Healthcare

[Legacy]

Chronic Diseases: The Leading Causes of Death and Disability in the United State (CDC)

Chronic Diseases: The Leading Causes of Death and Disability in the United States

Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems.

The Cost of Chronic Diseases and Health Risk Behaviors

In the United States, chronic diseases and conditions and the health risk behaviors that cause them account for most health care costs.

Eighty-six percent of all health care spending in 2010 was for people with one or more chronic medical conditions.

Multiple Chronic Conditions (CDC)

Chronic diseases and conditions—such as heart disease, stroke, cancer, type 2 diabetes, obesity, and arthritis—are among the most common, costly, and preventable of all health problems.

As of 2012, about half of all adults—117 million people—had one or more chronic health conditions. One of four adults had two or more chronic health conditions.1

One in four Americans has multiple chronic conditions, those that last a year or more and require ongoing medical attention or that limit activities of daily living.1 That number rises to three in four Americans aged 65 and older.2

Having multiple chronic conditions is also associated with substantial health care costs. Approximately 71% of the total health care spending in the United States is associated with care for the Americans with more than one chronic condition.2 Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending.3 People with multiple chronic conditions face substantial out-of-pocket costs of their care, including higher costs for prescription drugs.

 

[Legacy]

How Does Growth in Health Care Costs Affect the American Family?
(Analysis by Rand Corp, 2011) - prior to Congress passing the Affordable Care Act

In the ten-year period between 1999 and 2009, U.S. health care spending nearly doubled, climbing from $1.3 trillion to $2.5 trillion. In 2009, while the rest of the U.S. economy plunged into recession and millions lost their jobs, health care costs grew by 4 percent. As a result, the percentage of our nation's gross domestic product (GDP) devoted to health care reached 17.6 percent, up from 13.8 percent only ten years earlier. Although these numbers are striking, they do not easily translate into figures that are meaningful to individual Americans.

How Do Health Care Costs Affect Available Income?

Health care costs affect family finances in four ways:

-- the family's share of the health insurance premium (not taxed)
-- out-of-pocket spending — e.g., for co-pays, deductibles, and prescriptions
-- the employer's share of the health insurance premium (not taxed)
-- the portion of the family's federal and state taxes devoted to government health programs — e.g., Medicaid, Medicare, veterans' health care, and public health.

Special Feature: The Rising Costs of Health Care
A Decade of Health Care Cost Growth: Impact on the American Family (Feature, with article links. Rand)

 

[Legacy]

House Passes Mental Health Bill
Measure is first effort by lawmakers to specifically tackle federal policies on serious mental illness (Wall Street Journal)

America's Largest Mental Hospital Is a Jail
At Cook County, where a third of those incarcerated suffer from psychological disorders, officials are looking for ways to treat inmates less like prisoners and more like patients. (Atlantic)

 

[Legacy]

Zika funding

Zika funding

With a Zika appropriations bill failing in Congress, here are some funds transferred, given out in grants, made available from Medicaid or appropriated from state coffers.

- $510 million from an Ebola fund and $79 million from other funds for outbreaks and vaccines transferred by the President

- $26 million authorized by Florida's Governor from emergency funds

- $25 million in funding from grants by the CDC to states, cities, and territories to support efforts to protect Americans from Zika virus infection and associated adverse health outcomes,

- $48 million from the Dept of Health and Human Services for initial research into testing for Zika in blood products

Also, the Centers for Medicare and Medicaid Services (CMS) recently released a bulletin to state Medicaid Directors outlining how Medicaid funds can be used to both prevent the spread of Zika and treat people infected by the disease and infants born with microcephaly. With Medicaid covering roughly half of the births in America today, the program will finance many pregnancies potentially affected by Zika.

Zika May Place Burden On Medicaid

How states and their Governors are addressing Zika and are working with the CDC. Many of the Southern states, who will be most impacted by Zika, chose not to expand their Medicaid coverage and will have fewer people covered by Medicaid emergency response funds.

Zika Is Coming – And States Don’t Have The Emergency Funds To Handle It

 

[Legacy]

Obama administration moves to block health insurance mega-mergers (LA Times)

The Obama administration went to court Thursday to block two major health insurance mergers, siding with consumer advocates and medical groups worried that the consolidation of large national health plans could lead to higher premiums.

The long-anticipated move by the Justice Department and attorneys general in California and 10 other states, will at least temporarily prevent Anthem Inc.’s $48-billion purchase of Cigna Corp., a combination that would create the nation’s largest health insurer.

And it will stop Aetna Inc.’s $34-billion bid to acquire Humana Inc., a merger that would have combined the nation’s third- and fifth-biggest health plans.

“Competitive insurance markets are essential to providing Americans the affordable and high-quality healthcare they deserve,” Atty. Gen. Loretta E. Lynch said Thursday after the suits were filed in federal district court in Washington.

