WHO Wants Healthcare Reform

Last week, we spoke about the Senate health committee chairman Lamar Alexander (Tennessee) and member Patty Murray (Washington) introducing a draft package of legislation. The draft packages goal is to cut healthcare cost (Click “here” if you want to go to that blog to catch up on that news).

However, the World Health Organization (WHO) announced, at the World Health Assembly, that a new resolution to improve the transparency of pricing for medicines, vaccines, and other health products is on the way.

The resolution advised member states to publicly share information on the prices paid by the government and other buyers for drugs, products, and additional pricing determinants. The goal here is to help the general population make more of an educated and informed decision and for more affordable pricing to expand across all products.

In past WHO resolutions, they have looked for particular components of transparency for healthcare products. However, a recent request was to examine the impact of pricing on cancer medicines.

“This resolution ties these aspects together to request transparency of inputs across the value chain of health products and their impact on actual prices paid,” a WHO spokesperson told FierceHealthcare.

Now, to make sure these goals are being met, WHO will provide a progress report back to the assembly in the year 2021. The report will include information on monitoring the impact of price transparency and the feasibility of web-based tools for sharing information. Member states will have platforms to share their progress as well.

“Member states must increase transparency in accordance with their national and regional legal frameworks and contexts, but the resolution promotes public sharing on net prices, inputs across the value chain, patent status information, and other relevant information to improve access.” Affordable healthcare is a huge must, no matter the size of the country, the population in that country, or how much that country is worth. WHO is attempting to help those who can not help themselves because of poor government choices.

However, reforming the United States system will be a significant group effort by the government, provider, and payer. The complex payer mix in the U.S. makes the government visibility on the actual prices paid very difficult. WHO did note that the member state has already cooperated in moving toward a common goal of bettering healthcare.

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A Look at Types of Universal Healthcare

Americans all around the nation are giving their support for Medicare for all. On March 29 of this year, we wrote a blog called “Is Medicare For All the Solution?” In case you don’t know what Medicare For All is,

“Medicare For All is a universal health care plan that was developed by Vermont Senator, Bernie Sanders. This would be built off what former President Barack Obama had with the Affordable Care Act (ACA), also known as Obamacare. Medicare For All is a solution that would help give health insurance at affordable rates, covering primary and specialty healthcare, vision, hearing, dental, mental health, addiction services, and many other essential health care solutions.”

Niran S. Al-Agba, MD, explains universal health care through the following four points:
1. Most universal health care systems are not highly centralized,
2. Most universal coverage systems offer narrow benefit packages and incorporate cost-sharing for patients.
3. Private health insurance plays a significant role in most developed countries with universal coverage.
4. Countries with universal coverage have strict immigration policies to control health care expenditures.

The Commonwealth Fund recently compared universal health care systems around the globe with the United States single-payer bills proposed in Congress. The country that most resembles the US proposal (where decision making is centralized) is France. In France, the government is responsible for 77 percent of total health expenditures. However, there is an out-of-pocket cost share for patients that is around 7 percent, annually. A few other countries that also use a highly centralized system are the Netherlands, Singapore, and Taiwan. However, these countries have populations that are more similar to that of only one state in the US.

Another type of Universal Healthcare is a “hybrid” system, where decision making and financing are shared at the federal, regional, and local government levels. This form of government is the most cost-effective system to deliver universal health care coverage to a larger population. In Australia, Denmark, the United Kingdom, and Norway, policy making and resource allocation decisions remain centralized. However, there is flexibility within a region to distribute funds in a more individualized way that is best for local needs.

There is also a “decentralized” universal health coverage system, where decision making and resource allocation is regulated at the regional or provincial level. Canada, Germany, Sweden, and Switzerland use this system. For example, in Canada, each province receives (per capita) block grants from the federal government. A block grant is a fixed amount of money the government allocates to a province in advance. Regions are usually held accountable through the establishment of broad national guidelines to ensure fairness and service uniformity.

Now that we’ve gone over a few different universal health care systems which do you think is the best? Using our comment section is a safe place to share your opinions and see what others think about the article or things we’ve talked about in the blog.

New Tech Means Better Living

Israel is making a large payment on big data in medical research and treatment. There are plenty of startups and large companies that are parsing anonymized medical data, outcomes and results for patients, and patient data for signs on how diseases develop, how they can be treated, and how they can be prevented. The large payment is a $300 million investment in the big data digitization project. This would help make anonymized data available to researchers, pharmaceutical companies, and medical institutions.

