Wednesday, May 17, 2017

Comments on Maine’s 1115 Medicaid Waiver Application - Evidence and Empathy

DHHS is holding a public hearing on its Medicaid waiver application.  Below are the comments I will either read or submit (based on turnout at the hearing).

Good morning.  My name is Mitchell Stein, and I am an independent health policy consultant.  I offer these comments on Maine’s 1115 Medicaid waiver application as a private individual, no client is paying for my time, and I am solely responsible for my remarks.  I have spent my career working on various parts of our health care system. I started working for MetLife on long-term care insurance in 1991 and then spent over 15 years at Mercer Consulting in their healthcare practice.  I’ve lived in Maine for ten years during which time I’ve worked at Health Dialog, Consumers for Affordable Health Care and the Institute for Clinical and Economic Review.

As you might imagine, during this time my understanding of this complicated topic has grown, and my perspective has matured.  Today, when I analyze a proposed policy, I try and keep two things in mind; evidence and empathy.

Many speak of the need for evidence-based medicine.  Too much of our current treatment is based on what has been done in the past, not based on what works.  The same can be said of policy decisions.  Too many are made based on what sounds like a good idea, often contradicting the evidence of what has worked and what has not worked.

While evidence is crucial, equally important is maintaining empathy for the people we are trying to help.  If we start to treat them as data, we risk making decisions that denigrate their humanity.

With those points in mind, I will comment on two of the provisions of the proposed waiver: the asset test and the premium requirement.  Spoiler alert, the bottom line is that both provisions would end up costing the state money while discouraging coverage of individuals who are eligible for the program and in need of benefits. 

Before I continue, I’ll note that the written version of these comments contains details on the references I will cite.

Let’s start with asset tests.  On first blush, the requirement seems to make sense.  Why wouldn’t you want to keep individuals off the program if they sufficient assets to take care of themselves?  However, the evidence tells a different story.  While there are undoubtedly a few people who are gaming the system, experience in many states has shown that it costs much more in administrative costs to try and keep out these few bad actors than would ever be saved in program costs.  Additionally, while imposing these tests would keep out only a few bad actors, the added complexity would keep otherwise eligible individuals from getting the benefits they need.

The Kaiser Commission on Medicaid and the Uninsured produced a report of state experiences after eliminating the Medicaid asset test.  The report looked at the experience of ten states and concluded that the action cut administrative costs, improved program efficiency, and increased access to health care.  With that in mind, why would we want to add back this provision?

Quoting from the report: “The surveyed states generally found that, despite being cumbersome for agency staff to administer and onerous for applicants to document, an asset test actually kept few families from meeting Medicaid eligibility requirements and may have prevented some from completing the application process.”

Now let’s talk about the proposal to charge Medicaid beneficiaries premiums to participate in the program.  Again, at first, it may sound like a good idea – have individuals involved by contributing something to their coverage.  However, once again the evidence shows us that collecting premiums costs more money than is collected and the need for empathy reminds us that we are keeping individuals from receiving the care they need.

A review of the states currently charging their Medicaid enrollees premiums finds that for many, the premiums are unaffordable resulting in otherwise eligible individuals being dropped from the program.  Additionally, the attempted collection of premiums is not generating significant revenue for states.

Let’s look at two examples of the impact on enrollees:

In Michigan, 40 percent of people required to pay premiums are currently past due on their payments.

In Iowa out of approximately 17,000 enrollees subject to premiums, during December of 2015 5,760 cases were sent to collections for failure to pay while an additional 500 were disenrolled.  The previous month, 3,520 were disenrolled.

Now, let’s see what the impact is no state revenue:

In Arkansas, 2016 saw the state spend $12 million dollars to implement its premium program.  That after only collecting $384,000 in premiums the previous year.

In Michigan, the state is spending $20 million a year to implement the healthy Michigan program, while not all of that money goes to collecting premiums, a significant portion does.  And yet in 2015 during one three-month period the state averaged collections of only $181,000 in premium per month.

In conclusion, as we contemplate changes to the MaineCare program we must remember that the purpose of the Medicaid program is to promote health coverage and access.  It is more than fair to make changes that would save money while preserving this goal; however, the changes proposed under the 1115 waiver application would not do so.  Judged by the mantra of evidence and empathy, the proposed changes would result in increased administrative costs while denying benefits to eligible individuals in need of those benefits.

Acknowledgments:  In addition to the references cited, the resources of the Kaiser Family Foundation and Families USA have proven invaluable.  I’m also indebted to Deborah Roseman for her use of, and thoughts on, the phrase “evidence and empathy.”

Friday, May 5, 2017

Time to take a deep breath and then get back to work

OK, let’s all take a deep breath. I don’t want to stifle the outrage, believe me, I’m pissed, but we have a long road ahead. No one’s coverage has changed (yet). The ACA has not been repealed or replaced (yet). Passage in the House was only the first step so let’s all take a deep breath, maybe have a drink to drown our sorrows, and then get back to work.

At the end of this tweet is a summary of the AHCA as passed written by Tim Jost but I want to highlight a few things (you can find his analysis here).

Things to remember about the AHCA as passed by the House:
  • The ACA slightly transferred some funds from the rich to the poor, but the AHCA massively transfers money from the poor to the rich. It is an $880 billion transfer from people on Medicaid to people making more than $200K a year. 
  • The bill passed without hearings, with the final text made available mere hours before the vote, with many members of the House saying they had not read it, and without a CBO analysis. 
  • There was no public support for the bill: no provider groups, no patient groups, and no hospitals came out in support of the AHCA. 
  • As written it may benefit a few young healthy people, but it will harm many old, sick and low-income people.
  • Finally, note that supporters of the AHCA are still telling lies about the ACA – but now they are also telling lies about the AHCA (basically trying to convince people it’s not as bad as it is).

This weekend, Representatives and Senators will be returning home – they must be reminded how horrible we all think the bill is.

When they return to Washington, it’s the Senate’s turn. As of now, there are conflicting reports – some articles are saying the Senate will start from scratch, completely ignoring the bill as passed, some saying they will take the AHCA as the starting point. In either case, it will be an opportunity to change the bill.

The bill as currently conceived will also have to satisfy the reconciliation process – to pass the Senate with 51 votes instead of 60, all parts of the bill must impact the Federal budget. There are real questions if that is the case for some of the bill’s provisions. Again, an opportunity to change the bill.

If the Senate does manage to pass a bill, it is an open question as to if the new bill can get passed the House. Some of the provisions that won over the Freedom Caucus are the same provisions most likely to be changed by the Senate.

A long road and a lot of work ahead.

One more point before I stop for tonight; elections matter. We must remember those who voted for the bill in the house and do everything in our power to vote them out of office. The best way to avoid horrendous bills like this in the future is to take back Congress.