"These mergers would restrict competition for health insurance products sold in markets across the country and would give tremendous power over the nation’s health insurance industry to just three large companies,” she said. “Our actions seek to preserve competition that keeps premiums down and drives insurers to collaborate with doctors and hospitals to provide better healthcare for all Americans.”

California Atty. Gen. Kamala Harris warned that the mergers would “threaten the availability and quality of medical care” around Los Angeles and other California markets.

"This is a huge issue for our country,” said Martin Gaynor, a Carnegie Mellon health economist who has researched consolidation. “If we don’t do something about this now, we will have an even more consolidated, expensive, unresponsive health system than we have already, and once this happens, it will be extremely difficult, to impossible, to change."

 

[Legacy]

Provider Medicare Fraud

Provider Medicare Fraud

Justice Department Charges Three in $1 Billion Medicare Fraud Scheme in Florida:
Prosecutors outline details of its largest-ever single criminal health-care fraud case (WSJ, July 22, 2016

The Justice Department on Friday unsealed charges in its largest-ever criminal health-care-fraud case, charging three individuals with using a network of doctors, hospitals and health-care providers across South Florida to improperly bill more than $1 billion to Medicare and Medicaid.

Top SNF Therapy Provider Settles DOJ Lawsuit for $125 Million (June 2016)

The US Department of Justice (DOJ) announced that the nation's largest nursing home therapy provider has agreed to pay $125 million to settle a DOJ lawsuit that alleged the company engaged in a "systematic and broad-ranging scheme" to increase Medicare reimbursements by submitting false claims for rehabilitation therapy.

Florida doc sentenced to prison for Medicare fraud (Modern Healthcare, June 2016)

A Florida physician was sentenced to 46 months in prison after he pleaded guilty to a Medicare fraud scheme.

"]The War on Medicare Fraud: Medicare loses $60 billion each year to con artists. Here's why (AARP, June 2016)

WHERE DID ALL THE MONEY GO? That's what the authorities wondered, even after they searched the house of Jacques Roy. Inside the physician's lakefront home in the Dallas suburb of Rockwall, police found a fake Texas driver's license and Canadian birth certificate — both in the name of Michel Poulin — plus deposit slips from banks in the Cayman Islands and a guide to registering yachts there. Also found: a book called Hide Your Assets and Disappear: A Step-by-Step Guide to Vanishing Without a Trace.

But before he was able to make his escape, investigators from the Office of Inspector General for the U.S. Department of Health and Human Services (HHS) moved in, tipped off by Roy's astounding billing figures. From 2006 to 2011, prosecutors say Roy's business, Medistat Group Associates, certified over 11,000 Medicare beneficiaries to receive home health care, more than any other doctor in the country. The scheme involved recruiting thousands of healthy patients and billing for home care they did not need, and it netted $375 million from Medicare and Medicaid—the largest home health care fraud in the history of the programs. In April, Roy was convicted of eight counts of health care fraud and other charges.

The True Face of Medicare Fraud
A $712 million bust, the biggest in U.S. history, shows that the people most likely to bilk the system are doctors and medical providers, not “welfare queens.” (Atlantic, June19,2015)

Nearly lost Thursday in the response to the atrocity in Charleston was Attorney Loretta Lynch’s announcement of arrests in what she called “the largest criminal healthcare fraud takedown in the history of the Department of Justice.” A total of 243 people were arrested and charged with stealing $712 million from Medicare. The arrests included 46 doctors, nurses, pharmacy owners, and other medical professionals. Facilities billed the federal government for therapy sessions where patients were actually just moved, never treated. In a particularly disturbing case, a Michigan doctor allegedly “prescribed unnecessary narcotics in exchange for patients' identification information, which was used to generate false billings. Patients then became deeply addicted to the prescription narcotics and were bound to the scheme as long as they wanted to keep their access to the drugs.”

Examples of Healthcare Fraud Investigations - Fiscal Year 2015
The following examples of Healthcare Fraud Investigations are written from public record documents on file in the courts within the judicial district where the cases were prosecuted. (IRS)

U.S. Recovers $3.3 Billion in Federal Health-Care Fraud
Obama administration steps up efforts to prevent Medicare fraud, not just uncover it (WSJ, March 2015)

The government recovered $3.3 billion in fiscal 2014 from individuals and companies that tried to defraud federal health programs, part of an effort by the Obama administration to improve enforcement and prevent abusive billing practices.

 

[Legacy]

Medicare Provider Fraud II

Medicare Provider Fraud II

Above articles and detailed prosecution and/or charges against health care providers indicates the extent of health care fraud that we all pay for in one way or another. In federally- administered Medicare only, the cost is estimated to be $60 Billion per year. That does not include private health insurance for the same population where patients have assigned their benefits to particular health insurance companies - "Advantage plans" - in which the plans are paid directly by Medicare. Each of these like Blue Cross Blue Shields, United Health Care, Humana, etc. have their own hotlines for fraud and rely audits of a small percentage of charts, their patients whistleblowing and fraud detection software. sp, But these privately owned Advantage plans are not able to investigate cases like the federal government can even if the government is understaffed.