The investment that Israel is making could be a huge step forward in helping patients who are suffering from whatever disease they have quicker, easier, and possibly more affordable. Medical data is an incredible resource that can be used to save lives and also enable personalized medicine too. This new technology could help medical professionals predict and even intrude on the disease before a condition or illness appears.

One form of this big data to enhance care is K, a mobile app that enables patients to receive personalized search results based on other patients similar to them. K uses a large number of anonymized doctor visits in Maccabi over the last 25 years. This data is then personalized for users and gives a highly reliable passage of what their symptoms might be saying. To use this app, the patient needs to answer a series of easy questions, and then the app measures against similar cases collected during general practitioner visits.

However, one of the most innovative uses of big data in medical tech today would be the collaboration between Israel’s Maccabi HMO’s MK&M Big Data Science Institute and IBM. The project aims to assist doctors in automatically identifying breast cancer using mammography images from HMO’s database, which then teaches computers how to detect breast cancer in images. The system analyzes millions of images and then looks for lesions, markings, and other characteristics that could indicate cancer presence.

These advanced systems and others like them have the ability to eliminate diseases, provide effective treatment for patients, reduce costs, assist medical professionals, and relieve human misery. As a community, we should be excited to embrace this new, ever-evolving tech.

Another valuable resource available to our physicians is the Emerald Coast Medical Association member meetings. In these meetings, you will learn new information, meet fellow medical professionals, and have the ability to present your own views and concerns.


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Big Hospitals Sue HHS

Hospitals are beginning to follow in the footsteps of the American Hospital Association and are suing the Trump Administration for its decision to institute site-neutral payments.

The change, which is part of the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System rule-making for 2019, would lower reimbursements for hospital outpatient department services to match rates set by the physician fee schedule for clinic visits. This would mean lower costs for a patient’s insurance. However, hospitals would lose about $380 million in 2019 alone and possibly up to $760 million in 2020.  The colossal loss of money is causing an uproar with (as of right now) 38 hospitals signing the lawsuit.

This isn’t even helping the patient from what CMS Administrator Seema Verma says, “It doesn’t make sense for taxpayers, and it certainly doesn’t make sense for patients because they end up having to pay more depending on the site of service.”

However, this can be looked at as taking down the money hungry hospitals. University of Michigan health law professor Nicholas Bagley was among the observers who praised the Trump administration for the proposal, saying CMS is “picking a fight with powerful hospitals because it’s the right thing to do.” The site-neutral payments would mean, hospitals would have to offer the same care at lower prices.

The previous system had Medicare paying higher rates for services provided at the hospitals outpatient facilities. The Centers for Medicare & Medicaid Services projects the policy change will save the beneficiaries $150 million in co-payments annually; dropping the average copay from $23 to $9.

“The different payment rates also pushed hospitals to purchase independent practices to increase their reach and take advantage of the higher reimbursement rates,” Verma said. “Neutralizing payments would increase provider competition.” Competition could potentially turn into one hospital bettering the others, just because they have more resources and more funding.

However, Farzad Mostashari, MD, co-founder, and CEO of Aledade, said in a series of tweets that hospitals will fight the OPPS rule “bitterly” but that there could be a long-term benefit for them in it.

“The truth is that this proposal could help hospitals be more competitive in value-based contracts/ alternative payment models, and they should embrace the changes,” Mostashari wrote. “If rural hospitals or AMCs need subsidies, then we should do it directly, not through distorting payment policies.”

Here at Emerald Coast Medical Association, we care about your health too. Since 1981, over 50 local physicians banded together to create a Physician’s Security and Benefit plan.

The primary goals are:

  • Provide affordable health insurance to employees, physicians, and their families
  • Upon the death of a physician, provide insurance for the spouse and children of the physician
  • Use each others’ premium dollars to pay claims for those physicians and their family members who had serious medical conditions
  • To provide a premium-rating schedule that did not discriminate against those physicians and their employees who had incurred large medical claims
  • Avoid implementing “gatekeeper” type “managed care” features
  • Promote access to virtually all providers in and out of the state
  • Establish a stable alternative to those carriers who often abandon the insurance marketplace

You can get all this and more for being an Emerald Coast Medical Association Member.

