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ACA Round-Up: QHP Application Deadline Passes, House v. Price, Special Enrollment Periods

Sun, 25 Jun 2017 01:11:42 +0000

June 21, 2017, was the last day for insurers to file qualified health plan applications in the 39 states that use, including federally facilitated marketplace (FFM), plan management, and state-based marketplace-federal platform states. There were reportedly a few additional defections, including Anthem from Wisconsin and Indiana, but most insurers are back from last year, and a there are a few new entrants, notably Centene in several states. According to slides posted at the CMS website, insurers may make any changes they wish to their plan filings until August 16, 2017, except for adding plans, changing plan type or child-only value, or changing service areas without permission from CMS, as long as they get state regulator approval. Insurers that wish to change the service area served by a plan must petition CMS by August 4, 2017. From August 17, 2017, CMS will not allow further changes except data corrections needed to correct data display errors and align QHP plan displays with products and plans approved by the states. Insurers will have a final opportunity to withdraw plans during the plan confirmation process, which takes place between September 12 and 15, 2017. These deadlines are not statutory but are rather established by guidance. It is hard to believe, therefore, that if an insurer steps forward to cover a bare county (or which 44 currently are believed to exist in Missouri, Ohio, and Washington, CMS would not accept a late filing. The QHP filings are not public information. Some of the data contained in the applications will be made available in public use or landscape files in the fall. QHP filings contain some information on proposed rates, but uniform rate review templates for individual and small group market rate filings are not due at CMS until July 17, 2017 (although states have earlier deadlines, many of which have passed). Proposed rates will be published on the CMS website and by states on August 1, 2017. Final rates must be published by November 1, 2017. Court Orders House And Administration To Respond To States’ Request To Intervene In House v. Price On June 22nd, the District of Columbia Court of Appeals today ordered the government and the House to respond to the motion to intervene in House v. Price filed by attorneys general from 17 states and the District of Columbia. The House and administration must respond in 10 days, and the states have 7 days to reply. The states asked to intervene in the appeal of the litigation, arguing that uncertainty caused by the litigation was threatening their health insurance markets and that their interests were not adequately represented in the litigation. The House and the administration then asked the court not to lift the stay that has been imposed on the litigation to hear the states’ request, but the court ruled in favor of lifting the stay to let the states present their case for intervention. Pre-Enrollment Verification For Special Enrollment Periods On June 23, 2017, began requiring pre-enrollment verification for eligibility for loss of minimum essential coverage and permanent move special enrollment periods (SEPs).  CMS has posted at the Center for Consumer Information and Insurance Oversight website examples of the forms that it intends to use to: remind people who qualify for a SEP to pick a plan and confirm their eligibility, inform applicants who have already applied and picked a plan that they have 30 days to document eligibility, warn applicants ten days before the application of the 30-day period who have picked a plan but have not yet submitted eligibility verification documentation to do so, notify applicants when the documentation they have submitted is insufficient and to inform them of what more is needed to verify eligibility (apparently within the original 30-day period), notify applicants that their SEP eligibility has been verified and that they will be enrolled in coverage once they pay their first month’s premium (or, if they have not yet selected a plan, once they select a [...]

Medicaid Round Two: The Senate’s Draft “Better Care Reconciliation Act Of 2017”

