states that have yet to do so. It wants to expand federal subsidies under the health law so insurance will be affordable to more people. And it wants to stabilize premiums by persuading states to set up reinsurance programs, using a combination of federal and state funds to help pay the largest claims.

Beyond their desire to preserve the status quo, coalition members have done well by the Affordable Care Act. Many participants, such as the American Medical Association, the pharmaceuticals lobby and the hospital association, backed the A.C.A. from the start, banking that more insured Americans would mean more customers. The hospitals saw the health law’s Medicaid expansion as a lifeline as they struggled with the uninsured working poor.

Others, like the National Retail Federation, opposed the A.C.A. but have tried to make it work.

The need to bolster the Affordable Care Act will become even more urgent, the coalition says, if Texas and other states succeed in their lawsuit to invalidate the entire law.

Even without legislation to expand Medicare, the program is sure to grow because of the aging of the baby boom generation. The number of Medicare beneficiaries, 60 million today, is expected to top 75 million within a decade. The Congressional Budget Office estimates that Medicare spending will grow under current law to $1.5 trillion in 2029, double the total projected for this year.

E. Neil Trautwein, the vice president for health care policy at the retail federation, which represents companies like Walmart, McDonald’s and Amazon, said his top priority was to protect the stability of the coverage that employers provide to employees.

“We are trying to understand what will be coming at us,” Mr. Trautwein said. “Proposals on the left and the right, in Congress and on the campaign trail, could blow up the employer-based health care system that has worked pretty well for more than 60 years.”

The version of Medicare for all proposed by Mr. Sanders in 2017 could disrupt that coverage. It would expand the list of items and services covered by Medicare and would prohibit employers from duplicating any of those benefits.

When Mr. Sanders introduced that bill, it was endorsed by several Democratic senators who have since become candidates for the party’s presidential nomination: Cory Booker of New Jersey, Kirsten Gillibrand of New York, Kamala Harris of California and Elizabeth Warren of Massachusetts.

The more modest Medicare buy-in bill has been endorsed by Mr. Booker, Ms. Gillibrand and Ms. Harris, as well as by another Democratic candidate for president, Senator Amy Klobuchar of Minnesota, and a potential candidate, Senator Sherrod Brown of Ohio.

Yet another Democratic proposal, allowing states to create a Medicaid buy-in program for all their residents, regardless of income, has won support from 23 senators, including Mr. Booker, Mr. Brown, Ms. Gillibrand, Ms. Harris, Ms. Klobuchar and Ms. Warren.

Members of the coalition had different positions in the struggle to pass the Affordable Care Act in 2009 and 2010, but rave about it today. Ten million people have coverage through the exchanges, 14 million have gained Medicaid coverage, and in a strong economy more people have jobs that provide health insurance, they say.

Some members of the coalition have financial as well as philosophical reasons for resisting the push to expand Medicare. Doctors and hospitals say Medicare generally pays less than private insurance, and hospitals say the payments frequently do not cover the costs of providing care to Medicare patients.

“Chronic underpayment to providers creates access issues for seniors, particularly with physicians, who may limit the number of Medicare patients they see,” said Richard J. Pollack, the president of the American Hospital Association. Congress, he said, often makes changes in Medicare for reasons that have nothing to do with sound health policy — to offset the costs of tax cuts, for example.

Moreover, Mr. Pollack said: “The government can be an unreliable business partner. What happens when the government shuts down? What happens if the health care system is even more dependent on Medicare and the government shuts down again?”

But the coalition does not speak for all health care providers.

The American College of Physicians, the largest medical specialty organization in the country, has supported a Medicare buy-in for people 55 to 64.

And “during the whole debate over the Affordable Care Act, we supported having a public option in the individual insurance market in every state,” said Robert B. Doherty, senior vice president of the college, which represents 154,000 doctors who specialize in internal medicine.

Payers, Providers Push Back on Democrats’ Medicare Buy-In Plan

Calculator that says "Medicare" on it on top of money, next to bottle of pills

Source: FierceHealthcare

Earlier this week, Democrats introduced a bill that would allow people ages 50 and over to buy in to Medicare coverage, and the plan is already getting pushback from payers and providers.