No reason to wait, sign up today. We want to help you and your practice stay healthy and up to date on relevant information.

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Government Shutdown & Healthcare

The government shutdown between President Trump’s administration and congressional Democrats regarding funding of the “border wall” leaves many with questions regarding its immediate impact on changing current healthcare systems. While the ongoing partial government shutdown leaves the majority of the federal government’s public health programs unaffected, the lack of funding to specific departments has the potential to alter some important health-related initiatives.

Due to the passing of five major appropriation bills by Congress, the funding of the Department of Health and Human Services and the Department of Veterans Affairs has remained. This funding dampens immediate large-scale negative impacts because many government healthcare programs such as Obamacare, Medicare, and Medicaid are insulated and funded through September. Additionally, two other critical unaffected departments are the Center for Disease Control and Prevention and the National Institutes of Health, allowing for the continuation of public health surveillance and significant biomedical research respectively. Unfortunately, other government agencies such as the Food and Drug Administration are greatly affected. Due to the Department of Agriculture being completely shut down, the FDA is currently only operating at 60% of regular employees leading to potential problems regarding regulations and mandatory recalls of possible harmful goods.

Another detrimental effect of the government shutdown is an impact on the Indian Health Service (IHS). The IHS receives all of its funding from the recently shut down Department of the Interior, which has had widespread consequences to Native American tribes. The only services that can continue in these areas are “immediate needs of the patients, medical staff and medical facilities” and this lack of funding has been extended to suspending grants and other IHS health programs.

Well-known departments and agencies such as the Department of Homeland Security’s Office of Health Affairs and the Environmental Protection Agency have already been displaying negative aftermath of the government shutdown with all signs pointing to large detrimental effects if this continues for an extended period. Health inspectors at the United States borders and the Countering Weapons of Mass Destruction Office have already faced setbacks causing increased concern regarding possible decreased safety of US citizens. Furthermore, even the National Park Service has ceased all restroom maintenance and trash service due to funding leading to closures of popular parks such as Yosemite and Joshua Tree National Park due to unsanitary conditions.

Social Determinants of Health Influence in 2018

Social determinants of health (SDOH) started becoming more mainstream of a concern for the greater healthcare system in 2018. An individual’s socioeconomic status can put their health at risk. Locally, this has become even more apparent since Hurricane Michael hit the panhandle last October. SDOH is defined by the Centers for Disease Control and Prevention as “conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes.” These conditions can determine the health of people.

People have been living in unimaginable conditions since Hurricane Michael hit on October 10th, 2018. We are now in 2019, and many are still unable to live in their homes. Without proper housing and the many hazardous conditions around the panhandle that extend farther than just at home, there has been an increased rate of injury and illness. This hurricane has provided us with a prime example of social determinants impacting health.

The healthcare system has avoided addressing the issue of social determinants for a long time. In 2018, newly launched initiatives, as well as studies showing the need for these initiatives, have caused the healthcare system to take a new look at social determinants and how to address them.

Factors such as housing, transportation, food assistance, and personal finances have been taken into account to begin the process of reassessing healthcare’s take on social determinants. People with limited access to transportation and housing are at a higher risk of injury or illness, especially when they have limited ways to get to a physician. Medicaid plans on helping to offer affordable housing to those who need it. Patients without transportation often forego making an appointment or miss them when they do have them. Uber recently launched a “health dashboard” to provide free rides for those unable to get to a doctor when they need to.

In addition to this, Geisinger Health System started “Fresh Food Farmacy,” which cut costs among diabetic patients from anywhere between $48,000 to $240,000 per member. This caused the risk of serious complications or death for people with diabetes to drop to 40%, a great win for those working with diabetics. Cigna is also planning on offering financial planning services for their group members, as announced in December 2018. Financial stress can take a significant toll on a person’s physical and mental health.

With many physicians claiming social determinants “aren’t their problem,” there is still a long way to go with maintaining equity among Americans. However, now that the panhandle is experiencing even more of these social determinants than usual, we have been provided a new chance to tackle these determinants and make the panhandle a healthier place for everyone. These social determinants will continue to play a significant role in local health for everyone involved with the hurricane, but choosing to see the positive side of this great opportunity is best for our county’s health.

