From treehuggers, “Home Remedies,” Melissa Breyer, August 12, 2019

treehugger publication was also a part of Slate’s “Green Challenge” which Slate started publishing in conjunction with treehugger.org. a decade plus few years or so ago.

Chicken Soup for a Cold?

Toronto-based dietitian and Director of Food and Nutrition at Medcan, Leslie Beck:

“There is no evidence to prove that eating chicken soup is effective at treating the common cold. However, it’s not a total bust.” She continues;

“A 2000 University of Nebraska study found homemade chicken soup containing chicken, lots of vegetables, parsley, salt and pepper inhibits the activity of inflammation-causing white blood cells in blood samples taken from volunteers. It was thought this could reduce the flow of mucus and ease a stuffy nose. An earlier 1978 study found sipping hot chicken soup increased the velocity of nasal secretions in 15 healthy volunteers, an outcome possibly helping clear a stuffed-up nose. It was also found the effect lasted only 30 minutes and drinking hot water had the same effect.”

Another conclusion found in the same 1978 study was “Hot chicken soup, either through the aroma sensed at the posterior nares or through a mechanism related to taste, appears to possess an additional substance for increasing nasal mucus velocity.”

A 1998 UCLA report Coping with Allergies and Asthma notes, “chicken soup may improve the ability of the tiny hairline projections in the nose (called cilia) to prevent infectious particles from afflicting the body.”

It does lessen the sniffles . . .

Honey for Coughs

In “What works best for kids’ colds? Not medicine,” the author Melissa Breyer writes about a study showing honey outperforms the popular cough suppressant dextromethorphan (DM) in treating cough symptoms in children.

Dr. Shonna Yin from the N.Y.U. School of Medicine says that comfort for sick kids can come in the form of “plenty of fluids to keep children well hydrated, and honey for a cough in children over a year old.”

Prunes?

Science backs up the efficacy of prunes in helping improve regularity and better than psyllium. A half a cup of prunes has around 6 grams of fiber for around 200 calories. They also have the natural sugar, sorbitol, which can act as a laxative for some people.

Ginger for Nausea

Ginger is commonly used for medicinal purposes in Asian, Indian, and Arabic herbal traditions. In China, ginger has been used to aid all types of digestion disorders for more than 2,000 years. Health care professionals recommend ginger to help prevent or treat nausea and vomiting and as a digestive aid for mild stomach upset. Germany’s Commission E has approved ginger as a treatment for indigestion and motion sickness.

Hot or cold ginger tea can be made by grating or slicing fresh ginger and letting it steep in boiled water for 10 minutes or longer if you like it spicy. Hot, spicy, ginger tea with lemon and honey also does wonders for a stuffy nose as well.

How to Make Ginger Ale using Ginger.

Lavender to induce Sleep

Sleep expert Richard Shane, PhD ; “Research shows that smelling lavender decreases heart rate and blood pressure the key elements of relaxation (Reader’s Digest). The two main chemicals in lavender have been shown to have sedative and pain-relieving effects.”

2005 study found an exposure to lavender essential oil increased the percentage of deep or slow-wave sleep (SWS) in men and women. The study’s subjects reported “increased vigor the morning after exposure to lavender exposure corroborating the restorative SWS increase. Lavender serves as a mild sedative and has practical applications as a novel, nonphotic method for promoting deep sleep in young men and women and for producing gender-dependent sleep effects.”

Some truth in what mom and grandmother thought for their children and grand children. Maybe they did know best?

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half showed no signs of a prior, undiagnosed illness.” Sen. Chris Murphy (D-CT), and plainly speaking, they were not mentally ill.

Yesterday on Monday morning;

President Trump: “Mental illness and hatred pulls the trigger, not the gun. We must reform our mental health laws to better identify mentally disturbed individuals who may commit acts of violence and make sure those people not only get treatment and if necessary, involuntary confinement.” This is coming from a narcistic man who behaves irradicably and irrationally.

