Fwd: qotd: Will Liz Fowler determine the drugs you can have?

_______________________________________________
Quote-of-the-day mailing list
Quote-of-the-day@mccanne.org
http://two.pairlist.net/mailman/listinfo/quote-of-the-day

-------- Original Message --------
Subject: qotd: Will Liz Fowler determine the drugs you can have?
Date: Wed, 5 Dec 2012 14:04:52 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The Hill
December 4, 2012
Analysis finds big state-by-state swings in prescription coverage
By Sam Baker

President Obama's signature healthcare law requires insurance plans to
cover a range of prescription drugs, but the number of drugs covered
will vary widely from state to state, according to a new analysis from
Avalere Health.

Based on its analysis of state benchmark plans, Avalere said some states
cover as little as 45 percent of available drugs, while others cover
more than 99 percent.

"This means that ... linking drug coverage to the benchmark formulary
will result in drastically different coverage requirements
state-to-state," Avalere said.

http://thehill.com/blogs/healthwatch/health-reform-implementation/270829-analysis-finds-big-state-by-state-swings-in-rx-coverage

Map of state variations in number of drugs covered:
http://www.avalerehealth.net/news/spotlight/Avalere_Benchmark_Formulary_Breadth.pdf

And...

The Guardian
December 5, 2012
Obamacare architect leaves White House for pharmaceutical industry job
By Glenn Greenwald

When the legislation that became known as "Obamacare" was first drafted,
the key legislator was the Democratic Chairman of the Senate Finance
Committee, Max Baucus, whose committee took the lead in drafting the
legislation. As Baucus himself repeatedly boasted, the architect of that
legislation was Elizabeth Folwer, his chief health policy counsel;
indeed, as Marcy Wheeler discovered, it was Fowler who actually drafted it.

What was most amazing about all of that was that, before joining Baucus'
office as the point person for the health care bill, Fowler was the Vice
President for Public Policy and External Affairs (i.e. informal
lobbying) at WellPoint, the nation's largest health insurance provider
(before going to WellPoint, as well as after, Folwer had worked as
Baucus' top health care aide).

More amazingly still, when the Obama White House needed someone to
oversee implementation of Obamacare after the bill passed, it chose ...
Liz Fowler.

Now, as Politico's "Influence" column briefly noted on Tuesday, Fowler
is once again passing through the deeply corrupting revolving door as
she leaves the Obama administration to return to the loving and
lucrative arms of the private health care industry: "Elizabeth Fowler is
leaving the White House for a senior-level position leading 'global
health policy' at (pharmaceutical giant) Johnson & Johnson's government
affairs and policy group."

It's difficult to find someone who embodies the sleazy, anti-democratic,
corporatist revolving door that greases Washington as shamelessly and
purely as Liz Fowler.

http://www.guardian.co.uk/commentisfree/2012/dec/05/obamacare-fowler-lobbyist-industry1


Comment: A well designed, national, single payer financing system would
ensure that everyone would receive whatever appropriate drugs they might
need. Instead, we have an inefficient, fragmented, costly financing
system that imposes regulatory and financial barriers in the way of many
needed medications, in a manner inconsistent from state to state.

Congress and the President could have consulted with those fine folks at
Physicians for a National Health Program, and then we would have a
system that serves the needs of patients. Instead, they consulted a
"sleazy, anti-democratic, corporatist," Liz Fowler, who orchestrated a
program that instead primarily serves the needs of the insurance and
pharmaceutical industries. She had previously played a key role in the
2003 Medicare Prescription Drug Act (MMA), a program that prohibits
government contracting for drugs under Part D of Medicare. She entered
the revolving door as a pawn of the insurance industry and departs as a
pawn of the pharmaceutical industry - the very industries for which she
wrote the legislation.

Shame.

We can change it.

Fwd: qotd: Physicians find insurer ACO payment models "completely unfavorable"

_______________________________________________
Quote-of-the-day mailing list
Quote-of-the-day@mccanne.org
http://two.pairlist.net/mailman/listinfo/quote-of-the-day

-------- Original Message --------
Subject: qotd: Physicians find insurer ACO payment models "completely
unfavorable"
Date: Tue, 4 Dec 2012 10:44:08 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



American Medical News
December 3, 2012
Medical practices wary of insurer efforts on new payment programs
By Victoria Stagg Elliott

Medical practices have a low opinion of how insurers are operating
emerging payment programs, such as accountable care organizations,
patient-centered medical homes, shared savings and payment bundling,
according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.