Stress About Care Adds to Patients’ Health Concerns

As medical practitioners, we feel the stress of the nation’s health care issues every day. Continual paperwork, denial of claims, and ever-changing regulations put non-stop pressure on our offices. But the stress of a fractured health care system is impacting our patients’ lives even more significantly.

News readers around the world were stunned by last month’s story of the woman in Boston who, after having her leg trapped between a subway car and a platform, refused to allow an ambulance to be called for her because she couldn’t afford it. This is an extreme example, but it is no longer unusual for patients to refuse needed care or skip important follow-up visits, simply because of the cost involved.

Contrary to popular belief, it’s not just the uninsured who are financially unable to get medical help in the U.S., but also those with insurance. As deductibles and co-pays continue to rise, and the list of what is covered grows more and more specific, even those with “good” insurance find their bills mounting. A study published in January by the American Psychological Association (APA) shows that the cost of health care is a major life stressor for 2/3 of Americans, both those with incomes below and above $50,000 per year.

“Given the uncertain fate of our nation’s health care system, it is not surprising that the majority of adults surveyed expressed concerns about access to health care and costs,” says APA CEO Arthur C. Evans Jr, pointing out the ironic fact that “If stress becomes chronic, it can lead to significant health consequences.”

Patients who are afraid of healthcare costs often do not seek care when they need it. Early detection cannot happen if the patient does not come in until the symptoms become unbearable. Similarly, early detection cannot happen if the insurance company will not pay for diagnostic tests, or demand a co-pay the patient cannot pay out of pocket.

When patients see that the insurance companies and hospitals value profit over patients, they no longer trust their care providers. Even though the doctors have just as much conflict with the insurance providers, often the patient feels it’s a “me vs. them” relationship where the doctor is one of “them”. The doctor-patient relationship is damaged by the ongoing fight for profit even when you’re on the same side.

Other reasons for healthcare related stress ranged from the cost of insurance itself to rising medication costs, non-covered tests or procedures, and the possibility of changing coverage due to changing regulations. Younger people reported higher levels of stress about their health care than those over 65. Millennials and Gen-Xers are particularly worried about the future of healthcare in the US as well as the lack of coverage for mental health care. The stress of paying for health care should not be a factor in our patients’ health or mental wellness issues.

As care providers, we often feel powerless in the face of the edicts handed down by the government and health insurance companies. But we need to be aware that however helpless we feel, our patients have even less of a voice than we do. We must be their advocates, and make our views clear to the powers that be, medicine is about healing, not profits and paperwork.

As a member of the Emerald Coast Medical Association, you can add your voice to that of your peers and colleagues. On your own, it is hard to effect change in the system, but together we make a stronger, louder statement. If you are not yet a member, we encourage you to try out a meeting with no obligation.

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Will New FDA Guidance Really Lower Drug Prices?

One of the concerns most often voiced by Americans regarding healthcare is the high cost of prescription drugs. Even with insurance, not all drugs are affordable to every patient, while the same exact medication may be much more accessible to those living in other, comparable nations.

For example, Humira is one of the most commonly prescribed medications around the world. Used to treat many different ailments, such as psoriasis and arthritis, sales of the injectable drug topped $16 billion dollars worldwide in 2016. Patients in around the globe get the exact same product, manufactured by AbbVie Inc, but the prices they pay for their individual prescriptions vary wildly. In the United Kingdom, a Humira prescription costs about $1400, while in Switzerland it’s $820. By contrast, the United States has a hefty $2700 price tag on that same medication. Why is this?

The system in the United States is set-up much differently than those of other countries. Here, we do not negotiate or set limits on new prescription drugs as they enter the marketplace. Elsewhere, there are government agencies whose role is to weigh the benefits of new drugs and determine if the price is worth the cost. The reason these prices are government regulated around the world in ways that prices for consumer goods are not, is that, unlike stereos or furniture, medication is essential. Affordable access to medication is seen as a human right.

The benefit of our system is that it rewards innovation and encourages investment in research and development of new drugs. On the downside, these drugs come with a cost that renders them inaccessible to many people who need them.