The majority of seniors are on (straight) Medicare, but 31% of seniors are on Advantage plans. If a third of seniors are on Advantage plans and fraud is underreported, that adds another $20 Billion to provider fraud and abuse.

Medicare Advantage (Kaiser Family Foundation)

Identification and prosecution of these crimes have been facilitated by Medicare expanding their database in 2007 and accelerated by the requirement of electronic medical records by the Affordable Care Act.

The $272 billion swindle: Why thieves love America’s health-care system (Economist, May 2014)

Health care is a tempting target for thieves. Medicaid doles out $415 billion a year; Medicare (a federal scheme for the elderly), nearly $600 billion. Total health spending in America is a massive $2.7 trillion, or 17% of GDP. No one knows for sure how much of that is embezzled, but in 2012 Donald Berwick, a former head of the Centres for Medicare and Medicaid Services (CMS), and Andrew Hackbarth of the RAND Corporation, estimated that fraud (and the extra rules and inspections required to fight it) added as much as $98 billion, or roughly 10%, to annual Medicare and Medicaid spending—and up to $272 billion across the entire health system.

Punishments have grown tougher: last year the owner of a mental-health clinic got 30 years for false billing. Efforts to claw back stolen cash are highly cost-effective: in 2011-13 the government’s main fraud-control programme, run jointly by the Department of Health and Human Services (HHS) and the Department of Justice, recovered $8 for every $1 it spent.

Biggest healthcare frauds in 2015: Running list (Health Finance, Dec 2015)

 

[Legacy]

How to Pay for Health Care (Harvard Business Review)

Summary

The United States stands at a crossroads in how to pay for health care. Fee for service, the dominant payment model in the U.S. and many other countries, is now widely recognized as perhaps the single biggest obstacle to improving health care delivery. A battle is currently raging, outside of the public eye, between the advocates of two radically different payment approaches: capitation and bundled payments. The stakes are high, and the outcome will define the shape of the health care system for many years to come, for better or for worse.

In this article, the authors argue that although capitation may deliver modest savings in the short run, it brings significant risks and will fail to fundamentally change the trajectory of a broken system. The bundled payment model, in contrast, triggers competition between providers to create value where it matters—at the individual patient level—and puts health care on the right path.

The authors provide robust proof-of-concept examples of bundled payment initiatives in the U.S. and abroad, address the challenges of transitioning to bundled payments, and respond to critics’ concerns about obstacles to implementation.

Excerpt:

Fee for service rewards the quantity but not the quality or efficiency of medical care. The most common alternative payment system today—fixed annual budgets for providers—is not much better, since the budgets are disconnected from the actual patient needs that arise during the year. Fixed budgets inevitably lead to long waits for nonemergency care and create pressure to increase budgets each year.

We need a better way to pay for health care, one that rewards providers for delivering superior value to patients: that is, for achieving better health outcomes at lower cost. The move toward “value-based reimbursement” is accelerating, which is an encouraging trend. And the Centers for Medicare & Medicaid Services (CMS), to its credit, is leading the charge in the United States.

 

[Legacy]

Antimicrobial Resistance

Antimicrobial Resistance

The CDC has some good info.
About Antimicrobial Resistance

Estimating the Economic Costs of Antimicrobial Resistance (Rand Corp)

We focused only on the effects that AMR has on the economy through disruption of the supply of labour, by estimating the impact that an increase in resistance would have on the labour force through two mechanisms.

-- Increased mortality – as deaths attributable to AMR permanently reduce the size of the working-age population; and
-- Increased morbidity – as prolonged periods of sickness temporarily reduce the size of the global workforce and may, in severe cases, lead to permanent reductions in labour efficiency (productivity)

Findings

Depending on the scenario, we estimate that failing to tackle AMR will mean that the world population by 2050 will be between 11 million and 444 million lower than it would otherwise be in the absence of AMR. The lower bound is a result of a scenario where resistance rates have been successfully kept at a relatively low rate while the upper bound reflects a scenario for a world with no effective antimicrobial drugs.

Global Working-Age Population Lost to Drug-Resistant "Superbugs," in Millions
A chart of the global working-age population lost to drug-resistant 'superbugs', in millions.At current rates of antimicrobial resistance, we estimate that 2.5 million people will be lost to to drug-resistant "superbugs" in 2020, 5.9 million will be lost in 2030, and 15 million will be lost in 2050. By comparison, at a 100% rate of antimicrobial resistance, we estimate that 92.3 million people will be lost in 2020, 200 million will be lost in 2030, and 444.1 million will be lost in 2050.

The reduction in population and the morbidity impact would also reduce the level of world Gross Domestic Product (GDP). We estimate that by 2050 the world economy would be smaller by between 0.06% and 3.1%, again depending on the scenario. Since these GDP losses are annual and thus compound over time, they result in a cumulative loss that ranges between $2.1 trillion and $124.5 trillion.