Researchers asked practices to rate the willingness of seven large
payers to engage in innovative models on a scale of one, meaning
completely unwilling, to five, which indicates completely willing.
Medicare Part B scored the highest at 1.95, and United Healthcare was
the highest private payer at 1.82.

When asked to rate the favorability of these payment models to the
practice on a scale of one to five, Medicare Part B scored highest at 1.68.

Health industry insiders said the scores on innovative payment models
reflect physicians' frustrations with programs they believe were not
designed for their specialty or size, and that insurers were not
flexible in negotiating terms.

ACOs serve 25 million to 31 million patients, a "remarkable achievement
for a care arrangement that was scarcely on the map at all two years
ago," according to a report released Nov. 26 by management consulting
company Oliver Wyman.

Cigna's collaborative accountable care program includes 42 participating
entities, mostly large, with about 10,000 physicians providing care for
400,000 members. A paper in the November Health Affairs found the plan's
ACO program improved quality and lowered costs.

http://www.ama-assn.org/amednews/2012/12/03/bisa1203.htm?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20121203
<http://www.ama-assn.org/amednews/2012/12/03/bisa1203.htm?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20121203>

And...

MGMA-ACMPE
Practice Perspectives on Payer Performance, 2012

For the fifth year in a row, the Medical Group Management Association
(MGMA) has conducted its poll to determine group practice professionals'
attitudes about payer interactions.

Of the payers who are willing to engage in innovative payment models
(accountable care, shared savings, medical homes or payment bundling),
how favorable or unfavorable do you consider these options to be to your
practice?

Rating average / Payer

1.68 Medicare Part B
1.62 United Healthcare
1.62 Aetna
1.58 Cigna
1.57 Anthem
1.55 Humana
1.48 Coventry

(Based upon a 5 point scale where 1 = Completely unfavorable, 2 =
Moderately unfavorable, 3 = Neutral, 4 = Moderately favorable, and 5 =
Completely favorable.)

http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=1372690

And...

Health Affairs
November 2012
A Collaborative Accountable Care Model In Three Practices Showed
Promising Early Results On Costs And Quality Of Care
By Richard B. Salmon, Mark I. Sanderson, Barbara A. Walters, Karen
Kennedy, Robert C. Flores and Alan M. Muney

Cigna's Collaborative Accountable Care initiative provides financial
incentives to physician groups and integrated delivery systems to
improve the quality and efficiency of care for patients in commercial
open-access benefit plans.

Although not statistically significant, these early results revealed
favorable trends in total medical costs and quality of care.

http://content.healthaffairs.org/content/31/11/2379.abstract


Comment: These early results should sound the alarms on our current
efforts to implement accountable care organizations (ACOs). We've barely
begun and already about 30 million patients have been assigned to ACOs.
Yet look at how that is working.

Health care professionals in group practices were polled on how
favorable or unfavorable the insurers' innovative payment models,
primarily ACOs, were to their practices. The average rating for all
insurers was in the 1s - "completely unfavorable"!

Further, we are now seeing the same response from the insurers that we
did with earlier efforts at managed care. They were telling us then that
we were receiving higher quality care at lower cost. As it turned out,
costs continued to rise and quality remained mediocre.

Now Cigna is reporting that the recent Health Affairs article that they
authored showed that their "ACO program improved quality and lowered
costs." Yet the article actually states that these early results were
"not statistically significant."

This turkey has already taken off, and yet it can't fly. The health care
of 30 million patients is already at stake, and they are being cared for
health care professionals who find the arrangement COMPLETELY UNFAVORABLE!

Fwd: qotd: Cash upfront for ED visits?

_______________________________________________
Quote-of-the-day mailing list
Quote-of-the-day@mccanne.org
http://two.pairlist.net/mailman/listinfo/quote-of-the-day

-------- Original Message --------
Subject: qotd: Cash upfront for ED visits?
Date: Mon, 3 Dec 2012 14:08:48 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



American Medical News
December 3, 2012
New ED drama? Hospitals demand upfront fee for nonemergencies
By Kevin B. O'Reilly

(A small) but growing number of hospitals give patients whose problems
are deemed nonemergent a choice: Pay an initial fee to get the problem
treated in the ED, or seek care elsewhere. The fees range from $100 to
$180 for uninsured patients, or the relevant co-pay or deductible for
insured patients.