Under the most recent proposal, people between the ages of 50 and 65 could buy a Medicare plan and qualify for subsidies and tax credits under the Affordable Care Act (ACA). The Medicare at 50 Act, led by Sen. Debbie Stabenow, D-Mich., would fund enrollment through premiums and would eventually lower costs for younger people by moving more people into the higher age bracket, its sponsors argue.

However, David Merritt, executive vice president of public affairs and strategic initiatives at America’s Health Insurance Plans (AHIP), called the proposal a “slippery slope to government-run healthcare for every American.”

Merritt told FierceHealthcare that U.S. healthcare is not a one-size-fits-all system and that a vast majority of Americans are satisfied with the coverage they have today, whether it be through Medicare Advantage, Medicaid or private coverage.

“They have choice and control over their coverage, options, and treatment,” Merritt said. “Instead of taking away the coverage that works for them today, let’s focus on protecting and improving what’s working and fixing what’s not. That’s the most effective way to guarantee that every American has affordable coverage and high-quality care.”

The Federation of American Hospitals (FAH) shares similar concerns, saying in a blog post that the bill “would harm more Americans than it would help.” The post said that allowing more people into the Medicare program would weaken the system for those who are already in it.

Instead, the FAH suggests that “Congress should work to sustain and expand affordable private coverage.”

In a recent blog post, the American Hospital Association’s (AHA) president and CEO, Rick Pollack, reiterated his support for strengthening the existing Affordable Care Act and expanding Medicare, but cautioned not to resort to a one-size-fits-all approach.

He argues that this form of government-run coverage poses risks to many U.S. citizens.

“If Congress controls all payments to providers, delivery system reforms to improve care, enhance quality and reduce costs may no longer be a priority as the government would be able to simply ratchet down reimbursement,” Pollack wrote in a blog post earlier this year.

In addition, relying more fully on Medicare and Medicaid would be costly for hospitals, the AHA said. According to the AHA’s fact sheet on the underpayment of Medicare and Medicaid, hospitals received only 87 cents for every dollar spent caring for Medicare and Medicaid patients in 2017.

Despite the concern from the industry, plans to expand Medicare are popular with voters. According to a recent poll from the Kaiser Family Foundation, 77% of the public supports offering Medicare to those 50 and older.

Universal Health Care in California: $17 Billion a Year, Says One Estimate

Source: San Francisco Chronicle

Universal health care in California could cost $17.3 billion a year, under one plan proposed Friday by UC Berkeley health policy researchers.

The paper offers one path for getting about 3 million uninsured Californians health coverage. It is one of several recent estimates from researchers and legislators who have devised various ways to work toward universal coverage in the state. It is not a plan for a single-payer system.

The figure is significantly higher than other analyses, which found that working toward universal coverage by expanding Medi-Cal insurance for the poor would cost less than half of that. That is because the paper builds in the assumption that the uninsured would get on private health insurance plans, whereas other estimates factor in federal funding for getting more people on Medi-Cal, which is jointly paid for by the federal and state governments.

The paper, by Richard Scheffler and Stephen Shortell of Berkeley’s School of Public Health, proposes a mix of new taxes on the health care industry, California employers and airline travelers, paired with contributions from the state’s general fund and premium payments from individuals who are now uninsured.

The ideas, presented Friday to a group of California health policy researchers and advocates, are considered one early stab at financing universal coverage and are not included in legislative proposals.

The largest source of financing, 41 percent, would come from a 3 percent tax on the revenue of hospitals, nursing homes, drug companies, home care providers and insurance companies, which would generate an estimated $7.2 billion a year. The tax would not apply to public hospitals.

The next largest source of funding, 31 percent or $5.2 billion, would come from currently uninsured residents who would pay a monthly premium for a health plan — envisioned as a plan bought through the insurance marketplace Covered California. The premium would be paid by those who earn too much to qualify for Medi-Cal, the insurance program for the poor, and would average out to $123 a month per person. The authors do not specify how many people would pay this premium, or address how to incentivize this population — many of whom are undocumented and hesitant to participate in government programs — to buy into the system.

The paper also proposes a tax on international and business class travelers who fly into and out of California’s five largest airports: Los Angeles International Airport, San Francisco International Airport, San Diego International Airport, Oakland International Airport and San Jose International Airport. The taxes would be $50 per ticket for domestic business class passengers, $60 per ticket for for economy international passengers and $250 per ticket for international business passengers. These five airports see a collective 188 million passengers each year, according to the authors’ analysis of California Department of Transportation air passenger traffic data. The tax would generate $2.3 billion a year.