Our study included only costs resulting from the disruption of the supply of effective labour and did not attempt to quantify other impacts such as increased healthcare costs and wider indirect social costs. The full potential costs of AMR amount to a world without effective antimicrobial drugs, with serious repercussions for modern healthcare as we know it. Our results should be understood as an underestimate of the true total cost of AMR.

 

[Legacy]

Our health care costs are getting dangerously high (The Week)

Last year, health care spending in the U.S. claimed 17.8 percent of the overall economy and held relatively steady. But within the coming decade, health care will consume 20 percent of the overall economy, marking an important turning point for government policy makers.

A recent report by the Centers on Medicare and Medicaid Services (CMS) projects a 5.8 percent annual growth rate in health costs between now and 2025. That is a more robust rate than we've seen throughout most of the Obama administration that would exceed the overall economic growth rate by 1.3 percentage points.

Among the reports more salient findings:

- Health care spending will average in excess of $10,000 a person this year — the highest level ever — and continue to climb.
- Medicare and Medicaid spending for seniors and low-income people will rev up in the coming decade after something of a lull.
- Prescription drug prices will continue to increase sharply, especially the pricey specialty drugs.

 

[Legacy]

Duplicate

 

[Legacy]

U.S. faces 90,000 doctor shortage by 2025, medical school association warns

The U.S. Is Running Out of Nurses

 

[Legacy]

The O'Neill Review: A Critical Step in Taking Global Action Against AMR (Antimicrobial Resistance) (Rand Corp)

We found that a continuation of the current situation — a world with no increases in the rates of infection or resistance — would result in a loss of between 11 million and 14 million working-age adults globally by 2050. The burden would be borne disproportionately by less-affluent regions, such as Sub-Saharan Africa and Southeast Asia, due to their relatively high prevalence of infectious diseases, such as HIV/AIDS and malaria.

We also constructed a “doomsday scenario,” which simulated a world with no effective antibiotics. In this scenario, the total value of loss of life would reach 444 million by 2050. In economic terms, this would result in a cumulative loss of more than 100 trillion USD, or an average annual loss of approximately 3 trillion dollars.

From "TACKLING DRUG-RESISTANT INFECTIONS GLOBALLY: FINAL REPORT AND RECOMMENDATIONS" linked in article above:

As with all forecasts of this sort, it is of course possible that our estimates may turn out to be too large, but we believe it is even more likely that they could be too small. This is because we did not even consider the secondary effects of antibiotics losing their effectiveness, such as the risks in carrying out caesarean sections, hip replacements, or gut surgery. And in the short 19 months since we started, new forms of resistance have emerged that we did not contemplate occurring so soon...

 

[Legacy]

OVERKILL: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? (ANNALS OF HEALTH CARE MAY 11, 2015 ISSUE reprinted in NYT magazine)

The researchers called it “low-value care.” But, really, it was no-value care. They studied how often people received one of twenty-six tests or treatments that scientific and professional organizations have consistently determined to have no benefit or to be outright harmful. Their list included doing an EEG for an uncomplicated headache (EEGs are for diagnosing seizure disorders, not headaches), or doing a CT or MRI scan for low-back pain in patients without any signs of a neurological problem (studies consistently show that scanning such patients adds nothing except cost), or putting a coronary-artery stent in patients with stable cardiac disease (the likelihood of a heart attack or death after five years is unaffected by the stent). In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

 

[Veritate Duce Progredi]

OVERKILL: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? (ANNALS OF HEALTH CARE MAY 11, 2015 ISSUE reprinted in NYT magazine)

I don't have time to read that entire article but does it discuss the thought process physicians have when ordering these unnecessary tests? Is it because they don't want to leave themselves exposed to litigation if the patient has a more serious condition? I believe tort reform in medicine needs to be at the top of the list if we want to see healthcare costs go down.

 

[Legacy]

In Alabama, football is more important than living

But if it's our health, we yawn.

What I mean is that Alabama now has a lower life expectancy than Mexico or Vietnam. We are shorter-lived than people in Sri Lanka or Uruguay.

Think about that. In health, Alabama is a middle rank 3rd world country.

That's assuming that life expectancy is a reasonable measure of health. Is it?

Of course, I know – and you know -- many of the things that increase or decrease life expectancy. One thing you may not realize decreases it, though, is living in the US.

Americans in the 1800's were among the longest-lived people in the world. By 1950 when the United Nations began collecting worldwide health information, the US ranked 12th in life expectancy.

Not bad, but probably not particularly good either, as our per capita wealth was the highest in the world at that point – by a long shot. Things have gotten worse though. In a recent study of more than 180 countries, the US ranked 36th in life expectancy, sandwiched between Cuba and Chile – yes, just below Chile.

Why the US has such a low life expectancy is not so obvious. After all, we have some of the finest doctors and hospitals in the world.

Getting back to Alabama, we are particularly unhealthy even by American standards. Thank God for Mississippi, indeed. We are 49th in life expectancy. We are #1 in one respect. We have the city – Gadsden – with the lowest life expectancy in the entire country.