Sat, 24 Jun 2017 21:25:21 +0000

Although it differs in important details, the draft Medicaid provisions of the Better Care Reconciliation Act — the Senate’s version of Affordable Care Act “repeal and replace” —  share the vision of its House-passed counterpart, the American Health Care Act: to, as much as possible, shield the federal government from the cost of Medicaid. Like the House, the Senate would accomplish this goal by fundamentally altering the terms of Medicaid itself rather than by ending it and replacing its entitlement structure with a new, successor program as Congress did in 1996 when it replaced the Aid to Families with Dependent Children (AFDC) program with Temporary Assistance to Needy Families (TANF). Medicaid is far too complex, and the rules of reconciliation far too constrained, to permit the creation of a new program. Instead, both the House and Senate revise the terms of a law that states have relied on for over a half century to fund health care for the indigent, a basic function of all state governments. The Senate bill, like the House measure, will have massive financial consequences for states, regardless of whether a state has opted for the ACA Medicaid expansion or eschewed this choice. States that want to continue to qualify for federal Medicaid contributions – so vital not only to health care but to their overall economies as measured in employment and local economic activities — will have little choice but to make up the deficits created by legislation that grafts unprecedented payment constraints onto the statutory federal funding formula. Inevitably, the caps mean that states with costlier programs will face larger funding deficits. But the cost of Medicaid is not simply a function of design choices states make in terms of whom and what to cover. Even states with constrained programs will face a funding gap driven by essentially uncontrollable factors such as the decline of good paying jobs that carry health insurance, an aging population, and public health catastrophes such as Zika or the opioid crisis. Indeed, it is fundamentally wrong to think of states’ Medicaid design choices as optional, even though they are as a matter of law. States choose to cover optional groups and services in response to underlying economic, demographic, and health forces such as infant mortality, elevated disability rates among children and adults, or high numbers of very old residents. Thus, while the Medicaid and CHIP Payment and Access Commission recently reported to Congress, only slightly more than 47 percent of all Medicaid spending is for mandatory services to mandatory populations, the report also reminds us that in a statute in which prescription drugs and inpatient psychiatric rehabilitation services for adults are technically optional, virtually nothing that Medicaid covers is truly a state option. State programs reflect their effort to deal with population health. The potential federal funding losses to states stemming from the pending legislation are immense. The Urban Institute pegs the dollar loss flowing from the House version of the legislation at $373.6 billion over ten years; over $50 billion of that amount would be tied to the decline in federal payments for traditional populations and the rest would be linked to the combined effect of the loss of the enhanced federal payment rate for the ACA expansion population coupled and the per capita cap. Urban also points out that the losses would grow far higher if states respond to the loss of enhanced federal funding for the expansion population by eliminating coverage entirely. Urban also reports that under a scenario that applies the capping formula used in the Senate draft (the same formula used by Speaker Paul Ryan in A Better Way) 10-year losses would climb to $841 billion — $467.4 billion less in federal funding than provided by the House. Other reports add key dimensions to the Urban research.  Researchers at Brookings show that had the House version of the per capita cap been enacted in 2004, by 2011 stat[...]

The Senate Health Care Bill

Fri, 23 Jun 2017 17:41:41 +0000

Yesterday, Senate Republican leaders released a discussion draft of their version of health-care legislation, the Better Care Reconciliation Act (BCRA). Senate Majority Leader Mitch McConnell plans to put this legislation to a vote next week with the expectation of passing it. The Senate Republican plan is best understood as a GOP amendment to the existing Affordable Care Act (ACA). Indeed, one could imagine that, back in 2009, if the Republicans had attempted to modify rather than defeat the ACA, this is the kind of amendment they would have offered. The BCRA repeals most of the tax hikes of the ACA, cuts back substantially on the spending in the ACA, eliminates enforcement of the ACA’s individual and employer mandates, and provides more space for state decision-making and initiative. Even with these changes, much of the ACA’s structure is left in place. The following is a condensed summary of the main features of the Senate proposal with some thoughts about the bill’s likely effects. Building on the ACA’s Tax Credits The House-passed American Health Care Act (AHCA) would repeal the ACA’s premium credits, which are adjusted based on household income, and replace them with age-adjusted tax credits that are not scaled to income except for households with incomes above $75,000 per year. Senate Republicans have chosen to use the ACA’s premium credit structure as their starting point rather than the AHCA’s age-adjusted credits. The Senate legislation would make three important changes to the ACA’s premium credit structure. First, it would add an age-adjustment to them, beginning in 2020. Second, it ties the calculation of these credits to higher-deductible insurance plans, which means the value of the credits would be lower. Third, it would allow taxpayers below 100 percent of the federal poverty line (FPL) who are ineligible for Medicaid to get the credits, too. Providing tax credits for insurance enrollment for persons below 100 percent of the FPL is an especially consequential proposal. Nineteen states have not expanded their Medicaid programs under the terms of the ACA, leaving millions of people with incomes below the poverty line without a realistic option of getting health insurance. As federal support for Medicaid is lowered in future years, more people are likely to become eligible for this tax credit, which, unlike Medicaid, is financed entirely by the federal government. Very low-income households receiving this credit could enroll in health insurance while paying minimal premiums themselves. A person with income at the 2017 federal poverty level would pay a maximum of 2 percent of their income, or $23.10 a month for coverage; they could also pay less if they use their federal credit to purchase a plan with a premium below the median price of a plan in the market. The credit is also tied to age, with older persons expected to pay higher premiums. People in their 20s with incomes at 350 percent of the FPL would pay a maximum of 6.4 percent of their income in premiums, which equals $260 a month; a person in his 60’s with an income at the same level would pay a maximum of 16.2 percent of his income, or $655 per month. Far-Reaching Medicaid Reforms Like the House bill, the Senate legislation includes far-reaching reforms to the Medicaid program. First, the bill would roll back the enhanced federal matching funds for Medicaid over the period 2020 to 2024. States would be allowed to maintain enrollment for the population covered by the ACA, but at the regular, rather than enhanced, federal match rates. The Senate bill also places a new per-person limit on the amount of federal matching funds for five different categories of Medicaid enrollees. The per-person limits are based on state-specific pattern of spending for these populations in recent years. These limits would be indexed to grow with inflation in the medical services sector through 2024, and then by the consumer price index in 2025 and later. Because Medicaid spending typically grows faste[...]