The remaining funding would come from the state’s general fund in the amount of $1.7 billion, and a tax on employers that would generate $979 million. The employer tax would be modeled after Healthy San Francisco, a program started in 2007 to cover the city’s 14,000 uninsured residents. It would require employers that don’t provide insurance to their workers to pay into a fund by levying a 4 percent surcharge on customers. It would apply to for-profit employers with more than 20 workers and nonprofit employers with more than 50 workers.

Under the plan, the revenue generated through these proposed new taxes would go toward what’s known as integrated care systems to expand their geographic reach and offer more insurance plans on Covered California. The biggest and most well-known integrated system is Kaiser, which provides both the insurance coverage and health care services to its patients, but others have started forming their own integrated care systems in recent years including Sutter Health’s HMO plan, Sharp Health Care in San Diego and HealthCare Partners in Los Angeles. Those integrated care plans would be offered on Covered California.

Scheffler and Shortell say they hope their ideas are a starting point for debate and will inspire action by state legislators.

“We’re hoping for some interest from Sacramento,” Scheffler said.

Some policy experts who reviewed the paper raised questions about some of the proposed taxes and the cost estimate. Ken Jacobs, chair of the UC Berkeley Labor Center, said $17 billion is much too high for achieving universal coverage because it doesn’t take into account the federal dollars that would be available if the state were to expand Medi-Cal to more uninsured people.

A state-level employer mandate could face legal challenges, as Healthy San Francisco did, because of federal preemption issues under the Employee Retirement Income Security Act, or ERISA, Jacobs said. Similarly, the airline tax might run afoul of federal laws regulating interstate commerce and airlines. And the tax on hospitals would need a two-thirds vote in the Legislature and buy-in from health care providers.

“I look at the (financing) as throwing some ideas on the table to start a discussion,” Jacobs said.

Other proposed measures and analyses put different cost estimates for getting California closer to universal coverage. A report released this month by Covered California found that providing more financial assistance to consumers to buy plans would cost between $2.1 billion and $2.7 billion a year.

One bill, AB-4, proposes expanding Medi-Cal to all undocumented adults — a move the Legislative Analyst’s Office has estimated would cost $3 billion annually. Another bill, AB-174, aims to provide financial assistance to those making between $48,000 and $72,000 to buy insurance. It would cost $40 million to $75 million a year, according to estimates included in a previous bill.

Gov. Gavin Newsom’s proposed budget included expanding Medi-Cal coverage to undocumented young adults between ages 19 and 25, and providing state-funded financial assistance to help Californians buy insurance — both of which would be steps toward universal coverage in the state. It is unclear how much the initiatives would cost.

Californians Want Leaders to Expand Access to Mental Health Care, Kaiser Survey Finds

Image result for Californians Want Leaders to Expand Access to Mental Health Care, Kaiser Survey Finds images

Source: Sacramento Bee

Californians indicated In a survey released Thursday that they want state leaders to put a priority on ensuring that people with mental health conditions can get access to treatment, with 49 percent saying it’s extremely important and 39 percent saying it’s very important.

The Kaiser Family Foundation and California Health Care Foundation designed and conducted the poll of 1,404 Californians in November and December, looking to gauge health care priorities and experiences in a state considered a leader in health-care trends. The study’s author noted that, while on the campaign trail, Gov. Gavin Newsom made health care a priority and announced sweeping plans for change in health care.

Survey findings offer a view of what state residents want, the survey authors said, as the new governor takes the reins and a new legislative session begins. Asked to rank what they felt state leaders should make their top priorities, poll respondents put improving public education in the top spot, but following closely behind was making health care more affordable.

While 86 percent of those surveyed considered improving public education very or extremely important, health care affordability ranked highly with 80 percent. Coming in third was making housing more affordable at 75 percent. The findings had an error rate of plus or minus 3 percentage points.

Asked to assess what aspects of health care mattered most to them, survey respondents ranked expanding access to mental health care as most crucial. Next on the list was making sure all Californians have access to health care and third, lowering the cost of health care for Californians.

“About half — 52 percent — of Californians say their community does not have enough mental health providers to serve the needs of local residents, compared to 27 percent who say it does have enough and 21 percent who say they don’t know enough to say,” survey authors said.