Speaking truth to power

24 hrs, 3 stories 

Stein said there’s nothing wrong with the structure of a reinsurance program like MGARA, but the key is how well it’s funded.
“In the end, it all comes down to how much money is put in,” Stein said.

MPBN May 2, 2017
And the invisible high-risk pool, Stein says, is just one small proposal within the larger health bill. 
“There’s nothing inherently wrong with it, but it doesn’t really fix all the other problems of the bill,” he says. 
Stein says those include changes to essential health benefits and cuts to the Medicaid program.

Bangor Daily News May 3, 2017
High-risk pools can work in theory, but only if they’re properly funded, said Mitchell Stein, a health policy expert who worked for the advocacy group Consumers for Affordable Health Care when Maine passed PL 90. They usually aren’t and historically have failed, leaving people with pre-existing conditions facing unaffordable premiums, he said. “It all comes down to money, as it usually does,” Stein said.
Under congressional Republicans’ plan, $110 billion would fund a high-risk pool over 10 years. One study estimates that it would cost at least $178 billion every year to adequately fund it. “The dollar amounts the Republicans are talking about are woefully inadequate chump change,” Stein said. 

Saturday, March 25, 2017

What just happened, and what happens next?

I think it’s safe to say that over the last few days we saw an unprecedented defeat for the party in power.  Despite having majorities in both houses of Congress and the Presidency, they were unable to fulfill a promise seven years in the making – instead, as put by Bill Gardner, The ACA Won.

Did you ever think you would hear Paul Ryan say, “Obamacare is the law of the land”? 

Today I mostly want to talk about next steps, but before that, I’ll take a little space to discuss how we got here.  Books and dissertations will be written about what went on, and I’m sure Tina Fey is already working on the movie version starring Alec Baldwin – but in the meantime, here’s my review (if you’ve already overdosed on coverage, feel free to skip down to the what’s next section).


First, it’s important to remember that the AHCA was not really a healthcare bill, it was a bill designed to cut Medicaid to pay for a huge tax cut.  And in case you forgot, here’s who would have benefited from those tax cuts:

After the initial introduction of the bill, it was clear that there was not enough Republican support for passage.  Changes started to be made to the bill, including to how the Essential Health Benefits (EHB) package portion of the law works.  As a reminder of why the EHB is so important, know that when last left to the states, only 12 required maternity coverage & only 17 states required mental health coverage.

Within the Republican party, there was opposition to the bill from both the left and the right.  The eventual defeat exemplifies that it’s hard to get someplace when you can’t agree on where you’re going.  In fact, as discussed by Jonathan Chait “It became the repeal bill because nobody in the Republican Party had a better idea.”  

This lack of a better idea resulted in a bill that before it was pulled had just a 17% approval rating in national polls.

Unsurprisingly, The President did not take any responsibility for the bill's defeat.  You can read here about the 6 ways President Trump tried to spin his total defeat on health care.  And in case you want even more, the NY Times takes a look at How the Health Care Vote Fell Apart, Step by Step.


The Setup

The question now is what will the administration do.  In remarks after the bill's defeat, the President said: “I’ve been saying for the last year and a half that the best thing we can do politically speaking is let Obamacare explode, it is exploding now.”

It is not exploding (we’ll get to that in a minute) but there are problems, and there are actions the administration can take to make those problems worse.

From NY Times reporter Margot Sanger-Katz:

The President seems to assume that even though Republicans control Congress and he is President, they won’t be blamed for what happens next – a dubious assumption some would say.

Before continuing, let’s talk about that “explosion”.  Simply put, it’s just not happening.  There is no death spiral.  The way the ACA was designed, most covered individuals are shielded from premium increases because the subsidies are based on the premiums, not on other factors.  It can be argued that is not a good way to control costs, but it’s still the way the law is written, meaning even if premiums were to go up significantly again this year, most individuals on the exchange would not feel the impact. 

Outstanding Issues

However, as I said, there are outstanding issues.  Insurers are deciding right now if they will offer products on the marketplace in 2018.  Insurers and the actuaries that work for them hate uncertainty.  Two looming areas of uncertainty are the cost-sharing subsidy lawsuit and the status of the risk adjustment programs. 

Those purchasing coverage on the marketplace earning less than 250% of FPL are eligible to receive cost-sharing subsidies.  However, those funds need to be allocated by Congress.  Over the past several years, when Congress failed to do so, the Obama Administration paid them out of other funds resulting in the House suing the President.  If the current administration decides not to pay these subsidies, insurers would be on the hook for the payments, resulting in large losses (the losses are theoretical, if the insurers do not receive the payments, they would pull out of the market).

The ACA had three risk adjustment programs designed to smooth out the impact of one company getting stuck with more sick people than another.  One of the programs (risk corridors) relied on funding being allocated - which it wasn't.  Failure to receive these payments would also result in insurers leaving the market.

These two issues feed into another immediate area of concern – there are some markets with no or only one insurer. 

Administrative Action (Sabotage)

In addition to the existing issues, there are actions the administration can take to make matters worse.  They’ve already made some changes that on the face are not game-changers, but they raise concern over how the law will be implemented.

Starting with the one of most concern, enforcement of the individual mandate.  The mandate is needed to keep the system in balance – while the mandate is part of the law, how rigorously it is enforced is subject to the actions of the administration, and they’ve already said they will be less strict.

HHS has also announced changes to the enrollment process – making the enrollment period shorter and making it harder to enroll during special enrollment periods. 

During the last open-enrollment period, the Administration pulled advertising during the final week (after Trump’s inauguration) resulting in a perceptible blip in enrollments.  Advertising and the use of navigators are essential to successful enrollment periods – both activities that the Administration controls through HHS.

Still on the table

It’s worth remembering that two ideas beloved by conservatives are still floating out there – Medicaid work requirements and block granting.  Both would be harmful to those who rely on the program.  You can find more information here:
Round 2
Last night, Rep. Keith Ellison (Deputy Chairman of the Democratic National Committee) tweeted out:  Don't gloat, get ready for round 2

Addressing the issues outlined above as well as fixing known problems is the next battle.
 “No federal benefits program -- not Medicare, not Medicaid, not the marketplace -- can thrive without constant adjustment, from administrators and legislators. Since inception, the ACA marketplace has been denied such essential adjustment, and has in fact had to withstand outright sabotage from Republicans -- who threw up hurdles to the training of enrollment counselors, undercut funding for a crucial risk adjustment program, and refused to fix obvious flaws, such as the so-called "family glitch" that renders many whose employers offer family coverage they find unaffordable ineligible for marketplace subsidies.”    Xpostfactoid


Will there be an opportunity to ensure the ACA continues to work and perhaps even make it better?  The only answer to that is the one provided by my totem, shruggie ¯\_()_/¯

But just because we don’t know if we will be successful, does not mean we shouldn’t try.