The Payment Reform Landscape: Is The Debate Over Retrospective Versus Prospective Bundled Payments A Distraction?

Fri, 23 Jun 2017 13:25:47 +0000

Based on surveys of health plans by Catalyst for Payment Reform, less than 3 percent of payments in the commercial market are “bundled.” One can argue that there have been more conferences and webinars about bundled payment than actual bundled payments. In the public sector, however, there is much more experimentation with and usage of bundled payment through Medicare and Medicaid. There is good reason to pursue bundled payment. At least in theory, a bundle represents the best thinking on how much it costs to treat the course of an identifiable illness, disease, or injury. It also addresses the tendency to inflate costs with excessive, and often unnecessary, medical intervention. But progress has been slow, in part, because of a wide array of variables that go into calculating a bundled payment, including: Which costs does the bundle include? Which providers get which portion of the bundle? What timeframe does a bundle cover? What happens with outlier cases that come in below cost or, more likely, above? These and other questions have stunted the growth of what could be a breakout idea. Is The Focus On Prospective Payment A Barrier? Some believe that the holy grail of bundled payments is prospective bundles—setting a price for a course of care that has not yet occurred and paying only that amount at the start of the episode of care. The thinking behind prospective payment is that the incentives for cost containment will be stronger because providers will be loath to overspend when they know there’s no chance of additional payment. They also sound administratively simpler for the payer—just cut one check, and don’t worry about figuring out who did what. (It’s strange, however, that there doesn’t seem to be an equal push for prospective global payments. Total cost of care contracts with accountable care organizations or other health systems are almost always settled retrospectively against a target decided in advance.) However, prospective bundled payments can be difficult to implement because they require deciding which provider receives the funds and can be trusted to distribute them properly among all providers involved in an episode. Legal and turf issues can stymie the effort. The difference between retrospective and prospective payments is not significant enough to delay implementation of bundled payment in the hopes of perfecting prospective bundling. Payers shouldn’t go into a retrospective bundled payment arrangement without having agreed upon a budget for a procedure or other episode of care in advance, even though they may settle debts and credits on the back end. In addition, providers, like most people, have an aversion to loss, and if the payment arrangement includes downside risk, they will work hard to avoid any losses. This means that waiting for the means to implement prospective bundles on a broad scale is not sufficient cause for delaying the use of bundled payment. Focus On The Real Problems There are real challenges that need to be addressed in many of the alternative payment models being discussed today, including bundled payments, whether paid prospectively or retrospectively. These include: Prospectively Setting The Price And Budget Coming to agreement on a reasonable budget (and therefore payment amount) takes analysis and negotiation on the part of the providers and payers. Ideally, the arrangement includes a separate payment for evaluation, so providers are paid partially for helping to determine when patients do not need the care the bundle covers. And bundles won’t save payers money if the price for the bundle is too high. Risk Adjustment In setting a bundled payment amount, providers will want payers to consider that some patients are sicker and more complicated than others. Identifying these patients and deciding how much to adjust the bundled payment upward can be a subject of debate. The idea is to hold providers responsible for the costs they can control, not the ones they can[...]

