DCMedical News: Friday, April 29, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session. Publication will resume May 10.
THE BIG STORY Friday, April 29, 2022
Taking Advantage
The Inspector General of the Department of Health and Human Services has faulted Medicare Advantage (MA) programs for denying expensive but medically necessary care. The plans are marketed through comparatively inexpensive lifestyle and convenience amenities to seniors.
Historically, the "Medicare Type C" plan (since 1995) has limited physician panels and hospital choices, with limits not often discovered by enrollees until they need a specific doctor or hospital. More recently, Medicare Advantage scandals have involved "risk adjustment," controversial "after the fact" enhancement of the relative acuity of disease or intensity of services or both, increasing reimbursement to the MA plans. The plans argue vigorously that they are less costly to the Medicare program, despite evidence (convincing to the Medicare Payment and Access Commission, MedPAC) to the contrary.
Now reviewers find that MA plans are "throwing a spanner into the works," holding up their approval of what is "medically necessary," and often refusing to pay even the claims they accept as necessary. The report (here) and a summary in The New York Times (here) say that "Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program." Tens of millions of denials are issued each year for both authorization and reimbursements, an echo of similar findings from a study in 2018 (here) showing that private plans were reversing about three-quarters of their denials on appeal.
The NYT reports that enrollment in the privatized version of Medicare has more than doubled in the last decade. With so much of group commercial health insurance offered through self-insured employers—meaning that insurer profit is not based on underwriting, only on the much smaller income from administration—the public programs have become the primary source of profit for health insurers. The profit in an MA plan is made up of savings from enrolling lower cost doctors and hospitals; higher reimbursement "adjusted" payments; and now evidence of delayed and denied medically necessary care; all of this income offset only slightly by the cost of convenience amenities offered in aggressive marketing campaigns.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
National Academies Draft Plan for Clinical Workforce Well-Being
The NAM Clinician Well-Being Collaborative is working to develop a National Plan for health workforce well-being (here). The draft plan will be released in May 2022 for public input. The NAM will also host a public input event on the day of the draft’s release, May 20.
"The National Plan will coordinate collective action across priority areas, including: positive work and learning environments and culture; measurement, assessment, strategies, and research of well-being; mental health and stigma; compliance, regulatory, and policy barriers for health workers’ daily work; effective technology tools; effects of COVID-19 on the health workforce; recruitment of the next generation." Stay tuned.
Creeping Privatization in the UK's National Health
A report in The Financial Times (here) describes the Americanization of the British health system, not only through sale of pieces of the system to American corporations, but also by adoption of the American practice of putting the burden of medical care increasingly on the sick.
"British healthcare is quietly inching into the private sector, and what is most concerning is that it is increasingly those least able to pay who are being forced away from the NHS. If I told you that in the US, with its notoriously expensive healthcare system, the number resorting to crowdfunding campaigns to pay exorbitant private medical expenses has risen 20-fold in the past five years, I’m sure you wouldn’t be surprised. But those statistics don’t refer to the US, they refer to the UK."
HOSPITALS AND OTHER HEALTH CARE FACILITIES
National Cancer Institute-Designated Hospitals Mark Up Cancer Chemotherapy, Disguise the Results
A study in JAMA Internal Medicine (here) says that 61 NCI-designated hospitals were deficient in disclosing chemotherapy prices to patients, but enthusiastic in marking them up. The researchers found that "Most NCI-designated cancer centers did not publicly disclose payer-specific prices for cancer therapies as required by federal regulation." Median drug price markups across all centers and payers ranged between 118.4% (sipuleucel-T) and 633.6% (leuprolide) . . . Negotiated prices also varied considerably between payers at the same center." STAT+ covers the research, here.
DRUGS & DEVICES
Opinion Says Medicare Got it Right
An essay in STAT (here) is headlined "Medicare got it right: Unproven Alzheimer’s drug would have threatened the financial stability of 60 million Americans," in addition to its impact on the Medicare program. The actual decision (National Coverage Determination on Aduhelm, 53 pgs.) is here, analysis in another STAT piece here.
Subscription Model for Antibiotic Development Launched in England
A report in The Financial Times (here) notes that "The UK is set to become the first country in the world to pay drug companies a fixed fee for supplying antibiotics . . . Under the deal being struck by the NHS with Pfizer of the US and Shionogi of Japan, the drug companies will be paid a fixed fee of £10mn a year. The current reimbursement system based on sales volume often fails to provide sufficient revenue to justify research and development spending."
Executive Action—Congress Not Needed—May Be Enough to Command Drug Prices
A group of legal scholars has, through Senator Warren (letter and proposal here), offered an opinion that three initiatives requiring only executive action should be used to exert increased control over drug prices. The Senator writes, "According to . . . experts from Yale Law School, Harvard Medical School, and Columbia Law School: High prescription drug prices in the United States . . . do not typically reflect material factors like supply shortages, manufacturing difficulties, or labor costs. Instead, drug prices are high primarily because brand-name drug companies use government-granted exclusivities, such as patents, to prevent competition and charge high prices."
They continue, "Existing law gives the executive branch several tools . . . [which] can help the Administration break patent barriers, foster competition where currently there is none, and drive down prices. Critically, using them requires no additional congressional action. This letter describes . . . the 'government patent use power' codified at 28 U.S.C. § 1498, and the Bayh-Dole Act’s 'royalty-free license' and 'march-in rights.' These tools are integral, longstanding, and legitimate parts of our patent system. Together, their directed use can help the government obtain fair prices for prescription drugs."
READINGS & REFERENCES
Pushing Back Against Influencers
The GAO has reported (summary here, coverage in Regulatory Focus, here) that government agencies need better tools with which to fight political influence. IHP reports, "Key HHS agencies that are instrumental to managing the COVID-19 response lack policies to prevent political pressure from influencing decisions that should be based on science . . . The four agencies the GAO examined were FDA, the Centers for Disease Control and Prevention, the National Institutes of Health, and the Office of the Assistant Secretary for Preparedness and Response."
Select Coronavirus Public Health Resources and References may be found here. The JAMA Patient Page explains the current status of oral anti-viral medications for COVID-19, here.
2022 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
May 10, 11, 12, 13, 16, 17, 18, 19
June 7, 8, 9, 10, 13, 14, 15, 16, 21, 22, 23, 24
July 12, 13, 14, 15, 18, 19, 20, 21, 26, 27, 28, 29
August, Congress adjourned, no issues
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org