Among the topics of conversation should be the addition of a public option (to address markets without enough insurers) and the possibility of a Medicare buy-in for 55+ (to address high premium costs for seniors).

Another avenue is to try and find middle ground with moderate Republicans.  While I still find a lot not to like about Cassidy-Collins, can it be a starting point for negotiations?  This NY Times op-ed looks at the possibility: The Democrats’ Next Move on Health Care.

Before I go, one more link – this one to a piece in Harvard Business Review written by the President and Vice President of the Commonwealth Fund:

  • First, we need to create balanced risk pools that include both healthy and less healthy persons in individual insurance markets.
  • Second, we need to extend subsidies higher up the income scale than the ACA’s limit of 400% of the federal poverty level.
  • Third, if we want private insurers to participate in ensuring that Americans have access to affordable insurance, the business of selling this product must be viable.
  • Fourth, and perhaps most important, public and private stakeholders must accelerate efforts to control the costs of health care services, which are the primary determinants of the cost of health insurance in all markets, including employer-sponsored, individual, and public.

(bullets excerpted from above link)

To sum up, we won a victory with the defeat of the AHCA, but there are many battles ahead to preserve (and expand on) the successes of the ACA.

Sunday, February 26, 2017

A tumultuous 48 hours for the future of the ACA

Friday and Saturday (2/24-2/25) saw several developments concerning the future of the ACA.  We now know more directionally about the “replacement” plans, where this is will all end up is still anyone’s guess.

Let’s look at what happened and what it might mean.  Here’s the timeline:
  • Fri AM - First analysis of the net financial impact on Americans of the proposed Republican modifications to health care premiums after tax credits, plus cost sharing.
  • Fri PM – Leaked full text of Republican legislation presumably presented to CBO for scoring (dated February 10, 2017)
  • Fri PM – updated Medicaid details leaked
  • Sat – Presentation to National Governor’s Association on the impact of ACA replacement

After seven years, the Republicans have put together draft legislation on how they would replace the ACA. Based on other developments, parts of the draft are already out of date (particularly the Medicaid section); however, understanding the approach taken is still informative (and terrifying).

Let’s review the highlights…  (Below, for those interested, I go into the gory details and provide links for each of the four developments.)

The analysis based on the general approach (not the specific draft legislation) does not paint a pretty picture.  Higher costs for most coupled with fewer benefits for those who can still afford coverage and millions losing coverage.

The draft bill contains the following:
  • For funding, the plan would eliminate all of the ACA taxes and instead limit the tax deductibility of employer-sponsored health insurance.  This is an approach that has been supported by economists on both the right and the left for years (think Cadillac tax), but the forces stakeholders will marshal to prevent this change are formidable.
  • Regarding Medicaid, the draft eliminates the expansion and changes the entire program to a per-capita funding basis.  These changes have been called a “non-starter” by some in Congress and by several governors (including prominent Republicans).
  • Regarding private insurance, the essential health benefits definition is eliminated, a continuous coverage requirement for pre-existing condition coverages is added, and the individual mandate is eliminated.  Taken together, these changes are a recipe for market instability.

The most recent information on Medicaid indicates the expansion will continue to be funded at current levels (at least for a period of time) and new money would be available to the states that had not expanded.

The National Governors Association has been meeting in Washington DC.  On Saturday, they were given a private presentation outlining the potential impact of a sample replacement plan.  It would be an understatement to say most of the governors were not pleased.  Across the country, the net result would be millions more uninsured and increased financial burden to the states.  (If you just click on one link, click on the one to the actual presentation, it’s eye-opening.)

So, what does this all mean?  State budgets threatened, millions more without insurance, and the individual market in a death spiral.  If you think that will be a tough sell, you’re right.  There is already significant opposition from within the Republican party:
While the chances of the currently outlined plan passing are small – the danger remains real.  Even if the above plans are mitigated, millions will lose coverage and millions more will face higher costs.

The details:

Fri AM - First analysis of the net financial impact on Americans of the proposed Republican modifications to health care premiums after tax credits, plus cost sharing.

“We estimate that the Republican approach would increase the average total cost for an individual covered by the Affordable Care Act by $1,744 per year. The impact would be particularly severe for individuals ages 55 to 64, whose total costs would increase by $6,089 annually.”

“These estimates are average cost increases. Scaling back essential health benefits would raise costs for some individuals by even more.”

“Doing so dramatically changes the picture. The Republican plans do reduce premiums — predictably, given how much less coverage consumers would receive. But our analysis shows that the current Republican proposals would substantially increase total costs on average — not to mention the risks of a financially devastating health care expense.”

Fri PM – Leaked full text of Republican legislation presumably presented to CBO for scoring (dated February 10, 2017)

 “The legislation would take down the foundation of Obamacare, including the unpopular individual mandate, subsidies based on people’s income, and all of the law’s taxes. It would significantly roll back Medicaid spending and give states money to create high-risk pools for some people with pre-existing conditions. Some elements would be effective right away; others not until 2020.”

“According to the document, there’s only one single revenue generator to pay for the new tax credits and grants. Republicans are proposing to cap the tax exemption for employer-sponsored insurance at the 90th percentile of current premiums. That means benefits above that level would be taxed.”

“The leaked draft makes insurance better for people who are young and healthy. It makes insurance worse for people who are old and sick.”

  • Continuous coverage requirement for pre-existing condition coverage
  • Tax credits by age, not income, not adjusted for premium costs
  • 5:1 rating band based on age (as opposed to current 3:1)
  • Essential health benefits package up to each state
  • Continue to allow “grandfathered” plans and allow to enroll new members
  • Eliminate funding for Medicaid expansion
  • Turn Medicaid into a per-capita program, sending each state fixed sum (on a scale of 1-10, with 1 being block grants, per-capita is a 2.
  • $100 billion over a decade to finance state programs that would cover people with the highest medical costs (including but not limited to high-risk pools)

Bill text:  The _______________ Act of 2017  (Note they could not even agree on a name.)

Fri PM – updated Medicaid details leaked

“It would temporarily keep federal dollars flowing to cover almost the entire cost of the roughly 11 million Americans who have gained Medicaid coverage but would block that enhanced funding for any new participants.

At the same time, the GOP approach would open a fresh spigot of aid for the states — all but one of which has a Republican governor — that eschewed the additional Medicaid money because of their elected officials’ antipathy to the law. This extra aid would probably go to hospitals with a large share of poor and uninsured patients.”

