DCMedical News: Wednesday, May 1, 2019
DCMedical News-DCMN
Washington, D.C.
Wednesday, May 1, 2019
DCMedical News is published every day both the House and the Senate are in session. Subscription information below.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Primary Care:
A RAND study (study report here, Modern Healthcare story here) says primary care amounts to 2% to 3% of Medicare spending, while a 2017 Milbank study (here) said that primary care amounts to 7% of commercial health insurance spending. According to the RAND group, “Primary care spending represented a small percentage of total fee-for-service Medicare spending and varied substantially across populations and states. Primary care spending percentages were lower among medically complex populations.”
CMS begins more experiments (announcement here, STAT report here, Wall Street Journal report here, with the headline “Trump Administration Launches Program to Rein In Medicare Costs”) with primary care payment. What’s new? These payment models are transformative, value-based, “The next evolution of risk-sharing arrangements to produce value and high quality health care. Building on lessons learned from initiatives involving Medicare Accountable Care Organizations (ACOs), such as the Medicare Shared Savings Program and the Next Generation ACO Model, the payment model options available under DC [Direct Contracting] also leverage innovative approaches from Medicare Advantage and private sector risk-sharing arrangements.” The AMA (here) thinks these transformative, value-based models will help prepare physicians to “take on” financial and business risk.
And, of course, the 2019 update of the Association of American Medical Colleges physician supply and demand study (here) projects a primary care shortage of 21,000 to 55,000 physicians by 2032, depending on how one defines “primary care,” and also depending on the rate of physician burnout and premature retirement secondary to the explosive growth of payment red tape and third party meddling.
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
Medicare-for-X:
Among the invited witnesses at the House Rules Committee hearing on “Medicare-for-All,” one star was the Commonwealth Fund’s Sara Collins, testimony here, slides here. Her summary: “The number of uninsured people in the United States has fallen by nearly half since the ACA was signed into law, dropping from a historical peak of 48.6 million people in 2010 to 29.7 million in 2018 . . . However, three distinct, yet interrelated, problems remain: millions of people are still uninsured, millions of people with insurance have plans that are leaving them underinsured, and health care costs are growing faster than median income in most states. After dropping significantly through 2015, the national uninsured rate has held steady at around 9 percent, with ominous upticks in 14 states in 2017. These stalled gains stem from four primary factors: Seventeen states have not yet expanded Medicaid, including the heavily populated states of Florida and Texas. People with incomes just over the marketplace subsidy threshold (about $48,560 for an individual and $100,000 for a family of four) and many in employer plans have high premium contributions relative to income. Congressional and executive actions regarding the individual market and Medicaid have reduced potential enrollment in both. Undocumented immigrants are ineligible for subsidized coverage under the ACA.”
She added, “In addition to the 29.7 million people who lack insurance, an estimated 44 million working-age adults with insurance are underinsured because they have high out-of-pocket costs and deductibles relative to their income. This is up from 29 million in 2010, according to Commonwealth Fund survey data. The greatest growth in the share of underinsured adults is occurring among those in employer health plans. However, people who buy plans on their own through the individual market — including the ACA marketplaces — are underinsured at the highest rates.”
Global Health Spending:
An article in JAMA (here) reports that “Health spending has increased so much in high-income countries (ranging up to $10,802 per person) that health expenditures account for a substantial amount of national spending in many countries. Still, these high-income countries remain outliers when health spending worldwide is considered. Together, the 61 high-income countries made up 81.0% of total health spending in 2016, even though they included only 16.6% of the global population and 13.7% of the disability-adjusted life-years (i.e., health burden). The United States alone accounts for 41.7% of global health spending, although it accounts for only 4.4% of the global population.”
1.4 Million More Uninsured, Reports the Congressional Budget Office:
Sarah Kliff in Vox (here) reports that “The CBO estimates that the number of Americans without insurance has risen from 27.5 million in 2016 to 28.9 million in 2018, an increase of 1.4 million Americans going uninsured.”
DRUGS & DEVICES
PBMs Under the Gun in 41 States
Pharmacy Benefit Managers are under scrutiny for opaque and seemingly outrageous profiteering according to a report in The Columbus Dispatch (here) and a database of proposed PBM legislation maintained by the National Academy for State Health Policy, at https://nashp.org/rx-legislative-tracker-2019/. “They once were the obscure middlemen reaping billions off prescription-drug transactions as they worked behind a veil of secrecy. But a wave of reforms to the $400 billion-a-year industry of pharmacy benefit management is cresting across the United States. According to the National Academy for State Health Policy, 101 PBM reform bills are being considered in 41 states this year . . . Following a Dispatch analysis last year of confidential pharmacy-reimbursement data, the Ohio Department of Medicaid released its own analysis showing that in 2017, CVS Caremark and OptumRx charged taxpayers $224 million more for drugs than they reimbursed pharmacists.”
READINGS AND REFERENCES
From late Uwe Reinhardt (“Priced Out: The Economic and Ethical Costs of American Health Care”): Continuing from the introduction, “This taboo on explicitly raising questions on social ethics in health care is of the same kindred spirit that now drives so many college students to stifle debates on topics that make them feel uncomfortable. It is nothing new in American culture. None other than Alexis de Tocqueville remarked on this cultural trait in chapter 15 of his book Democracy in America (1835), where he delivered himself of the following passage: ‘I know of no country in which there is so little independence of mind and freedom of discussion as in America.’ . . . Not surprisingly, our national health policy is a bundle of confusion and contradictions.”
U.S. House of Representatives:
Members at https://www.house.gov/representatives.
Committees and Members at https://www.house.gov/committees.
U. S. Senate:
Members at https://www.senate.gov/general/contact_information/senators_cfm.cfm.
Committees and Members at https://www.senate.gov/committees/membership_assignments.htm.
House and Senate 2019 Calendar of Regularly Scheduled Sessions, here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
May publication dates: 2, 7, 8, 9, 10, 14 15, 16, 17, 20, 21, 22, 23
June publication dates: 5, 6, 7, 8, 11, 12, 13, 14, 25, 26, 27, 28
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.