Unpacking The Senate’s Take On ACA Repeal And Replace

Fri, 23 Jun 2017 02:05:41 +0000

On June 22, 2017, Senate Majority Leader Mitch McConnell (R-KY) released the Senate GOP’s version of Affordable Care Act repeal, the Better Care Reconciliation Act of 2017. The Senate bill is in many respects quite different from the House’s American Health Care Act (AHCA), which was introduced on March 6, 2017; AHCA passed on May 6 by a narrow, mostly party line 217 to 213 vote after lengthy negotiations and a series of amendments. Although the Senate bill has the same bill number at the House, it entirely strikes the House bill and adopts a new bill with a new title. All of its amendments are amendments to the ACA itself or of other existing laws, not to the House bill. The majority of the Senate bill is focused on changes to the Medicaid program. This post includes a brief summary of the Medicaid provisions by Sara Rosenbaum, who will examine these in greater detail in a post in the near future. The remainder of this post by Timothy Jost focuses on the non-Medicaid sections of the legislation. A Quick Review Of The House Bill As adopted, the House, the AHCA: Eliminated the taxes and tax increases imposed by the ACA (most, but not all of them for 2017); Phased out enhanced funding for the Medicaid expansions beginning in 2020 and imposed either a block grant or per capita caps on Medicaid; Permitted work requirements for Medicaid recipients and repealed various ACA Medicaid provisions; Removed the ACA’s individual and employer mandate penalties retroactively to 2016: Increased age rating ratios from 1 to 3 to 1 to 5 in the individual and small group market and allowed states to go higher by waiver; Repealed the ACA’s actuarial value requirements; Repealed funding for the Prevention and Public Health Fund; Withdrew funding for Planned Parenthood for one year; Permitted states to waive the ACA’s essential health benefit requirements; Imposed a penalty on individuals who failed to maintain continuous coverage; Alternatively allowed states to obtain a waiver to allow insurers to health status underwrite individuals who do not maintain continuous coverage; Created funds amounting to $138 billion to assist states in dealing with high-cost consumers and for other purposes; Liberalized requirements for Health Savings Accounts; and Ended the ACA’s means tested subsidies as of 2020 and substituted for them age-adjusted fixed-dollar tax credits. The House version of the AHCA left six of the ACA’s ten titles, and virtually all of its insurance reforms, in place. The AHCA did not repeal or amend the ACA’s prohibition against preexisting condition exclusion clauses; its guaranteed issue and renewal requirements (except insofar as it allowed penalties for individuals with a gap in coverage); its requirement that health plans cover preventive services without cost sharing, its requirement that health plans and insurers cover adult children to age 26; or many other popular provisions. The Senate Better Care bill leaves these provisions in place as well. Indeed, the House bill likely left many of them alone because most involved issues that could not be addressed by the Senate under budget reconciliation procedures being employed by Republicans. Reconciliation allows Senate passage with 51 votes (or 50 votes plus Vice President Pence’s tiebreaker) rather than the 60 votes normally needed to end a filibuster. However, the Senate’s Byrd Rule  restricts these procedures to provisions that affect the revenues or expenditures of the federal government and do not do so simply incidental to some other purpose. It is likely that parts of the Senate draft will be challenged under the Byrd rule. If the Senate Parliamentarian rules that challenged provisions are “extraneous,” it will take a three-fifths vote of the Senate for them to move forward, which is very unlikely to happen. The final Senate bill may, therefore, look different than the bill introduced on June 22. In addition, the bill remains subject to con[...]