Sat – Presentation to National Governor’s Association on the impact of ACA replacement
From the Axios coverage:
  • “The impact would vary by state, but in a sample state that expanded Medicaid, it's estimated that:
  • The state would lose $635 million in federal funding, a 65 percent decrease.
  • 110,000 current enrollees would no longer be able to afford a plan.
  • 20,000 currently uninsured people would buy a plan with the new tax credit provided by the GOP plan.
  • Additionally, 115,000 low-income people may lose Medicaid coverage, with no affordable alternative on the individual market.
  • A per capita cap — which would limit funding for each person in the program — would reduce federal spending by 24 percent over five years, requiring the state to spend $6.2 billion to close the gap.
In a sample non-expansion state, it's estimated that:
  • The state would lose $885 million in federal funding, an 80 percent decrease.
  • 130,000 current enrollees would no longer be able to afford a plan.
  • 10,000 currently uninsured people would be able to buy coverage with the new tax credit.
  • A per capita cap would reduce federal spending by 6 percent over five years, requiring states to spend $1.5 billion to close the gap

Key takeaways (excerpted from presentation):
  • Medicaid caps are likely to result in state funding gaps
  • Capped funding is likely to be paired with more flexibility for states on coverage and benefits
  • Because states must balance their budgets annually, reductions in federal funding may lead to cuts in eligibility, benefits, or payment rates
  • Per capita caps offer more flexibility to respond to enrollment growth, but they cannot easily adapt to new products or technology (e.g., high-cost drugs)

Tuesday, February 14, 2017

Rep Poliquin and the ACA - slogans are easy, policy is hard

Hi, it's been a while since I've posted on this blog.  However, now that I'm back on my own, it's a good place to park some of my longer musings on healthcare.

Representative Poliquin of Maine’s second district has prepared a handy form letter to send to constituents who write or call his office expressing support for the ACA.  I thought it would be helpful to walk through some of his statements to see how they hold up.  A full copy of the letter is at the end of this post (I’ve removed the name of the recipient who shared the letter with me).

Just for fun, along with each of my comments, I’ll include sources for my statements – you know, facts. Before we get started, a note about my perspective.  As many of you know, I support the ACA and continue to think it is a great step forward.  Twenty million more people have health insurance now than before the law was passed.  However, no one denies that the law needs adjustments.  Changes are often required after a complicated law gets passed.  Unfortunately, in this case, due to the partisan rancor in DC, once the law was passed there were no fixes permitted by Congress, leading to the current issues.

Now let's look at some specifics.

“…suffocating under the spiking ObamaCare monthly premiums...”

Yes, premiums went up for 2017 at a greater rate than they did the previous two years - but let’s remember how premiums acted before the passage of the ACA – they went up in even greater increments. It is also worth noting is that the headlines regarding spiking premiums refer to averages across carriers and across the country.  In many states, the market is working well.  States that have chosen to expand Medicaid (MaineCare) have seen lower premium increases than states like Maine that have not.  Additionally, the subsidies received by many of the enrollees will shield them from the increases.

“…losses of more than 30 million of taxpayer dollars...”

He is referring to Maine Community Health Options (MCHO), one of the COOP plans that were created through the ACA.  These plans do not receive federal money.  What they have received is loan guarantees from the Federal Government.  While MCHO had a bad year in 2016, they are recovering; as noted by Maine’s Bureau of Insurance: “CHO's ability to stabilize its operations in 2016 and achieve plan results up to this point is encouraging and merits its re-entry into the Maine individual health insurance market for 2017.”

“…supported the Obamacare repeal initiation vote...”

Many times, over the past several years the house has voted to repeal the ACA.  In all that time, they have not come up with a replacement plan.  It’s easy to vote for a bill that you know will be vetoed – it’s a lot harder to come up with workable policy proposals.

This link is a walk through the history of promises by the Republicans to come up with a replacement plan:

“…replacement includes coverage for pre-existing health conditions...”

Slogans are easy; policy is hard.   What does Rep. Poliquin mean by including coverage for pre-existing conditions?  If, as in the ACA, it means they will be charged the same rate as everyone else then there will need to be a mechanism, like the mandate, so that people do not just purchase coverage when they need it.  If they mean something else, we need details – it will be easy to say it includes coverage but how much might that coverage cost?  Will they require "continuous coverage" - an ideal state that in the real world is hard to execute?

“…eliminate job-killing taxes...”

My question here is how will the replacement plan be financed if the taxes associated with the ACA are eliminated?  Providing Medicaid or subsidies takes money.  If the taxes are repealed, how will the replacement plan be funded?  What do you think the chances are that the Republican House and Senate will impose new taxes to cover their “replacement” plan?

If they don’t intend to provide subsidies at least as large as the current ones, millions of people will lose coverage, contrary to the current promises of Republican leadership and the President.  Don't be fooled by the phrase "universal access”.  Access is not coverage.  I have access to purchasing a Lamborghini, but that doesn't mean I have the funds to do so.

To sum up, the letter below contains several half-truths and misdirections.  It also gives no credit to the positive impact the law has had.  As the debate over the future of the ACA continues, let's try and stick to the facts.

Monday, June 8, 2015

Sometimes I just can’t help myself…

While I’ve started my new job at ICER, I can't help but continue to pay attention to the ACA J

This morning the Supreme Court rejected Maine's challenge to the constitutionality of an ACA provision governing Medicaid. This was the administration's attempt to drop 19 and 20-year-olds from Medicaid, claiming that the Maintenance of Effort provision of the original law was unconstitutional.  The Supreme Court refused to hear the case so eligible 19 and 20-year-olds will remain covered in Maine.

That’s what they announced.  What they did not do was release their opinion on King v. Burwell (the subsidy case).  However, with the ruling expected in the next few weeks, focus is again turning to the case and what would happen if the court rules that subsidies cannot be provided through the federal exchange.

First, for those needing a refresher, here is a review of the oral arguments:  Revisiting Oral Arguments In The King v. Burwell Obamacare Supreme Court Case.

Now, let’s take a look at what the public thinks the court should do.  While they are still ambivalent about “Obamacare” as a whole, the majority of the public don’t want the subsidies to end (55% to 38%): Public to Supreme Court: Don’t gut Obamacare.

But what happens if the court finds against the subsidies? You end up with a case of the dog catching the car.  Once it happens, the dog is not sure what to do...  

The Republicans keep saying they have a plan, but in fact they have several (meaning there is no agreement on how they would proceed).  Here is a great review of potential Republican “fixes” to an adverse Supreme Court decision.  As the article makes clear, they all attach conditions to extending the subsidies that would end up destroying the individual insurance market:  The GOP has 5 plans to fix Obamacare if the Supreme Court blows it up. They're all a mess.

That’s on the Federal level, but what about the states? Not much hope there either as:  Most states unlikely to create insurance exchanges to save ACA subsidies.

If there is an adverse decision but no fix, we’ll see the blame game play out.  In the President’s remarks today, you can see he has begun to frame the issue a certain way:  Barack Obama Wants You to Think the Obamacare Lawsuit Is Ridiculous: President says the Supreme Court probably shouldn’t have even taken up the King v Burwell case.

