We Hate the Preauthorization of Drugs

Medical care in the US is absurdly expensive; no one wants to pay for costly new treatments.

Understandably, payers want discounts, and interestingly, pharmaceutical companies want to provide them. But how do you match up hundreds of payers with hundreds of drugs?

Ten years ago, the delivery of drugs in the US changed dramatically. "Pharmacy benefits managers" became a major force in healthcare. These managers could represent hundreds of health plans and aggregate their buying clout to create bulk purchases of drugs at a steep discount. The drugs were then sold to payers at a higher price -- the difference represented a profit for the pharmacy benefits manager. Acting as an intermediary and without meaningful transparency, pharmacy benefits managers made millions of dollars.

What value did they provide to earn this money?

To limit costs, pharmacy benefits managers and payers partnered to "manage" the adoption of expensive drugs. If a new drug could provide important benefits for 5 million patients, payers would suffer less financial pain if use of the drug were limited to only 500,000 patients. How might that be done?

  • First, they might tell the pharmaceutical company that the evidence supporting the new drug was not compelling. (It did not matter if this was true!). Take a drug that is better than a generic in reducing the risk of myocardial infarction but it did not reduce the risk of cardiovascular death. Suddenly and unreasonably, the drug was deemed substandard -- even though preventing myocardial infarctions was certainly a good thing. So pharmacy benefits managers demanded a price cut.
  • Second, they might delve into the data and identify artificial subgroups that appeared to benefit the most. If a drug reduced the risk of a clinical event by 30%, they would find a subgroup that benefited by 35%. They would approve use of the drug only for this subgroup, and not for the subgroup that benefitted by 25%. This was not a scientific process; differences in the responses in subgroups were probably due to the play of chance. The real problem: those who appeared (by chance) to have benefitted a bit less were likely to be deprived of the drug altogether.
  • Third, they required prescribers to run the gauntlet of preauthorization. No matter how thorough the initial request, the initial response was typically "no". Of course, the physician could resubmit the form; eventually, the answer could be "yes". But physicians were not inclined to spend hours to make repeated efforts to gain approval of a new drug for each patient.

Physicians could hire a full-time person to tackle the preauthorization issues. Oncologists routinely have such a person embedded in their practices, but most cardiologists do not. Why the difference? Medical oncologists receive significant sums of money (in professional fees) to deliver oncology drugs to patients. In contrast, cardiologists do not make any money when they prescribe cardiovascular drugs.

That means that cancer patients generally receive the treatments they need. But patients with heart disease do not receive the best therapies, even though a new cardiovascular drug is typically priced at <10% of the cost of a new cancer drug. The uptake of new cancer drugs is very rapid, whereas the adoption of new cardiovascular drugs is uniformly slow. Accordingly, there are many new cancer drugs each year, but new cardiovascular drugs are scarce.


Clinton Twp. man with disability fights benefit cut-off

Thanks and a hat tip to Joe H......

https://goo.gl/YhhSZG

Chris Meadows always considered himself as leading an independent, if challenged, lifestyle.

Meadows recalls as a child being able to run and ride a bike like other boys. Now 39, he accepts that muscular dystrophy has robbed him of the use of his legs and left him with limited arm movement.

But despite setbacks, he went on to graduate from high school with honors and obtained a degree from Michigan State University in four years.

He found a full-time job with the Social Security Administration and purchased and modified his own home, where he lives with Del, his chihuahua.

He is now facing the reality that health care budget cutbacks may cost him his Medicaid benefits, forcing him to move out of his house and stop living on his own.

“I never considered myself disabled until recently,” said Meadows, who was informed this year by Macomb County Community Mental Health his “needs” had changed and he should find somewhere else to live.

Meadows – who insists his health has been stable for 10 years – is comfortable in the neat bungalow he outfitted with wooden floors, widened doorways and an entrance ramp to accommodate his wheelchair. He also bought a wheelchair-accessible van with his savings.

“I want to look someone in the eye and have them tell me why I can’t live on my own,” he said. “I’m not looking for a crutch. And I sure don’t want sympathy. I just want to be treated like everyone else.

“I am fighting this for myself but also for other people like me whose lives will be affected by cutbacks.”

Towards that end, Meadows recently obtained a face-to-face hearing for July 18 before an administrative law judge in Macomb County to request that his Medicaid benefits be left in place. If his appeal is rejected, Meadows was told he has two options.