Pulling Back Curtain On Hospital Prices Adds New Wrinkle In Cost Control

Image result for Pulling Back Curtain On Hospital Prices Adds New Wrinkle In Cost Control images

Source: Kaiser Health News

As President Donald Trump was fighting with Congress over the shutdown and funding for a border wall, his administration implemented a new rule that could be a game changer for health care.

Starting this month, hospitals must publicly reveal the contents of their master price lists — called “chargemasters” — online. These are the prices that most patients never notice because their insurers negotiate them down or they appear buried as line items on hospital bills. What has long been shrouded in darkness is now being thrown into the light.

For the moment, these lists won’t seem very useful to the average patient — and they have been criticized for that reason. They are often hundreds of pages long, filled with medical codes and abbreviations. Each document is an overwhelming compendium listing a rack rate for every little item a hospital dispenses and every service it performs: a blood test for anemia. The price of lying in the operating suite and recovery room (billed in 15-minute intervals). The scalpel. The drill bit. The bag of IV salt water. The Tylenol pill. No item is too small to be bar coded and charged.

But don’t dismiss the lists as useless. Think of them as raw material to be mined for billing transparency and patient rights. For years, these prices have been a tightly guarded industrial secret. When advocates have tried to wrest them free, hospitals have argued that they are proprietary information. And, hospitals claim, these rates are irrelevant, since — after insurers whittle them down — no one actually pays them.

Of course, the argument is false, and our wallets know it.

First of all, hospitals routinely go after patients without insurance or whose insurer is not in their network. When Wanda Wickizer had a brain hemorrhage in 2013, a Virginia hospital billed her $286,000 after a 20 percent “uninsured” discount on a hospital bill of $357,000 — the list price, according to chargemaster charges. Medicare would have paid less than $100,000 for her treatment.

Second, those list prices form the starting point for negotiations, allowing hospitals and insurers to take credit for beneficence, when there is none.

Not!

If a supposedly $1,000 TV is “on sale” for $80, it’s not really a discount. It’s an absurd list price.

Just as airlines have been shown to exaggerate flight times so they can boast about on-time arrivals, hospitals set prices crazy high so they can tout their generous discounts (while insurers tout their negotiating prowess).

Another rationale for those prices is just plain greed. Dr. Warren Browner, the chief executive of California Pacific Medical Center, describes this as the “Saudi sheikh problem”: “You don’t really want to change your charges if you have a Saudi sheikh come in with a suitcase full of cash who’s going to pay full charges,” he said.

But in an era when American patients are expected to be good consumers and are paying more of their bills in the form of copays and deductibles, they have a right to the information on list prices. They have a right to make sure they are reasonable.

Although making chargemaster pricing public will not, by itself, reform our high-priced medical system, it is an important first step. Maybe, just maybe, a hospital will think twice before charging a $6,000 “operating room fee” for a routine colonoscopy if its competitor down the street is listing its price at $1,000. Making this information public should bring list prices more in line with what is actually paid by an insurer, a far better measure of value.

And while the lists are far from user-friendly, researchers and entrepreneurs can now create apps to make it easier for patients to match procedures to their codes and crunch the numbers. With access to list prices on your phone, you could reject the $300 sling in the emergency room and instead order one for one-tenth of the price on Amazon. You could see in advance the $399 rate your hospital charges for each allergen it applies in a skin test and avoid the $48,000 allergy test — with an $8,000 deductible.

As a next step, regulators should insist that these prices be easily accessible on hospitals’ home pages — perhaps in the place of “PAY YOUR BILL NOW” — and translated into plain English. Seema Verma, the head of the Centers for Medicare & Medicaid Services, has suggested that she may well do so.

Patients can help, too: Check out your hospital’s price list. If it’s not detailed or complete enough, demand more. For discrete items, like an MRI of the brain or a vitamin D blood test, take the trouble to scan the chargemaster for the item. Reject an overpriced procedure (even if your insurer is paying the bulk of the bill) and take your business elsewhere.

Justice Louis Brandeis famously said, “Sunlight is said to be the best of disinfectants; electric light the most efficient policeman.” But, in this case, the reform will work only if people take the trouble to look — and to act — now that the lights are turned on.

Last Updated 06/19/2019

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