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The Power in Planning Ahead

April 17, 2017
4:53 pm

Now that most of us have filed our taxes for 2016, this is an opportune time to review our health planning with the same level of attention.  There is a nationwide effort to make the day after Tax Day “National Healthcare Decisions Day” – a day in which we think about our long-term healthcare needs and make a plan for how we would like to be cared for in our final days.  At one point or another, all families face challenges with advanced illness and must make decisions about end-of-life care, but too few of us have given thought to issues like designating power of attorney or creating advance directives and living wills.  Advanced illnesses cause many challenges for families.  One of the most difficult is when family members become the primary caregiver for their loved ones and are placed in decision-making roles that they never expected.  Advanced care planning is a useful tool that can assist individuals in preparing for end-of-life care, and keeping family members and healthcare providers updated on their wishes.

For individuals faced with end-of-life care decisions, it is important to have conversations with their physicians about their treatment options and their wishes regarding advanced illness care.  Studies indicate that patients and their families are interested in discussing their end-of-life options with their physicians.  However, there is concern that physicians may lack the training or resources to engage in long-term conversations with their patients on end-of-life healthcare decisions.   For instance, a recent survey of 736 physicians, link above, found that less than one-third reported any formal training on discussing end-of-life care with their patients and their families.

The Coalition to Transform Advanced Care (CTAC), a non-partisan organization, is collaborating with the AHIP Foundation on “The Advanced Care Project,” which offers suggestions for how healthcare professionals can help patients make their decisions about their end-of-life care needs.  A combination of education and collaboration on advanced care allows for patients and family caregivers to develop their own care plan that is specifically designed to fit their needs.

Healthcare plans and providers are embarking on their own initiatives to assist and ensure that patients are able to make their own decisions about their healthcare.  For instance, Aetna offers support to its members through its Compassionate Care Programs, in which individuals experiencing end-of-life care are assisted by nurse care managers who are available to provide resources to patients and their family members, as well as assist physicians in managing the care of the patient.   The Franciscan Missionaries of Our Lady Health System in Louisiana is collaborating with the Louisiana Health Care Quality Forum in the Louisiana Physician Orders for Scope of Treatment (LaPOST) initiative on how a patient’s desires and goals into their treatment plan can be medically translated and applied to multiple healthcare settings.

SCAN Health Plan has constructed a new system to make it possible for patients and their families to understand the full array of care options available to them and to receive treatment that best fits their values, goals, and cultural preferences.  This system is called the Program for Advanced Illness (PAI). A palliative-trained nurse case manager serves as the member’s personal advocate.  The nurse will help members and their caregivers navigate care options that reflect patient’s goals and wishes, encouraging articulation and documentation of end-of-life requests while identifying healthcare proxies and making referrals to hospice.  Additionally, the nurse will communicate with all medical staff and other parties to ensure everyone understands the critical decisions being made as well as following up with the family to offer bereavement services.  More program details are available in the Viable Solutions compendium recently released by the Healthcare Leadership Council.

On National Healthcare Decisions Day, let us continue to have the conversation about how healthcare providers can best assist individuals in making their own decisions about their health care needs.  Create an advance directive and talk to your family and friends about the importance of care planning.  Visit www.nhdd.org for more information.

The Mythology of Safe, Cheap Drugs from Canada

February 24, 2017
1:54 pm

In January, the U.S. Senate rejected legislation, as it has multiple times in the past, which would have allowed the importation of prescription drugs from Canada.  Apparently believing that a bad idea can never have too much exposure, some senators are reportedly poised to bring drug importation up for another vote.  The evidence on this issue hasn’t changed and neither should the outcome.

Last month, the Congressional Research Service provided lawmakers with a report on the safety of the Canadian drug supply that should have put this issue to rest once and for all.  The report, compiled by a Senate committee in Canada, illustrated the differences between the rigorous drug safety infrastructure maintained here in the United States and the protocols in other countries which are, well, less extensive.  While both Canada and the U.S., for example, import ingredients used to manufacture prescription medications, the U.S. Food and Drug Administration conducts hundreds of inspections at foreign manufacturing facilities each year.  Canadian authorities conducted only 14 in 2013 and 2014.