A New Definition Of Health Equity To Guide Future Efforts And Measure Progress

Thu, 22 Jun 2017 12:43:19 +0000

Editor’s note: Paula Braveman was one of the theme advisors for the June 2017 Health Affairs equity theme issue. Until recently, talking about “equity” as a health researcher in the United States seemed almost radical. Today, the term “health equity” is mainstream. The number of scientific papers with “health equity” in the title or text has skyrocketed. Some of this work examines the health effects of racism and other forms of discrimination, some addresses biases in science, and some explicitly mentions social justice. It’s gratifying to see a broad research agenda developing around health equity. In particular, it is thrilling to realize that explicit discussions about health equity are occurring across the country, among health policy researchers and their funders — and in boardrooms, hearing rooms, community meetings, in print, and online. Yet it is clear that health equity means different things to different people. And while it’s not imperative that everyone define it exactly the same way, a common understanding of the core elements of health equity is essential — for researchers, advocates, decision makers, and policy makers. The words we use can matter. Definitions can matter. While some differences in definitions may reflect only stylistic preferences, others convey values and beliefs that can be used explicitly or implicitly to justify and promote particular views, policies, and practices. Clarity is particularly important because pursuing equity often involves engaging diverse audiences and stakeholders, each with their own constituents, beliefs, and agendas. And in an era of data, a sound definition is crucial to shape the benchmarks against which progress can be measured. Health Equity in a Culture of Health The Robert Wood Johnson Foundation’s “Culture of Health” initiative aims for a society in which “every person has an equal opportunity to live the healthiest life they can.” “Every person” includes those who have been most marginalized — people of color, those living in poverty or with disability, Lesbian, Gay, Bisexual Transgender, and Queer or questioning persons, and others who have historically been excluded from mainstream society. Embarking on this initiative led RWJF to explore how people were talking and thinking about health equity. My colleagues and I at the University of California, San Francisco, joined RWJF staff in that exploration a year or so ago. That joint work culminated in a report “What Is Health Equity? And What Difference Does a Definition Make?,” released in May. There is no lack of definitions of health equity—the American Public Health Association, Centers for Disease Control and Prevention, Health Resources and Services Administration, National Association of County and City Health Officials, World Health Organization, and countless other public health organizations have their own—each with its own strengths and weaknesses. In crafting a definition, this was both encouraging and a bit daunting. We identified a set of criteria, trying to capture the essential elements. We sought a definition of health equity that would: Reflect a commitment to fair and just practices across all sectors of society. This means that education, housing, transportation, community development, commerce, finance, and other sectors must be involved in efforts for health equity, and that our definition should acknowledge explicitly that health equity requires efforts beyond the health care sector. Be sufficiently unambiguous and concrete that it can guide policy priorities. We felt that many existing definitions were inspiring to those who already were committed to this work, but some were abstract and general enough that they left too much room for interpretation. Be actionable. Be conceptually and technically sound, and consistent with current scientific knowledge. Be possible to operationalize for th[...]

Health Affairs Web First: Significant Racial Disparities Found In Hospital Readmissions

Wed, 21 Jun 2017 21:38:56 +0000


Reducing thirty-day surgical readmission rates has been a major initiative under the Hospital Readmissions Reduction Program of the Affordable Care Act (ACA). Racial disparities in surgical outcomes, such as thirty-day hospital rehospitalizations have been well documented—and a new study, released by Health Affairs as a Web First, contributes to those findings. The study, which sampled New York fee-for-service Medicare and Medicare Advantage patients who received surgery in 2013, finds that black patients in traditional Medicare were 33 percent more likely than white patients to be readmitted to the hospital within thirty days.

For Medicare Advantage patients, the likelihood nearly doubled, to 64 percent. The study sample was limited to patients ages sixty-five and older who received one of the following six major surgeries:  isolated coronary artery bypass graft, pulmonary lobectomy, endovascular repair of abdonominal aortic aneurysm, open repair of abdominal aortic aneurysm, colectomy, and hip replacement.

“Our findings suggest that the risk-reduction strategies adopted by Medicare Advantage plans have not succeeded in lowering the markedly higher rates of readmission for black patients compared to white patients,” the authors Yue Li, Xi Cen, Xueya Cai, Caroline P. Thirukumaran, Jie Zhou, and Laurent G. Glance conclude. “Future qualitative research is necessary to understand which specific managed care approaches may be effective in reducing thirty-day readmissions for white and black beneficiaries, and why existing Medicare Advantage plans do not seem to be successful in reducing racial disparity in thirty-day surgical readmissions.”

Li, Cen, Cai, Thirukumaran, and Glance are affiliated with the University of Rochester School of Medicine and Dentistry; Zhou is with Harvard Medical School and  Brigham and Women’s Hospital.

This study will also appear in the July issue of Health Affairs.