There is little mystery about why Alabama ranks so low among American states. The Big Six factors affecting health in America are race, education, wealth, obesity, smoking, and exercise. In these factors, Alabama ranks 45th, 46th, 44th, 46th, tied for 41st, and 48th, respectively.

 

[Legacy]

Government-Protected ‘Monopolies’ Drive Drug Prices Higher, Study Says (CNBC)

TPP and the Dire Threat to Affordable Drug Prices (Huffington)

Drug Pricing Webcast (Harvard Medical School)

Drug prices inflated by exclusivity rights, JAMA article says

 

[irishff1014]

CEO received 671 percent raise during EpiPen price hike| Latest News Videos | Fox News

 

[Legacy]

I hope you've had some time to read the article, because there are multiple reasons and many factors involved in excessive health care spending.

I don't have time to read that entire article but does it discuss the thought process physicians have when ordering these unnecessary tests?

Is it because they don't want to leave themselves exposed to litigation if the patient has a more serious condition? I believe tort reform in medicine needs to be at the top of the list if we want to see healthcare costs go down.

Some excerpts:

In just a single year, the researchers reported, twenty-five to forty-two per cent of Medicare patients received at least one of the twenty-six useless tests and treatments.

In 2010, the Institute of Medicine issued a report stating that waste accounted for thirty per cent of health-care spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education. The report found that higher prices, administrative expenses, and fraud accounted for almost half of this waste. Bigger than any of those, however, was the amount spent on unnecessary health-care services. Now a far more detailed study confirmed that such waste was pervasive.

Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another. The costs appear to take thousands of dollars out of the paychecks of every household each year.

Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.

Well, as a doctor, I am far more concerned about doing too little than doing too much. It’s the scan, the test, the operation that I should have done that sticks with me—sometimes for years.

It is different, however, when I think about my experience as a patient or a family member. I can readily recall a disturbing number of instances of unnecessary care.

We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.

Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body.

The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests. Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish.

Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime.

The author mentions more reasons, but I do not have time to cut and paste them. Tort reform is not even mentioned as solution.

OVERKILL: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? (ANNALS OF HEALTH CARE MAY 11, 2015 ISSUE reprinted in NYT magazine)

 

[RDU Irish]

A Comparison of Hospital Administrative Costs in Eight Nations: U.S. Costs Exceed All Others by Far - The Commonwealth Fund

I know it is more fashionable to pick on drug companies but coffee chugging MDs who haven't touched patients for decades while skimming a big check off the top of the "non-profit" hospitals is a big problem (along with underutilized specialists).

 

[irish1958]

Bloodsuckers

Bloodsuckers

The High Cost of Prescription Drugs in the United States

Importance The increasing cost of prescription drugs in the United States has become a source of concern for patients, prescribers, payers, and policy makers.

Objectives To review the origins and effects of high drug prices in the US market and to consider policy options that could contain the cost of prescription drugs.

Evidence We reviewed the peer-reviewed medical and health policy literature from January 2005 to July 2016 for articles addressing the sources of drug prices in the United States, the justifications and consequences of high prices, and possible solutions.

Findings Per capita prescription drug spending in the United States exceeds that in all other countries, largely driven by brand-name drug prices that have been increasing in recent years at rates far beyond the consumer price index. In 2013, per capita spending on prescription drugs was $858 compared with an average of $400 for 19 other industrialized nations. In the United States, prescription medications now comprise an estimated 17% of overall personal health care services. The most important factor that allows manufacturers to set high drug prices is market exclusivity, protected by monopoly rights awarded upon Food and Drug Administration approval and by patents. The availability of generic drugs after this exclusivity period is the main means of reducing prices in the United States, but access to them may be delayed by numerous business and legal strategies. The primary counterweight against excessive pricing during market exclusivity is the negotiating power of the payer, which is currently constrained by several factors, including the requirement that most government drug payment plans cover nearly all products. Another key contributor to drug spending is physician prescribing choices when comparable alternatives are available at different costs. Although prices are often justified by the high cost of drug development, there is no evidence of an association between research and development costs and prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.

"Conclusions and Relevance High drug prices are the result of the approach the United States has taken to granting government-protected monopolies to drug manufacturers, combined with coverage requirements imposed on government-funded drug benefits. The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policy makers about these choices." Quoted from this weeks JAMA
August 23/30, 2016, Vol 316, No. 8

This is exactly the type of behavior that forced President Teddy Roosevelt and congress to institute antitrust legislation.
Congress, specifically the Republicans in the House are directly responsible for this mess as they forbid Medicare, Medicade, the VA and all other federal health agencies from negotiating any drug costs. They MUST pay, without question, whatever the drug companies charge.
BLOODSUCKERS and DIRTBAGS all of them: congressmen and drug company CEOs..

Another cause of excessive medical costs is that congress forces coverage for all sorts of unscientific and worthless medical procedures and quackery.
(See Dr Harriet Hall's video essays on Scientific Medicine on YouTube.)