Hospitals implementing the pay-first policy say it complies with the
Emergency Medical Treatment and Active Labor Act because all patients
receive the federally required medical screening regardless of ability
to pay. It is only after a patient's condition is deemed nonemergent
that upfront payment for further treatment in the ED is discussed.

Yet many doctors interviewed for this article found the growing trend
alarming. They said it unfairly targets patients with poor access to
primary care and is unlikely to alleviate ED crowding because nonurgent
problems make up less than 10% of visits. Emergency physicians added
that the policy could result in tragedy, because some seemingly
nonemergent conditions quickly worsen, and because some patients with
life-threatening problems may wrongly decide to steer clear of the ED to
avoid pay-first fees.

The pay trend is severely misguided, said Arthur L. Kellermann, MD, MPH,
who served on an Institute of Medicine emergency care panel and now is a
health policy researcher at the RAND Corp., an independent nonprofit
think tank.

"People don't go the ER as a recreational event," he said. "If you tell
me you have an urgent care clinic or walk-in clinic or other places
where these people can go straight to, then OK. But to tell someone to
just go away if you don't have $150, you have to be ignoring the fact
that if they had somewhere to go they wouldn't be there in the first
place. And you have to be damn sure that this patient doesn't have a
more serious problem. This is putting a Band-Aid on a gunshot wound."

"There are truly people who come to the ED with something very benign,
and it ends up being a major medical issue," said Patrick O'Malley, MD,
an emergency physician in a suburb of Columbia, S.C. "Determining who
those patients are right at the front door is difficult."

The pay-first policy appears to be aimed at discouraging uninsured
patients from visiting the ED, said Leora Horwitz, MD, assistant
professor of general internal medicine at Yale University School of
Medicine in Connecticut.

"A much better solution to this kind of problem would be to incentivize
primary care doctors to provide the care that's needed, to have evening
hours, weekend hours, and to have more urgent care centers," Dr. Horwitz
said. "There are many ways to improve access for patients without
barring the door of the ER as your solution."

http://www.ama-assn.org/amednews/2012/12/03/prl21203.htm


Comment: Over half of emergency department (ED) visits are truly urgent
or emergent and should be seen within minutes. About 35 percent are
semi-urgent and should be seen within a couple of hours. Only 8 percent
are non-urgent and could be seen the next day. Which of these patients
should never be seen in the ED?

If you assume that patients are fully capable of assessing the urgency
of their own problems and and that triage nurses are fully capable of
never making a judgement error, then perhaps the 8 percent who are
non-urgent should be seen by their primary care professionals at the
next available appointment. But such an assumption is a stretch since
the true urgency often cannot be determined with absolute certainty
until there is a full assessment of the problem.

Maybe that head cold is an acute bacterial sinusitis, which could lead
to meningitis or an abscess with sepsis. Maybe that gastrocnemius strain
is thromboplebitis, which could result in a pulmonary embolism. Maybe
that migraine is a rupturing berry aneurysm, which... well, you know.
Then again, maybe these really are minor, non-urgent problems that do
not need assessment in the ED.

How do you decide that? Do you have the triage nurse make a decision to
turn the patient away at the front desk with no further ED evaluation?
That can be a problem if the nurse's initial screen misses a serious
problem, which is certainly possible, even if infrequent.

The answer is easy. In this age of consumer-directed health care, you do
not turn anyone away. Instead, you require the patient who seems to have
a non-urgent problem to use their health care shopping skills by
requiring a payment up front. Thus the ultimate decision is not left
with the triage nurse but rather is left with the least qualified
individual in the ED - the patient.

Some patients will make the wrong decision - bad policy. This is
overkill, perhaps literally.

If a local ED is truly overburdened with routine medical problems, the
proper management should be to adjust capacity in the health care
system. If primary care services need to be extended to evening and
weekend hours, improve capacity so that can be done. If the void can be
filled with a free-standing urgent care clinic, then establish that. The
ED itself could be expanded to include a wing for less urgent problems,
staffed with a nurse practitioner of primary care physician, if
appropriate for the community. The marginal cost should not be much
different from a free-standing, off-hours clinic, if that.

Under a single payer system, some adjustments in capacity can be made by
administrators of the global budgets for the facilities. More extensive
changes might involve separate budgets established for capital
improvements. But creating financial barriers to care runs the risk of
having the patient decide to forgo beneficial health care that just
might possibly be lifesaving.

If the ED is crowded with the worried well, fix the system. Don't kill
the seriously ill patient hidden amongst them.