Deploying The Cascade Of Care Framework To Address The Opioid Epidemic Means Taking A Closer Look At Quality Measures

Wed, 21 Jun 2017 14:43:40 +0000

In a March 13, 2017, Health Affairs Blog post, Arthur Robin Williams, Edward Nunes, and Mark Olfson propose repurposing the “Cascade of Care” framework, once used to combat the HIV/AIDS crisis, to fight the opioid epidemic. Williams and colleagues propose developing performance measures to track the success of the state grants across the five framework stages: Diagnosis among those affected Linkage to care among those diagnosed Medication initiation among those entering care Retention for at least six months among those initiating medication Continuous abstinence among those retained We applaud Williams and colleagues for highlighting the concept of the cascade of care as a useful framework to address the opioid epidemic. To make this vision a reality, there are important steps that need to be taken to develop the framework’s quality measures and how to use the measures to guide work with states, managed care organizations, localities, treatment providers, recovery support services, and others to end the opioid crisis. Drawing On Federal Data Systems Data for the cascade of care can draw on existing federal data collection systems. For example, the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health (NSDUH) is the primary source for information on the prevalence of substance use disorders including opioid use disorders. Although federal data systems do not currently capture information on whether an individual with an opioid use disorder was diagnosed by a health professional or told by a professional that he or she had a substance use disorder, the first stage of the Cascade of Care Framework, this question could be added to the NSDUH or other national data sets such as those collected by the Centers for Disease Control and Prevention (CDC). For example, the CDC’s National Health and Nutrition Examination Survey (NHANES) determines whether respondents have diabetes using fasting blood glucose levels. The NHANES also asks respondents whether they have ever been told that they have diabetes. Thus, we have a good understanding of the prevalence of undiagnosed diabetes. These data are evaluated to determine the characteristics of populations that need to be targeted for more aggressive screening, assessment, and outreach efforts. For those with substance use disorders, being told by a trusted and nonjudgmental health professional that you have a diagnosable and treatable disorder can be a critical first step of engaging in treatment. The second stage of the framework—linkage to care among those diagnosed—is currently collected in the NSDUH survey. The NSDUH asks whether individuals received treatment for their substance use in the past year. Thus, one can track the percentage of individuals with addiction who received treatment. The NSDUH also recently modified the collection of prescription drug information and now collects information on how many people received prescriptions for buprenorphine, one of the three medications approved by the Food and Drug Administration (FDA) to treat opioid use disorders. To our knowledge, federal data systems do not currently collect national data on treatment of opioid use disorders with methadone or long-acting injectable naltrexone, the other medications FDA approved to treat opioid use disorders. National surveys may not be well suited to track the fourth stage—retention for at least six months among those initiating medication. However, the National Quality Forum recently endorsed a measure—Continuity of Pharmacotherapy for Opioid Use Disorder—that uses insurance claims data to measure the percentage of adults ages 18–64 with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment. Thus, health systems that adopt this measure will be able to track this quality measure.[...]

Building Sustainable Partnerships To Improve Access To Breast Cancer Treatment For Uninsured Women

Tue, 20 Jun 2017 17:34:21 +0000

Breast cancer is a terrifying disease for most women. In the United States, it is the leading cause of cancer deaths among women ages twenty to fifty-nine years. More than 5,100 women are diagnosed with—and at least 1,100 women die from—breast cancer in New York City each year. The breast cancer survival rate is also lower for uninsured women than for those with private health insurance coverage. Although access to affordable breast cancer screening and treatment has grown substantially over the past few years as a result of increased health insurance coverage options through the Affordable Care Act (ACA), many uninsured women are not able to obtain free or subsidized screening and treatment—in New York City and across the country as well—largely because of age and income-eligibility requirements that must be met to participate in cancer screening and treatment financial support programs. In New York City, a partnership-based payment and delivery system model designed for breast cancer called the Breast Treatment Task Force (BTTF) has facilitated more than 6,000 screenings and diagnostic procedures and seventy-one cancer treatments for more than 3,500 patients over the past decade. The BTTF is a nonprofit organization that facilitates breast cancer screening, education, diagnostic follow-up, and treatment for women without health insurance coverage. Most diagnostic and treatment services are provided to the BTTF free of charge by physicians, hospitals, imaging and radiology centers, and pharmaceutical companies, while other costs are covered through grants and donations from foundations (Avon Foundation for Women, Sy Syms Foundation, Harry S. Black and Allon Fuller Fund, and Investors Foundation) and other organizations (Barbells for Boobs and Pfizer). Which Patients Fall Through The Cracks? There is no question that high-quality cancer care depends on the ability of people to secure, travel to, and pay for needed diagnostics, treatment, and support services. While the Cancer Services Program of the New York State Department of Health provides cancer screening to uninsured and underinsured men and women throughout the state, many patients still fall through the cracks. In the case of breast cancer, that program provides mammograms and clinical breast exams at no cost to women ages forty and older, while younger women must wait for a health care provider licensed in New York to determine their eligibility for those services. This can mean anything from providing proof that one has multiple, close blood relatives who have been diagnosed with breast cancer in the past (like an aunt, mother, or sister), to demonstrating that one has a personal history of receiving thoracic (chest) irradiation as a teenager. Other patients who often fall through the cracks are low-income women who are ineligible for Medicaid or other state or federal assistance programs. This population remains uninsured because health insurance premiums can be as high as $5,000 per year. Thus, even if they suspect they have cancer or are actually diagnosed with it, they have few options when it comes to receiving follow-up testing and treatment. Lastly, while the ACA has ensured that people do not pay out-of-pocket costs for most cancer preventive services, most health insurance plans still do not fully cover some preventive services such as testing for the breast cancer (BRCA) gene. This is the case because most patients must be classified as high-risk first before undergoing such genetic testing, and, for most women, this means that they must have a prior diagnosis of cancer before age forty-five or have one or more close blood relatives who have been diagnosed with ovarian, pancreatic, prostate, or breast cancer. These restrictions increase the number of cancer patients who remain at risk, especially uninsured women who cannot [...]