Here the New Yorker takes an overall look at how the politics may play out:  The Obamacare Lawsuit Is a Government Shutdown, But for Health Care

And finally I share with you Republican Senator Thurn’s tweet from today:

Six million people risk losing their health care subsidies, yet @POTUS continues to deny that Obamacare is bad for the American people.

Think about how ridiculous that is.  The best response I saw (h/t to @sethdmichaels) was the following:

(A is bringing you a birthday cake)
(B smashes it with a bat)
B: "I can't believe A made it possible for you to lose your cake-he's so bad."

Kind of crazy if you ask me…

To conclude, let me say that I still think that the court will allow the subsidies to continue.  Based on nothing I give that a 75% chance of happening.  I even think it could end up being a 6-3 decision with both Roberts and Kennedy voting to allow the subsidies.  But that means I think there is a 25% chance that the ruling will determine that subsidies are not allowed on the federal exchange, thus putting into play the discussion above.

Stay tuned! 

Saturday, March 21, 2015

An Appreciation of Atul Gawande’s Being Mortal: Medicine and What Matters in the End

This is not a book review. If I were to write a review it would be very short: This is a great book, go read it. Instead below I share my appreciation for the book through excerpts that resonated most with me. They probably won’t be the same for you, but that’s OK, diversity of perspectives helps make life interesting

For me, there were three main points that stood out. None of them are new, but the way Dr. Gawande lays them out add new texture and clarity to our understanding 1) Neither medicine nor society as a whole deals well with mortality 2) We can gain better perspective due to certain life experiences 3) We can translate that perspective and do better by most importantly listening (although by saying “most importantly” I don't mean to minimize the physical changes to care that are needed).

First the problem – we just don’t handle the topic or mortality well. Neither the medical community:
The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world. Most doctors treat disease and figure that the rest will take care of itself. And if it doesn't— if a patient is becoming infirm and heading toward a nursing home— well, that isn't really a medical problem, is it?
Nor society in general:
This is the consequence of a society that faces the final phase of the human life cycle by trying not to think about it. We end up with institutions that address any number of societal goals— from freeing up hospital beds to taking burdens off families’ hands to coping with poverty among the elderly— but never the goal that matters to the people who reside in them: how to make life worth living when we’re weak and frail and can’t fend for ourselves anymore.
Second, for many of us there will come a time when we have to grapple with these issues. Gaining perspective often occurs because of something that happens to us or to a loved one. Perspective can open us up to thinking about mortality in a more helpful way. One of the reasons I think this is a great book is that the act of reading it can help many of us gain that perspective:
Tolstoy saw the chasm of perspective between those who have to contend with life’s fragility and those who don’t. He grasped the particular anguish of having to bear such knowledge alone. But he saw something else, as well: even when a sense of mortality reorders our desires, these desires are not impossible to satisfy.
This next passage may be the one paragraph I’ve ever read that best sums up the problem we face in dealing with mortality. We have not built our system about what we would want for ourselves and we suffer for it when inevitably we are in that system facing our own end:
A colleague once told her, Wilson said, “We want autonomy for ourselves and safety for those we love.” That remains the main problem and paradox for the frail. “Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.”
Gaining perspective, understanding what we would want in those circumstances, brings us to a key question:
And the insight was that as people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives— resisting the urge to fiddle and fix and control. It was not hard to see how important this idea could be for the patients I encountered in my daily practice— people facing mortal circumstances at every phase of life. But it posed a difficult question: When should we try to fix and when should we not? (emphasis added)
When we get to a point where we can ask the right questions, we have to be prepared to listen to and respect the answers:
People with serious illness have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The question therefore is not how we can afford this system’s expense. It is how we can build a health care system that will actually help people achieve what’s most important to them at the end of their lives.
The system we currently have is stacked against doing things appropriately. We have to battle against falling back into old habits:
The trouble is that we've built our medical system and culture around the long tail. We've created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets— and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan, but hope is our plan.
Finally, the book shows us individuals and groups across the country that are doing better. If we can learn from them the benefits are priceless:
In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish.
There you have it, my condensed journey. I’ll end by one last time encouraging you to read the book for yourself.

All excerpts from:
BEING MORTAL: Medicine and What Matters in the End
By Atul Gawande
282 pp. Metropolitan Books/Henry Holt & Company.

Friday, March 13, 2015

That Was The Week That Was - Issue 52 (Final Edition)

This is it, the final issue of “That Was The Week That Was”.  I've been thinking a lot about what I want to say, I thought about last lines of novels, movie quotes and more.  But in the end, it’s very simple, what I want to say is thank you.  Thank you for reading, thank you for sharing this time with me, and most of all thank you for caring enough about health care (both your own and everyone else’s) to take the time to think about these things.

While I’m saying thanks, a big thank you to the Maine Health Access Foundation for making this all possible by supporting this newsletter for the past year.

Remember, I'm not dying…  While I won't be producing this weekly newsletter, I expect I'll continue to have something to say on the topic of health care and will post occasional blogs.  I've added an email notification function to this blog if you're interested in keeping up. For those who are curious, no news yet on what comes next for me so stay tuned.

To help you keep up with health policy news going forward, I've put together this guide to the email subscriptions, websites and twitter feeds I use: How to be a health policy wonk.

And now, for the last time:  

This week we take a look at; more King v. Burwell news, detailed enrollment numbers, affordability issues, CBO cost estimates and more. So let’s get started.

ACA: Court Cases
Still thinking about the case?  If you want to feel like you were there, the audio recording of oral arguments have now been released: Audio file of King v. Burwell oral arguments.

Did you know there is a fantasy SCOTUS league?  Of course there is.  We know that often the “hive mind” is smarter than any one pundit.  So in the tradition of “ask the audience” take a look and get a sense of what people think will happen:  Fantasy SCOTUS - King v Burwell.

The NY Times took a detailed look at the potential human cost of a decision for the plaintiffs: A Roadmap for How Many People Could Lose Their Health Insurance “So how many people in how many states could be affected by the big Supreme Court case about Obamacare’s insurance subsidies? Good question. A combination of data problems and legal ambiguities make some basic facts about the case difficult to summarize easily. Last week, news media coverage included widely ranging numbers of people who could lose their insurance and where they live. Here’s why it’s hard to estimate.”

Then of course there is the political fallout.  What happens when the dog catches the car? GOP braces for ObamaCare win “While top Republicans in the House and Senate said this week that they are nearing a consensus on their efforts to create a back-up plan for the subsidies, almost no details have been shared about the half-dozen plans unveiled in the last two weeks. Most of the proposals are drawing criticism from their fellow conservatives behind the scenes. “It’s a couple lines in an op-ed. Who knows what it really means? In some of those, they may not know, frankly,” said one conservative strategist and former Hill healthcare staffer. Creating even a temporary solution for ObamaCare subsidies is a huge dilemma for the GOP-controlled Congress. Some Republicans have even said, albeit quietly, that the party could be better off if the administration’s policy survives the Supreme Court challenge.”