 

[Blazers46]

Just got off the phone with billing at a Dr office. 14 months agoI waited 4 hours to see a Doc and all they did was have me turn and cough and press on my press on my abdomen to see if I had a hernia. Doc then prescribes me ibuprofen stating its just general pain. Went to see another doc and I had a hernia. I am just now receiving a bill from the doc that made me wait 4 hours and saw me for 3 minutes and diagnosing me with general pain (what does that even mean?) They billed my insurance 780 dollars for the visit.

 

[pkt77242]

Mylan isn't alone: 11 drugmakers with off-the-charts pricing power

 

[woolybug25]

Just got off the phone with billing at a Dr office. 14 months agoI waited 4 hours to see a Doc and all they did was have me turn and cough and press on my press on my abdomen to see if I had a hernia. Doc then prescribes me ibuprofen stating its just general pain. Went to see another doc and I had a hernia. I am just now receiving a bill from the doc that made me wait 4 hours and saw me for 3 minutes and diagnosing me with general pain (what does that even mean?) They billed my insurance 780 dollars for the visit.

I bet bet bet tha thats what he pressed on.

 

[Domina Nostra]

While you can make marginal gains in efficiency, fairness, etc., the reality is that there is always going to be a tension between service and cost. You can't expect to pay significantly less and get the same services. Whether you pay for it in terms of longer average waits, lower quality of doctors, less incentive for innovative technology, or actual lower quality of service, you are going to pay for it.

When you wrap in a bunch of high-risk patients into the pool, you either have to pay more, or get less.

Sure, there are bad actors and inefficiencies in the current system. NO DOUBT. That is where I agree that marginal gains are possible. But the issue of socializing medicine is 100% about "fairness." Nobody should allow themselves to believe that we are not going to be able to provide everyone with the same access to medicine without making it more expensive and lower quality is just fooling themselves, IMO.

So if it the situation was this:
- 10% of the country gets excellent service for a decent price by weeding out the highest risk patients and strong bargaining power
- 50% get decent coverage at a decent price by because of some risk and little bargaining power
- 40% get bad coverage because they are high risk and have no bargaining power
AND
We could guarantee that 100% would get decent coverage at a decent price after socializing... then you go for it.

But what if, say:
- 50% gets excellent service for a decent price by weeding out the highest risk patients and strong bargaining power
- 35% get decent coverage at a decent price by because of some risk and little bargaining power
- 15% get bad coverage because they are high risk and have no bargaining power
AND
Do you still go for it? You would be making 50% worse off for the betterment of 15%

 

[MJ12666]

The High Cost of Prescription Drugs in the United States

Importance The increasing cost of prescription drugs in the United States has become a source of concern for patients, prescribers, payers, and policy makers.

Objectives To review the origins and effects of high drug prices in the US market and to consider policy options that could contain the cost of prescription drugs.

Evidence We reviewed the peer-reviewed medical and health policy literature from January 2005 to July 2016 for articles addressing the sources of drug prices in the United States, the justifications and consequences of high prices, and possible solutions.

Findings Per capita prescription drug spending in the United States exceeds that in all other countries, largely driven by brand-name drug prices that have been increasing in recent years at rates far beyond the consumer price index. In 2013, per capita spending on prescription drugs was $858 compared with an average of $400 for 19 other industrialized nations. In the United States, prescription medications now comprise an estimated 17% of overall personal health care services. The most important factor that allows manufacturers to set high drug prices is market exclusivity, protected by monopoly rights awarded upon Food and Drug Administration approval and by patents. The availability of generic drugs after this exclusivity period is the main means of reducing prices in the United States, but access to them may be delayed by numerous business and legal strategies. The primary counterweight against excessive pricing during market exclusivity is the negotiating power of the payer, which is currently constrained by several factors, including the requirement that most government drug payment plans cover nearly all products. Another key contributor to drug spending is physician prescribing choices when comparable alternatives are available at different costs. Although prices are often justified by the high cost of drug development, there is no evidence of an association between research and development costs and prices; rather, prescription drugs are priced in the United States primarily on the basis of what the market will bear.

"Conclusions and Relevance High drug prices are the result of the approach the United States has taken to granting government-protected monopolies to drug manufacturers, combined with coverage requirements imposed on government-funded drug benefits. The most realistic short-term strategies to address high prices include enforcing more stringent requirements for the award and extension of exclusivity rights; enhancing competition by ensuring timely generic drug availability; providing greater opportunities for meaningful price negotiation by governmental payers; generating more evidence about comparative cost-effectiveness of therapeutic alternatives; and more effectively educating patients, prescribers, payers, and policy makers about these choices." Quoted from this weeks JAMA
August 23/30, 2016, Vol 316, No. 8

This is exactly the type of behavior that forced President Teddy Roosevelt and congress to institute antitrust legislation.
Congress, specifically the Republicans in the House are directly responsible for this mess as they forbid Medicare, Medicade, the VA and all other federal health agencies from negotiating any drug costs. They MUST pay, without question, whatever the drug companies charge.
BLOODSUCKERS and DIRTBAGS all of them: congressmen and drug company CEOs..