At Drug Hearing, Senators Discuss Meanings Of Price And Value—And Debate Health Reform

Tue, 20 Jun 2017 15:44:41 +0000

On Tuesday, June 13, the Senate Health, Education, Labor, & Pensions (HELP) Committee held the first of three planned hearings on high drug prices. This hearing, titled “How the Drug Delivery System Affects What Patients Pay,” was designed to elicit basic information about how drug prices, overall spending, and patient costs have changed over time, and about the drivers of these metrics. The hearing featured four non-industry witnesses, with the plan that industry representatives will be included in future hearings. One of the most important points to come out of the hearing was that there is bipartisan concern about high drug prices. Even if there is as yet little agreement on what to do about it, Senators of both parties came out against the heavy burdens high drug prices have put on patients. More specifically, there were a number of topics which dominated the discussion, and I review three key areas below. The Elephant In the Room Although the stated focus of the hearing was about drug prices, the real focus of the hearing quickly became clear. Every Senate Democrat on the committee began their allotted time by discussing health care reform, blasting the secretive process by which Republicans are moving their health care bill through the chamber and opposing the bill’s substance. Ranking Member Patty Murray (D-WA) even asked Chairman Lamar Alexander (R-TN) if he would hold hearings on the bill. He responded that none were planned, and argued that her question was more appropriately directed at Senator Hatch, the Chair of the Finance Committee. Of course, the HELP Committee does also have jurisdiction over health care reform (the two committees oversee different portions of the issue), and HELP held dozens of roundtables, hearings, and walkthroughs in the lead-up to the passage of the Affordable Care Act. The partisan dynamic became even more pronounced when Chairman Alexander and Senators Susan Collins (R-ME) and Lisa Murkowski (R-AK) left to attend a private health care lunch with President Trump, leaving Senator Bill Cassidy (R-LA) as the sole Republican in the room with half a dozen (and at times, more) Democratic Senators, each of whom took the opportunity to criticize the health care bill. Senator Elizabeth Warren (D-MA) in particular took pains to link the question of drug access and affordability to the question of health care reform. For instance, health plans offered on the individual market prior to the Affordable Care Act were not required to cover prescription drugs. Further, if estimates that the Republican bill would kick more than 20 million Americans off of insurance are accurate, those Americans would presumably lose their existing access to affordable medications. Which Prices Matter, and Why? A number of Senators focused on the distinction between the list price of a drug, the price that is publicly reported by pharmaceutical companies, and the net price of the drug, a confidential price that takes into account the discounts and rebates provided in the system. Typically, discussions about year-over-year price increases have focused on the list prices of drugs, and net prices rise more slowly. However, both are still rising faster than the increase seen more generally in health care. The pharmaceutical industry has often taken the position that the confidential net price is the one that should matter in analyzing the problem of high drug prices, not the public list price. But as a number of Senators and panelists noted at the hearing, patients’ cost-sharing obligations are often calculated on the basis of list price, not the net price their insurer has negotiated. When coupled with the rise of high-deductible health plans, patients are increasingly being asked to pay large amounts out of pocket for their prescription drugs, a dynamic which has fu[...]