What about on the state level?  No clear answers there either as GOP governors scramble for answers on ObamaCare ““The Republicans potentially have a PR nightmare on their hands, because what’s going to happen when 8 million people are going to be denied subsidies?” said Ford O’Connell, a Republican strategist and member of The Hill’s Contributors Blog. The fight over King v. Burwell is further complicated by the fact that several GOP governors could be launching presidential campaigns near the time the court reveals its decision, expected in June.” 

Some states are trying to figure out their options: Health-Law Ruling Could Prompt Some States to Act “Nevada is one of three states that use for most day-to-day operations after their own exchanges ran into technical problems. It says it believes its residents would be able to keep tax credits—and that other states could do what it has done. Bruce Gilbert, the head of the Nevada insurance exchange, said he has talked with the federal government and states, including Delaware and Maine, about that possibility. A Delaware official said the state was reviewing all its options. Maine officials didn’t immediately comment.”

Presidential candidate Jeb Bush talked about his alternative. He seems to be worried about the wrong problem: Jeb Bush: Replace 'Monstrosity' Of Obamacare “Bush's criticism of Obamacare as "the greatest job suppressor in the so-called recovery" is interesting, given that the country is experiencing the greatest period of job growth in two decades. On Friday, the Labor Department announced that the economy gained 295,000 more jobs in February, ticking the unemployment rate down to 5.5 percent.”

And in trying to solve a non-existent problem, he seems intent on making things worse: Jeb Bush's consumer-choice model offers questionable choices ““Republicans are really saying that people should be free to avoid carrying insurance for problems they don't expect to have (a bout of depression, maybe, or a stroke that requires rehabilitation) or don't want to help pay for (pediatric and maternity care for men with no children, say). The former view shifts costs onto the unlucky; the latter shifts costs onto women and parents. Both undercut the purpose of insurance, which is pooling risk. Neither saves money. Yet in the abstract the argument sounds compelling. And it's going mostly unchallenged.””

Believe it or not, the Supreme Court does handle other cases than King v. Burwell.  This week they told a lower court to take another look at one of the contraceptive cases: Supreme Court orders another look at birth control coverage case “The U.S. Supreme Court on Monday took action in a case over how religious not-for-profit employers must meet the Affordable Care Act requirement to cover birth control for employees—a move some say could be significant for those employers.  Others, however, disagree, saying the action changes nothing legally.”

For now, I choose to listen to Tim Jost who said: “I do not believe too much should be read into the Supreme Court’s action.  The most likely explanation of the Supreme Court’s decision seems to be that several of the justices on the Court believe that, with about fifty cases challenging the federal rules accommodating the objections of religious organizations working their way up through the courts, this issue is not going away, but the Notre Dame case was not yet ripe for review; Notre Dame was decided not only before Hobby Lobby, but also before the latest set of regulations attempting to accommodate the objections of religious organizations, issued in August of 2014.  The Seventh Circuit, therefore, had not had occasion to consider both developments.” (This link also discusses CBO cost estimates which I cover in the Cost section below: Implementing Health Reform: Supreme Court Remands Contraceptive Case; ACA Cost Estimates Go Lower)

ACA: Enrollment
CMS released more detailed numbers from the just completed open enrollment period: Nationwide nearly 11.7 million consumers are enrolled in 2015 Health Insurance Marketplace coverage “More than 4.1 million young people selected a plan or were re-enrolled; nearly 7.7 million people with plan selections in states qualify for an average tax credit of $263 per month”

Lots of interesting information in the report: 86 Percent of Health Law Enrollees Receive Subsidies, White House Says.  You can find state specific results here: Health Exchange Enrollment Climbs in Second Year. And Jackie Farwell takes a look at Maine’s numbers here: Decoding Maine’s Obamacare enrollment numbers.

Others dived into the report looking at enrollment by age: Exchange enrollment sees limited progress with youth, minorities and income: Implementing Health Reform: March Enrollment Report Provides Income Data.  Also, more details on the results of reenrollment: Obamacare Enrollees Are Surprisingly Smart Shoppers.

ACA: Affordability
Like the author of this next piece, I often get asked why if health care costs are going down, the man on the street is not seeing any benefit.  Here is (part of) the answer: Your company's health insurance costs are going down. But yours are going up. “The Center for American Progress published a new report this month that gives the best answer I've seen to this question. It shows that no, the government isn't lying about slower health-care costs — they really are going up slower than they used to. But all those savings? They're not going to you, or me, or other consumers. They're accruing to the rest of the health-care system.”

The Kaiser Family Foundation took a detailed look at affordability from the perspective of cost sharing: Consumer Assets and Patient Cost Sharing “Plans with higher deductibles and other point of service costs provide health plan enrollees with incentives to make more cost conscious health care choices. For families with limited resources, however, high cost sharing can be a potential barrier to care and may lead these families to significant financial difficulties. Many current policies expose individual enrollees to thousands of dollars in cost sharing expenses and family expenses can easily top ten thousand dollars when someone becomes seriously ill.”

Vox boiled the report down to its essence: The health insurance deductibles are too damn high, in one chart “A new Kaiser Family Foundation study explores one big repercussion of that trend: lots of American families wouldn't have enough cash on hand to cover the average deductible.”

However, keep in mind that many of those enrolled through the marketplace not only receive premium subsidies, they receive cost sharing subsidies as well.  The Tim Jost post linked to in the enrollment section also takes a look at cost sharing subsidies (Implementing Health Reform: March Enrollment Report Provides Income Data). It’s not that I don’t think there is a problem, it’s that like everything else in healthcare, there are nuances to the situation that need to be taken into account.

Another truism about healthcare is that specific issues can make for strange bedfellows.  Pharmaceutical firms are teaming up with consumer groups to help pass state laws limiting copays.  While short term that can be good news for consumers, that’s not why the pharmaceutical firms are doing it. Long term these laws do nothing to stem the high cost of drugs – it just means we pay for it in premium dollars instead of in cost-sharing: “Such patient-assistance programs, which often are funded largely by drugmakers, have helped many Americans like Rucker afford the medications they need. But these programs' ties to pharmaceutical companies carry a high cost for the healthcare system, critics say. It's an issue with growing resonance as drug prices continue to climb. Prescription drug spending grew 13% in 2014, compared with 5.6% growth of healthcare spending overall, according to a recent Altarum Institute report.” (Lifesavers or kickbacks? Critics say patient-assistance programs help keep drug prices high)

In other affordability news, progress from the credit agencies in how medical debt is treated:  Credit Rating Agencies Agree To Be More Flexible About Medical Debt “The agencies say they will establish a 180-day waiting period before medical debt is added to someone’s credit report. In addition, the agencies agreed that when an insurer pays a bill, the debt will be promptly removed from the consumer’s credit report, unlike certain debts that remain for years.”