President Trump has recently taken some drugmakers to task over this, using Twitter to call out Pfizer by name, stating that “They are merely taking advantage of the poor & others unable to defend themselves, while at the same time giving bargain basement prices to other countries in Europe & elsewhere.“

Pfizer responded with assurance that they will not increase prices until their CEO has met with the president and discussed a plan. Consequently, other drug companies, such as Merck & Co., are also holding off on any price changes, because they don’t want to be the next ones called on the carpet by the President.

In an effort to be seen as actively battling high drug prices, the Trump administration released new guidance via the FDA in late July. Promoting the development of low-cost, generic, abuse-deterrent formulations of common pain medications, this guidance also aims to create more affordable options in important markets, such as device-drug combinations.

The same week, FDA Commissioner Scott Gottlieb, MD announced the long awaited Biosimilar Action Plan, which hopes to increase competition in the rapidly emerging market.

“While less than 2% of Americans use biologics, they represent 40% of total spending on prescription drugs,” he said in an address to the Brookings Institution. “Enabling a path to competition for biologics from biosimilars is a key to reducing costs and facilitating more innovation.” Gottlieb went on to say that the U.S. should “adopt a different approach to paying for these drugs. An ideal system would reimburse biologics in a competitively bid scheme, where we could take full advantage of the multi-source competition.”

Critics say that the changes and guidance being rolled out are mere window dressing. They accuse the president of using Twitter call-outs to appear tough on drugmakers while not making any significant changes. They also feel that the pharmaceutical companies are saving face by reducing prices on drugs, but only those that are less widely used or whose sales have been declining in recent years, rather than on more popular profit-generating medications.

As with most of the places where government and medicine intersect, there is a great deal of uncertainty regarding what changes will be coming our way in the near future. Emerald Coast Medical Association provides a strong network to offer guidance and support to our members as new guidelines are enacted and new laws are implemented.

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CMS Proposal Aims to Improve Doctor-Patient Relationships

In May, Health and Human Services Secretary Alex Azar told us that he planned to use his pen to make significant and hopefully positive changes to the healthcare industry in the United States. Staying true to his word, the HHS Centers for Medicare & Medicaid Services (CMS) has issued a proposal that could have a drastic, positive impact on doctor-patient relationships in the U.S.

The proposed rule would update the Medicare fee schedule for physicians and routines sweeping changes for the third year of the payment program implemented by MACRA. CMS higher-ups say they have been attentive to physicians and responded with these rules in order to allow practitioners more time with their patients.

The proposal was announced on July 12th. CMS Administrator Seema Verma stated in a press call, “Today’s proposals deliver on the pledge to put patients over paperwork by enabling doctors to spend more time with their patients. Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care.”

These proposals, which are part of the Physician Fee Schedule and Quality Payment Program, also serve to update Medicare to allow payments for virtual care, which would save money for beneficiaries while allowing them better access to quality treatment regardless of their location. Patients could connect with their care providers remotely, and the practitioners would have the opportunity to determine if the patient needs to come to the office or not. The clinician can be paid under this new proposal for both these “virtual visits” and for time spent evaluating photos or videos sent in electronically by the patient. Medicare coverage of “telehealth” benefits would also be expanded to include preventative services over the long-term.

Additionally, the reform would make broad changes to the reporting requirements in order to effectively put the focus on the most important measures, the ones that have the most impact on health outcomes. The shift in reporting would also encourage electronic information sharing between providers, so patients can be more effectively “followed” through the system by their entire care record.

If the new proposals are adopted and finalized, clinicians should see a boost in their productivity levels, which in turn is likely to lead to a better quality of care for their patients. CMS estimates that upwards of 50 work hours per year would be saved by the paperwork this proposal would eliminate from the workload of a doctor with 40% of their patients covered by Medicare.

This proposal also aims to advance President Trump’s efforts to lower prescription drug costs, by suggesting a change in the payment amounts for new drugs under Part B, so the payment amount is commensurate with the actual drug cost. This could significantly reduce the amount that seniors are asked to pay out of pocket, especially when it comes to newer drugs with high launch prices.

The proposal can be viewed at this link: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf  and HHS is asking for public comments and input to be submitted by September 10th 2018.

Emerald Coast Medical Association works to keep our members informed about changes that impact us as medical practitioners, at the federal as well as the state level. These changes, if they go into effect, will be significant to all of us, and we pledge to help our members understand and implement them. Together, we are stronger, and our shared knowledge improves the lives of all of us as well as our patients.

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