“I can stay where I am and get a Life Alert program, like those ‘I’ve fallen and can't get up’ commercials,” Meadows said. “If I am in need of help, I can call for paramedics or the fire department. If it’s not a matter of life or injury, I will be responsible to pay for their response.

“That means if I need repositioning in bed, which I do at night, or my wheelchair is stuck, I need to contact people and possibly taking them away from life and death situations,” he said.

The second option? To sell the house he bought nearly four years ago and move into a skilled care nursing facility.

State Single Payer And Medicaid Buy-In: A Look At California, New York, And Nevada

https://goo.gl/MqRRmN

Rising insurance premiums, lack of access, uncertainty, and commotion around Affordable Care Act (ACA) repeal, have all contributed to the growing discontent and unease surrounding health care reform. Pressure to act continues to mount. Insurance titans Humana, United Healthcare, and Aetna have all rolled-back participation on the ACA Marketplaces. Anthem recently announced that it would exit the Ohio health insurance Marketplace, potentially leaving at least 18 counties without an exchange plan next year. Missouri and Washington State are also facing similar Marketplace participation issues. States such as Alabama, Arizona, Illinois, Kansas, Minnesota, Oklahoma, Pennsylvania, and Tennessee have seen individual market exchange premiums increase more than 45 percent since 2016. Furthermore, participating exchange plans are asking for steep rate increases for next year—averaging between 11.1 percent and 44.7 percent.

These events have contributed to an economic and political climate ripe for disruptive legislation. While Congress and the current administration pursue solutions to address premium and access issues, more states are inserting themselves in the conversation. More than a dozen states have explored options to leverage federal 1332 and 1115 waivers, which would provide flexibility to develop market stabilizing programs and regulatory changes to their respective individual and Medicaid markets. More recently, a few state legislatures have leap-frogged one-off programs such as reinsurance or high-risk pools, and sought to create a truly different market structure. Three states’ legislatures, California, New York, and Nevada, have developed high-profile state-driven solutions to address consumer access and price-related concerns. While state-led waiver initiatives such as those from Alaska and Oklahoma are meant to provide an incremental stabilizing force to their respective markets, the models that California, New York, and Nevada legislatures proposed could fundamentally reshape the framework of state health markets more akin to what Massachusetts did 11 years ago.


State finds abuse, seeks changes at Judge Rotenberg Center

The fact that the Rotenberg Center continues to exist says more about social attitudes toward people with significant disabilities in America than all the inspiration porn in the world.....
https://goo.gl/W2p48B

The state recommends that the Judge Rotenberg Educational Center take a hard look at its policies after two now-former employees were charged with assaulting a patient.

The Massachusetts Disabled Persons Protection Commission investigation into the matter substantiated the abuse claims, according to the investigation report obtained by The Patriot Ledger.

The two ex-employees are charged with striking a tied-down mentally ill man with a belt and their hands on multiple occasions, as well as spitting on him at a Randolph residence owned by the Canton-based center.

“That (the two employees) acted with so little regard to (the victim’s) dignity and his behavioral program for such a period of time suggests that staff is either insufficiently trained or supported to carry out complex treatment programs for individuals with disabilities,” the commission wrote in its report.



First They Came for the Cripples

https://goo.gl/7j2uYA

I don’t have a problem with the sentiment expressed. It’s just that there’s a hole in it. It ought to begin with, “First they came for the cripples and I did not speak out because I was not a cripple.“

It would be nice if we could update Niemoller’s words for the sake of historical accuracy and inclusion. I know that’s difficult because first, he never mentioned cripples in his original statement; and second, he’s dead. But maybe his estate could grant permission to put words in his mouth, posthumously, just this once.

Because the “they” in this saying are, of course, Hitler and his Nazis. And they refined their extermination techniques by first practicing on snuffing out cripples. In 1939, Hitler launched a program called T4, named after the address of the Berlin headquarters for the program, Tiergartenstrasse 4. At this headquarters, a team of “medical experts” reviewed the records of all the institutionalized cripples in Germany and sent about 200,000 of them off on a field trip to take a shower. Except the rounded-up cripples didn’t know it was a one-way trip. The so-called group shower facilities were really gas chambers.

For a government to get away with treating a group of its citizens so shabbily, it must rationalize such behavior with a steady diet of propaganda. The victims must be dehumanized. The rest of the citizens have to feel that the victims pose some sort of threat to them and thus, wiping them out becomes an act of self-defense.

The T4 propaganda made cripples out to be a major threat due to the enormity of their dead weight. They were depicted as “useless eaters” living “burdensome lives.”