This is of particular concern when drug counterfeiting is becoming a global crisis.  Putting a crack in our closed drug inspection-and-approval system with importation legislation will place American patients and consumers at unnecessary risk.

What Congress should keep in mind is that laws already exist to permit drug importation from Canada.  The Secretary of Health and Human Services has the authority to permit drug imports, under the Medicare Prescription Drug Improvement and Modernization Act of 2003, if it can be certified that such action will generate substantial cost savings while protecting public safety.  No HHS Secretary in either Democratic or Republican administrations has ever made that certification.

There’s no doubt that drug importation is one of those crowd-pleasing issues that looks good on paper.  The reality is, though, that it offers very little, if any, gain for consumers while carrying a very high potential cost that is simply unacceptable.

Medicare Embraces the ‘Ounce of Prevention’ Philosophy

March 23, 2016
5:20 pm

We’ve long maintained that Medicare can be a stronger program, both in terms of protecting the health of its beneficiaries and in improved cost-efficiency, if it did a better job emphasizing prevention, diagnosis and early treatment, emulating many of the lessons being demonstrated every day in the private sector.

To the credit of HHS Secretary Sylvia Burwell, the Medicare program is now moving in this direction in a very significant way.

Today, Secretary Burwell announced that the Obama Administration will propose new rules this summer that would have Medicare provide coverage for diabetes prevention programs.  She cited a YMCA program that has enabled participants to cut their body weight by an average five percent, thus reducing the propensity for diabetes, a disease with extremely high incidence rates among the elderly.  Early interventions can prevent the need for more expensive healthcare services to treat diabetes symptoms, thus reducing Medicare expenditures.

HLC has long argued that Medicare should pay for services such as health coaching, aiding beneficiaries in practicing better dietary and exercise habits, as well as new technological innovations to help those with diabetes and prediabetes better monitor their health conditions.  We, in fact, sponsored a briefing for congressional staffers on the subject last year.

Secretary Burwell’s announcement today heralded an important new direction for the Medicare program.  In her words, the federal government is transitioning from “treating the sick to preventing the illness.”   We applaud her actions.

The Amazing, Classy, Winning (and Completely Ridiculous) $300 Billion Proposal

February 19, 2016
1:12 pm

It’s a notion we’ve heard a fair amount during the presidential campaign, this idea that Medicare should ‘negotiate’ prescription drug prices.  (There’s a very good reason I put ‘negotiate’ in quotes.  We’ll get to that in a moment.)  The concept reached all new levels of visibility in recent days when the leader in the polls on the Republican side told MSNBC’s “Morning Joe” program, “We don’t negotiate.  We don’t negotiate….If we negotiated the price of drugs, Joe, we’d save $300 billion a year.”

I’m not going to devote this post to litigating the $300 billion boast.  The Washington Post has already done that by giving it “Four Pinocchios” on its lack-of-truthfulness scale.  It is, of course, a mathematical impossibility to save $300 billion annually from a Medicare Part D prescription drug program that spends less than $80 billion per year.  A candidate making that claim has ventured into loaves-and-fishes territory.

But that particular absurdity notwithstanding, let’s discuss the proposal coming from the current presidential race leaders in both parties that the heavy hand of the federal government should be involved in drug pricing.  There are some myths attached to this idea that, in any reasonable debate, shouldn’t be shunted aside.

Myth #1 – In the Medicare program today, there are no negotiations to reduce drug prices.

This, of course, is patently untrue.  Prices in the Medicare Part D program are determined through a negotiation process involving private health plans and pharmacy benefit management (PBM) companies.  PBMs handle millions of individual pharmaceutical transactions yearly and have the bargaining power to achieve reasonable and realistic pricing.

The proof here is in the proverbial pudding.  Average monthly premiums for enrollees in the Part D program have, according to the Centers for Medicare and Medicaid Services, remained stable at an affordable level for the past five years.