ACA: Other
Regulations are one thing, compliance is another: “A new study by the Johns Hopkins Bloomberg School of Public Health found that consumer information on a quarter of the Obamacare plans that researchers examined appeared to go against a federal "parity" law designed to stop discrimination in coverage for people with mental health or addiction problems.” (Mental health coverage unequal in many Obamacare plans)

ACA: CBO Estimates
The Congressional Budget Office released new budget projections, including projections of what the ACA will cost going forward.  The numbers can only be described as remarkable: “The budget office has repeatedly lowered its estimate of the cost of the health care law since the bill was signed by President Obama in March 2010. At that time, the budget office said that the law’s insurance-related provisions would cost the federal government $710 billion from 2015 through 2019, the last year of the 10-year projection period used then. On Monday, Douglas W. Elmendorf, the director of the Congressional Budget Office, said the new projections indicated that “the cost will be $506 billion for that same period, a reduction of 29 percent.”  (Budget Office Again Reduces Its Estimate on Cost of the Affordable Care Act)

It has been endlessly debated as to if the current cost slowdown is the result of the recession or other systemic forces at work.  Regular readers know that I think it’s both.  Apparently the CBO agrees with me: “Behind these numbers is the sharp slowdown in health-care spending growth. The reduction "is largely a result of projections of slower growth in premiums and, to a lesser extent, slightly lower exchange enrollment," CBO analysts write. Some of that is likely the result of the recession — when people have less money, they tend to have less to spend on medical care. But what the CBO is saying in this report is it thinks the slowdown will have an effect that stretches out over the next decade and way past the recession.” (CBO: Obamacare subsidies will cost 20 percent less than expected)

While we've had some good news the past few years regarding cost, the battle is far from over.

Accountable Care Organizations (ACOs) are one of the ways people are trying to hold down costs while still improving quality.  This week an optimistic look from the Commonwealth Fund at how some of those experiments are going: A Unicorn Realized? Promising Medicaid ACO Programs Really Exist “Some people used to say that accountable care organizations (ACOs) are like unicorns—they sound amazing but nobody has seen one in real life. However, with hundreds of ACOs now sprouting up in an array of shapes and sizes in Medicare, Medicaid, and the commercial sector, this saying has finally been put to rest. Still, until recently, it’s been unclear whether ACOs can live up to the hype or are just a passing health care reform fad. Although the results are preliminary, the experiences of Medicaid ACO programs in Colorado, Minnesota, and Oregon show that this model of coordinating care—and then sharing in the resulting savings with payers—holds real promise.”

Also on the ACO front, CMS released details about their “next generation” ACO model.  To be honest, I have remained skeptical that ACOs can achieve everything promised (see unicorn label above).  That said, it looks like these new guidelines represent an improvement over current models: CMS preps 'next generation' ACO model “In a significant departure from Medicare's existing ACO programs—the Shared Savings Program and the Innovation Center's Pioneer model—patients will be able to voluntarily enroll in accountable care and in exchange, have their co-pays reduced or eliminated for some services, such as primary-care visits, Conway said.” Primary Sources: Press Release - Affordable Care Act initiative builds on success of ACOs and CMS resource page - Next Generation ACO Model

Of course payment reforms continues forward on many fronts.  On the benefit design side, reference pricing is all the rage.  Two pieces in Health Affairs sounds a note of caution on the concept:

Go Slow On Reference Pricing: Not Ready For Prime Time “Reference pricing is superficially appealing because it invokes powers that consumers exercise every day, as they weigh cost and value for items ranging from cold cereal to new cars. But it also raises significant issues regarding quality and access to care and has the potential to discriminate against sick and vulnerable patients. The strategy may also prove costly in relation to the benefits it confers. We urge a go-slow approach and more careful regulation.”

Go Slow On Reference Pricing: Why The Federal Agencies Have It Wrong On Regulations “Network adequacy rules involve a delicate balance of ensuring access while protecting affordability. Plans have limited tools to obtain lower prices, and exclusion from networks can help control expenditures. By contrast, reference pricing promises little savings, and so regulation and policy should focus on ensuring access and avoiding the problems we’ve enumerated.”

With all the changes in payments and benefits, we’ve seen an acceleration in provider consolidation.  Some argue that the new systems will be able to provide better care at lower cost, but others have questions: Consolidation and health reform “There’s little disagreement that health care providers are consolidating. I do not detect a similar degree of agreement about the consequences. Hospitals and other providers tend to justify consolidation on the grounds that it will improve quality and reduce costs. For years, health policy experts viewed such claims skeptically.”

Every week there is another state talking about Medicaid Expansion (not actually expanding, but at least talking about it).  This week was no different: “None have an easy path, but at least they’re talking: “Kansas, Utah, and Montana all took steps towards the coverage expansion this week, a move that could expand health-care coverage to 297,000 of their low-income residents. They're among the 22 states that have not expanded their Medicaid programs after the Supreme Court made that part of the health law optional in 2012.” (The big Obamacare news last week wasn't at the Supreme Court. It was in Kansas.)

The news out of Florida asked a different question, is the Administration shifting its strategy when it comes to dealing with the states on this topic? Is the Obama Administration Playing Hardball on Health Care? The current debate in Florida over Medicaid funding could be a sign of things to come. “Florida has more than $1 billion in federal Medicaid funding that will expire this summer, and the Centers for Medicare and Medicaid Services has already said that that funding, which helps compensate health care providers that serve a lot of uninsured and low-income Floridians, won't be renewed as is. Legislators are now rushing to take up Medicaid expansion this month.”

The coming of Spring can only mean one thing – it’s “Doc Fix” season!  The annual game where Congress finds a way to prevent the automatic cuts to Medicare reimbursement levels from going through: Get Excited, Everyone, It’s ‘Doc Fix’ Time “Doctors will see a cut of more than 20 percent in their Medicare payments unless Congress steps in by the end of the month. Congress almost surely will step in—it always does. And it will probably just delay the cut for another few months—as it always does.”

Although last year they seemed to get close to a permanent fix, it fell apart in the end. Some hold out hope that this year will be different: Momentum building in Congress for $174 billion Medicare fix “Momentum is building in Congress for a proposal that would abolish Medicare cuts, top Republicans said Thursday, despite the emerging battle over the $174 billion price tag. Optimism has been growing this week that Congress could finally reach its long-sought goal of ending the automatic cuts to doctors under Medicare, which come through what is known as the Sustainable Growth Rate (SGR).”