Another cause of excessive medical costs is that congress forces coverage for all sorts of unscientific and worthless medical procedures and quackery.
(See Dr Harriet Hall's video essays on Scientific Medicine on YouTube.)

This is not true. "They" cannot charge government agencies whatever they want. This statement is simply ignorant. When selling to a government agency they must charge the government the lowest wholesale price based on sales to any "third" party in the US. If it is discovered that they overcharged the drug company is subject to very punitive fines. and the VA actually does negotiate for lower prices.

https://www.justice.gov/opa/pr/glax...-resolve-fraud-allegations-and-failure-report

VA buys drugs cheaply, many veterans benefit | Physicians for a National Health Program

 

[irish1958]

This is not true. "They" cannot charge government agencies whatever they want. This statement is simply ignorant. When selling to a government agency they must charge the government the lowest wholesale price based on sales to any "third" party in the US. If it is discovered that they overcharged the drug company is subject to very punitive fines. and the VA actually does negotiate for lower prices.

https://www.justice.gov/opa/pr/glax...-resolve-fraud-allegations-and-failure-report

VA buys drugs cheaply, many veterans benefit | Physicians for a National Health Program

Unfortunately, it is true. The old trick of forcing your competitors out of business, buying them out and other legal maneuvers to create virtual monopolies allows them to set exorbitant prices, the lowest exorbitant price is what the government must pay.
Thank EpiPen: the epinepherine costs $3.00, the packaging perhaps $5.00, and the distribution perhaps another $5.00. There is no developing cost. The quality control costs are the same as any consumer product, such as a bottle of katchup or a pound of hamburger. So the product cost are much less than $20 but they charge $600+. The family will need an average of four units per year or $2400 per year in drug costs. Since the company has established a monopoly, this is what everybody, including the government by law must pay. The reason the CEO today refused to lower the price is for that reason. Out of the goodness of her heart she offered some customers a $300 reduction on one unit; most will pay full price (or their insurance company will).
The drug companies have legions of lawyers working 24/7 plotting "legal" ways to establish ways to screw the consumers
Reread the AMA editorial. It is really the way it is.

 

[MJ12666]

Unfortunately, it is true. The old trick of forcing your competitors out of business, buying them out and other legal maneuvers to create virtual monopolies allows them to set exorbitant prices, the lowest exorbitant price is what the government must pay.
Thank EpiPen: the epinepherine costs $3.00, the packaging perhaps $5.00, and the distribution perhaps another $5.00. There is no developing cost. The quality control costs are the same as any consumer product, such as a bottle of katchup or a pound of hamburger. So the product cost are much less than $20 but they charge $600+. The family will need an average of four units per year or $2400 per year in drug costs. Since the company has established a monopoly, this is what everybody, including the government by law must pay. The reason the CEO today refused to lower the price is for that reason. Out of the goodness of her heart she offered some customers a $300 reduction on one unit; most will pay full price (or their insurance company will).
The drug companies have legions of lawyers working 24/7 plotting "legal" ways to establish ways to screw the consumers
Reread the AMA editorial. It is really the way it is.

I am not going to waste my time any more on this issue. I will say that I do agree that I that the federal government should set the price for Rx drugs at the time they are brought to market. Any further increases should be tied to inflation.

 

[Legacy]

This is not true. "They" cannot charge government agencies whatever they want. This statement is simply ignorant. When selling to a government agency they must charge the government the lowest wholesale price based on sales to any "third" party in the US. If it is discovered that they overcharged the drug company is subject to very punitive fines. and the VA actually does negotiate for lower prices.

https://www.justice.gov/opa/pr/glax...-resolve-fraud-allegations-and-failure-report

VA buys drugs cheaply, many veterans benefit | Physicians for a National Health Program

You are correct about government drug price controls for only those agencies who are authorized and who negotiate on specific prices for specific drugs like with the VA. When Congress authorized the Affordable Care Act, this type of negotiating was not enacted nor is there any price negotiation in other federal programs.

Health insurance companies can only pass along these increases with higher rates, high deductible plans or shifting meds to higher tiers for which the consumer pays more. Here's more from the JAMA article, The High Cost of Prescription Drugs in the United States

Between 2013 and 2015, net spending on prescription drugs increased approximately 20% in the United States,2 outpacing a forecast 11% increase in aggregate health care expenditures.3 Prescription medications now comprise an estimated 17% of total health care costs,4 and prescription medication coverage constitutes 19% of employer-based insurance benefits.5 Since the advent of the Medicare drug benefit in 2006, government entities have paid for approximately 40% of the nation’s total retail prescription drug expenditure.6

The primary reason for increasing drug spending is the high price of branded products protected by market exclusivity provisions granted by the US Patent and Trademark Office and the Food and Drug Administration (FDA) (Table 2). Although brand-name drugs comprise only 10% of all dispensed prescriptions in the United States, they account for 72% of drug spending.15 Between 2008 and 2015, prices for the most commonly used brand-name drugs increased 164%, far in excess of the consumer price index (12%).16,17 The annual cost of a growing number of “specialty drugs”—high-cost, often injectable biologic medications such as eculizumab (Soliris), pralatrexate (Folotyn), and elosulfase alfa (Vimizim)—exceeds $250 000 per patient.