Myth #2 – Federal government involvement in Medicare drug pricing is a pro-consumer idea.

Proponents of federally-dictated drug pricing make it seem all so simple, that if the government takes over drug price negotiations then Medicare prices will drop to the level of the Veterans Administration.  They don’t, however, explain the tradeoffs that come with this kind of policy change.  When you arbitrarily lower prices, you invariably restrict accessibility.  In the VA, for example, nearly one-fifth of the 200 most commonly prescribed drugs are not on its national formulary.  As noted in a paper by the Center for Medicine in the Public Interest, the vast majority of drugs not made available to VA patients are accessible within Medicare Part D prescription drug plans.

This is why the Congressional Budget Office has traditionally been reluctant to ascribe any real savings to the concept of federal price negotiations within Medicare, because of the unlikelihood that lawmakers will tell their senior citizen constituents that many of the drugs on which they depend will no longer be available to them.

And let’s not forget that artificial price controls on pharmaceuticals have an inevitable impact on research and development of new therapies, an unacceptable outcome when devastating (and costly) chronic illnesses like diabetes and heart disease are affecting millions.

Myth #3 – We need hard-nosed federal negotiators sitting at the table with pharmaceutical company executives to push down prices.

The mental image of two sides bickering over numbers from their respective sides of a table is a fallacy.  The reason I put ‘negotiate’ in quotation marks is because there really is no such thing.  The federal government establishes pricing levels and drugmakers must agree to meet those prices in order to be in the Medicare Part D formulary.  This has two effects – (1) the aforementioned restricted access to therapies and (2) the end of competition in the Part D program.  Today, plans compete with each other to provide greater value to enrollees.  With a single federally-set pricing level, the benefits of consumer choice and competition are lost.

The good news here is that there are ways to address healthcare costs while, instead of hurting patients and consumers, actually elevating care quality and bolstering innovation.  The Healthcare Leadership Council unveiled a series of proposals this week to accomplish those goals and I’ll be discussing these in more details in a series of forthcoming posts. Watch this space.

Bringing Value to the Patient and the Healthcare System: A New Report

February 04, 2016
4:52 pm

This week the Patient-Centered Primary Care Collaborative (PCPCC) unveiled its fifth annual report on the patient centered medical home’s (PCMH) impact on cost and quality.  In the quest to improve population health and reduce cost, PCPCC has collected data from peer-reviewed studies on medical homes’ costs and utilization.  Several Healthcare Leadership Council (HLC) members – Anthem, Aetna, Johnson & Johnson, McKesson, Merck, Premier and Takeda — are executive members of PCPCC. The results are instructive in the continuing discussion on how to elevate healthcare quality while containing overall spending.  Key takeaways from the report include:

  • A focus on primary care drives down cost and utilization
  • Best results came from sites that used multiple payers
  • It is essential to align payment with performance

The panel that discussed the findings included Marci Nielsen, CEO of PCPCC, Alissa Fox, SVP of the Office of Policy and Representation at Blue Cross Blue Shield Association, Chris Koller, President of Milbank Memorial Fund, and Len Nichols, Director of the Center for Health Policy Research and Ethics at George Mason University.

The experts stated that PCMH’s have demonstrated the ability to control costs by providing the right care.  Delivery reform and payment reform go hand in hand; one will not succeed without the other.  As the nation works toward a value-based healthcare system it is important to be mindful of the cost of transformation.  Incentives must be right, there will be a need for antitrust exemptions, and the industry will rely on national standards but local relationships.  Currently, fee-for-service does not reimburse services that are key to coordinating patient care.  The PCMH model is not one size fits all, according to the panel, and more research is needed to identify which varying components are demonstrating the most value.  Defining measures and identifying best practices are necessary steps in ensuring successful implementation of the PCMH model.

This discussion on how to improve value within the healthcare system will reach an important juncture later this month when the Healthcare Leadership Council unveils specific policy recommendations – endorsed by virtually all sectors of the healthcare industry in addition to patient advocacy organizations – on how to remove barriers to quality-enhancing, cost-saving health innovations.  Watch this space for more information.