Another sign of Spring, at least for the past few years, has been the attempts to minimize the cuts to Medicare Advantage plans.  A quick review, Medicare Advantage was supposed to be a way for private insurance to provide Medicare benefits less expensively than the government.  Instead over the years it grew to cost as much as 120% of standard Medicare per enrollee.  The ACA has provisions to bring the private costs more in line with standard Medicare.  However, the private insurance companies have made a nice profit on their Medicare Advantage plans and don’t want to see those changes go through. So, each year CMS announces new reimbursement levels and Congress pressures them increase the proposed rates. This year’s episode is just getting underway: Congress Pleads for CMS to Stop Private Medicare Cuts “A group of 239 House members is sending a letter, provided exclusively to National Journal, to the Centers for Medicare and Medicaid Services on Thursday, urging the agency to reverse the cuts to the private Medicare plans, which serve 16 million seniors, that CMS proposed last month.”

I love the First Amendment.  Freedom of speech is one of our most important rights.  But like anything in the real world, it should not be absolute.  I don’t believe you have the right to yell “fire” in a crowded theater when there is no fire. With that in mind, I find this movement to stem the FDAs power disturbing: How the First Amendment is undermining the FDA’s power to regulate drugs “The Food and Drug Administration is proposing to allow pharmaceutical companies to contradict official safety warnings in sales presentations to customers. … The proposal “seriously undermines FDA authority,” Sidney M. Wolfe, founder of Public Citizen’s Health Research Group wrote Wednesday to the agency. “Its main supporters are drug companies and their associations, all of which would benefit from being allowed and encouraged to sell more drugs by making them seem safer than FDA has judged them to be.””

A report from Express Scripts shows that Drug Costs Grew Last Year at Fastest Rate in Decade “Per-person spending by commercial health plans jumped 13 percent, the most since 2003, as spending on specialty drugs grew 31 percent. That includes cancer drugs, which rose 21 percent last year, and hepatitis C treatments, which rose more than eightfold, pushed up by Gilead Sciences Inc.’s Sovaldi.”

An increase in drug costs is not in and of itself a bad thing.  Drugs hold the promise of treating people and helping their conditions improve.  If a new drug costs twice as much as an old drug, but allows those taking it to live 10 more years, that’s probably a good value.

That said, evidence that we are not getting significant improvements in treatment for (at least some) of the extra spending: The high price of precision medicine “Why are prices for specialty drugs rising so quickly? In most cases, it's not because they offer significant improvements over previous therapies. A new study in the Journal of Economic Perspectives, which looked at the price and health benefits of 58 anti-cancer drugs approved between 1995 and 2013, found “gains in survival time associated with recently approved anti-cancer drugs are typically measured in months, not years.” What has gone up significantly is the cost of each month of life gained through the new treatments. The inflation-adjusted price for new anti-cancer drugs rose 10% a year over those 18 years, according to the study. In 1995, patients and insurers paid $54,100 (in 2013 dollars) for a year of extra life. By 2005, that had gone up to $139,100 a year, and by 2013 it was $207,000.”

If the costs don’t get us, the antibiotic-resistant superbugs will: 7 scary facts about antibiotic-resistant superbugs “Scientists and public-health officials are a careful bunch who don't often use terms like "nightmare," "apocalypse," and "catastrophe." That is, until they're talking about the issue of antibiotic resistance. More and more, as we learn that the threat of drug-resistant superbugs could literally spell our end, it's become a worry akin to climate change: an overwhelming but intangible menace that can be difficult to rally around.”

System Transformation
As a patient, there is nothing more important than understanding our treatment options and their potential impact – but the sad truth is we often don’t: The truth about medicine: we usually overestimate the benefits and underestimate the harms “Looking at 36 studies on a range of medical interventions — from cancer screening tests to medications and surgeries — a pair of Australian researchers discovered that, overwhelmingly, patients overestimated the benefits and underestimated the harms.”

Here is a look back at the influence of “big sugar” on government efforts to stem tooth decay.  Think what a difference it may have made to our current obesity problem if in the 50s and 60s the government had moved forward with the recommendation to eat less sugar: The untold story of how the sugar industry shaped key government research about your teeth “Despite a widespread understanding that sugar played a key role in tooth decay, sugar industry leaders advocated for policies that did not recommend people eat less sugar, according to an archive of industry letters dating back to the 1950s preserved by the University of Illinois and analyzed by a team of researchers at the University of California in San Francisco. And the government listened, according to a new report.”

End of Life Care
Vox pulled together five excellent pieces on the topic (and yes, my regular readers will have already encountered some of them in these pages): 5 moving, beautiful essays about death and dying “It is never easy to contemplate the end-of-life, whether its own our experience or that of a loved one. This has made a recent swath of beautiful essays a surprise.”

As end of life care and decisions get more attention, there is the need to bring our electronic health records into the picture: Non-interoperable directives: End-of-life wishes and EHRs don't yet mesh “Advance directives could be available to all caregivers through interoperable electronic health-record systems. But for a majority of patients and providers, it's not happening. Often, directives are not electronically accessible to emergency physicians, emergency medical technicians, and nursing home or hospice staff when they need them. Few EHR developers have templates in their systems to create, store and exchange end-of-life directives.”

The benefits of empathy training are not limited to end of life care, but they would certainly help there as well: Efforts To Instill Empathy Among Doctors Is Paying Dividends “Studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout and a lower risk of malpractice suits and errors.”

An important meta-analysis out of Australia showing yet again that Homeopathy is nonsense: Americans spend billions on homeopathy. The best evidence says they're wasting their money. “What may be the most exhaustive review yet of the evidence for homeopathy has come to a very strong conclusion: the treatment doesn't work, and people should stop wasting their time, money, and potentially their health on what amounts to junk science.”

Apple Watch
Why am I talking about an Apple product announcement?  Because there is potential for it to revolutionize health care in two ways.

The first is the idea that it can help us accomplish some of our goals such as remembering to stand up every hour – a great goal but some remain skeptical the watch will fix the problems of our sedentary lifestyle: Stop Bashing Apple Watch. It Could Change Health Care After All  and Apple is trying to launch a health revolution. Researchers are skeptical.

The second, perhaps even more revolutionary element, is by providing a new way for health researchers to engage study participants: Apple's ResearchKit draws massive interest (and some reservations) “Ethicists and patient-safety advocates are optimistic about the promise but also point to limitations and potential downsides, especially if the tools aren't carefully rolled out by healthcare providers and software developers. The research, they say, should be subject to the supervision of institutional review boards and the same rules of informed consent as traditional studies.”

That’s a wrap – thanks again for reading! 

All comments and suggestions are welcome; please let me know what you think.

Funded by support from the Maine Health Access Foundation

*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"