Although brand-name drugs account for the greatest increase in prescription drug expenditures, another area that has captured the attention of the public and of policy makers has been the sharp increase in the costs of some older generic drugs. In 2015, Turing Pharmaceuticals raised the price of pyrimethamine (Daraprim), a 63-year-old treatment for toxoplasmosis, by 5500%, from $13.50 to $750 a pill.22 The company was able to set the high price despite the absence of any patent protection because no other competing manufacturer was licensed to market the drug in the United States. Significant increases in the prices of other older drugs include isoproterenol (2500%), nitroprusside (1700%), and digoxin (637%). Even though the prices of most generic drug products have remained stable between 2008 and 2015, those of almost 400 (approximately 2% of the sample investigated) increased by more than 1000%.23

The most important factor that allows manufacturers to set high drug prices for brand-name drugs is market exclusivity,28 which arises from 2 forms of legal protection against competition. Together, these factors generate government-granted monopoly rights for a defined period. Initial regulatory exclusivity is awarded at FDA approval. New small-molecule drug products automatically earn a guaranteed period of 5 to 7 years before a generic competitor can be sold,29 and new biologic drugs are protected from competition for 12 years.30 The second type of market protection is patent-related exclusivity because manufacturers can receive patents lasting 20 years or more for their inventions.31 The US Patent and Trademark Office issues this intellectual property right—originally written into the US Constitution to encourage innovation—for inventions that are “novel,” “useful,” and “non-obvious.”32

Because permissive US Patent and Trademark Office standards for novelty or usefulness make it relatively easy to patent many nontherapeutic aspects of a drug, companies can strategically patent small changes and try to influence prescribers and patients to transition from one linked product to the next, sometimes discontinuing production of older versions of the drug. For their part, generic manufacturers have engaged in litigation with brand-name manufacturers that could lead to the patents being invalidated, but these suits are frequently settled.55 Historically, brand-name manufacturers have offered substantial financial inducements as part of these settlements to generic manufacturers to delay or even abort generic introduction.48 Settlements involving large cash transfers are called “pay for delay”; for example, in a patent challenge case related to the antibiotic ciprofloxacin (Cipro), the potential generic manufacturer received upfront and quarterly payments totaling $398 million as part of the settlement and agreed to wait until patent expiration to market its product.56

During a drug’s market exclusivity period, the primary counterweight against excessive pricing is the negotiating power of the payer. Among public payers, Medicare covers approximately 40 million adults, most aged 65 years and older, for outpatient (Part D) and inpatient (Part B) drug costs.67 Medicaid, the federal- and state-funded health insurance program for low-income individuals, covers prescription drug costs for another 72 million Americans.68 Other public payers include the Veterans Health Administration, the Department of Defense health care system, state prison systems, and the federal employee health benefits program. In contrast, private payers provide insurance coverage to 177 million persons in the United States.69 This is often accomplished through 3 large pharmaceutical benefits management companies: Express Scripts, Caremark, and UnitedHealthcare.70 Approximately 29 million Americans have no public or private prescription drug coverage—a rate far higher than in nearly all other industrialized countries.71

Several features of the US marketplace constrain the ability of public and private payers to negotiate lower drug prices. Medicare, for example, accounts for 29% of the nation’s prescription drug expenditure,72 but federal law prevents it from leveraging its considerable purchasing power to secure lower drug prices while requiring it to provide broad coverage, including all products in some therapeutic categories, such as oncology. Based in part on considerable lobbying and arguments that government negotiating power could decrease revenues for the pharmaceutical industry,73 Congress included a provision in the law that created the Medicare drug benefit program, prohibiting the Centers for Medicare & Medicaid Services from negotiating drug prices or from interfering with negotiations between individual Part D vendors and drug companies.74 This made prescription drugs under Part D one of the few aspects of health care for which Centers for Medicare & Medicaid Services does not negotiate or set prices.

Imagine if Congress allowed Medicare with 40% of total drug expenditures to negotiate drug prices like the VA can.

 

[Legacy]

A Shortage in the Nation's Maternal Health Care

“It’s very simple,” said William Rayburn, a professor of obstetrics and gynecology at the University of New Mexico who has written on maternal health issues. “Our population is continuing to grow faster than we are producing ob-gyns.”

Nearly half the counties in the U.S. don’t have a single obstetrician/gynecologist and 56 percent are without a nurse midwife, according to the American College of Nurse-Midwives (ACNM).

“There are women in California who have to drive hours in order to see an ob-gyn,” said California Assemblywoman Autumn Burke, a Democrat.