In response to President Trump’s remarks, Senator Chris Murphy (D-CT).

“Nineteen of 20 murderers had no diagnosis of a mental illness. Four out of 5 mass shooters had no mental illness diagnosis, and half showed no signs of a prior, undiagnosed illness. Framing mass shootings as just a mental illness problem is a gun industry trope. Period. Stop.”

In any case, the courts make little allowance for mental illness or for those who plead insanity. Those who are mentally ill and convicted of felony are locked away at level 4 prisons with the general population and the treatment is minimal. Trump’s “lock them up” comment of involuntary confinement just takes it one step further than the courts and without their interference.

Back to Senator Murphy and social media comments: some commenters agreed with Senator Murphy’s point about the validity of linking such events to mental illness as these comments only serve to stigmatize anyone with a mental illness. Other commenters questioned whether it is possible for a person to kill multiple strangers, at random, and not be mentally ill. One Twitter commenter; “So a healthy person does this?”

Yes, it can be a healthy normal person more often than not.

A much-cited 2016 review by forensic psychiatrists James L. Knoll IV MD and George D. Annas MD, SUNY Upstate Medical University in Syracuse New York may have been what Senator Murphy was referencing to in his comments.

Both doctors Knoll and Annas acknowledged the public and the media find the question of “mental illness” hard to resist.

“After all, who but a madman would execute innocent people in broad daylight, while planning to commit suicide or waiting to be killed by police?”

Adding to Knoll and Annas’s findings as well as other research; only a “minority” of mass shootings (however defined) have been perpetrated by individuals having recognized mental disorders.

“Few perpetrators of mass shootings have had verified histories of being in psychiatric treatment for serious mental illness.”

Again Knoll and Annas: Such individuals can function (perhaps marginally) in society and do not typically seek out mental health treatment. In most cases, it cannot fairly be said that a perpetrator ‘fell through the cracks’ of the mental health system. Rather, these individuals typically plan their actions well outside the awareness of mental health professionals.”

Mass shooters may not meet the criteria of a disorder as stated in DSM-5 – “Diagnostic and Statistical Manual of Mental Disorders.” They may have an ill-defined trouble of the mind, harboring anger or revenge and for which the field of mental health field has no immediate, quick-acting ‘treatment. “Psychiatrists and in particular forensic psychiatrists understand that dark and depraved acts are frequently committed for other reasons besides mental illness and more often committed for those other reasons.”

Can the matter of a hidden anger or other undefined trouble be resolved by labeling it ‘mental illness’ and calling for greater scrutiny of ‘troubled’ individuals? Knoll believes we would solve nothing by doing so and even risk making matters worse. This mindset makes us vulnerable to creating new and misguided laws. Such attempts further the medieval notion of equating mental illness with ‘evil’ or criminal behavior.

Mental health treatment has its limits is not designed to detect and uncover potential violent extremists. Formal psychiatric screening is not likely to identify those who may commit massacres.

Noting the wave of mass shootings beginning in the late 1990s; there was another propellant besides guns and mental illness both of which existed for a long time, and to which Knoll added the media as another. “It seems difficult to deny that the media coverage since the late 90s” has made it certain that those who commit heinous crimes become celebrities through the development of an online “Columbiner culture” glorifying the Columbine High School shooters and the others following in their footsteps.

We must eliminate the media attention gained from mass shooting.

“Conundrum: Why Isn’t Killing 22 People ‘Mental Illness’?” — Psychiatrists say the question is beside the point, MedPage Today, John Gever, Managing Editor, August 5, 2019

“Mass Shootings and Mental Illness,” Gun Violence and Mental Illness. James L. Knoll M.D. and George D. Annas M.D.

“The Health 202: Trump blamed mental illness for mass shootings. The reality is more complicated” The Washington Post, Paige Winfield Cunningham

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We use large-scale federal survey data linked to administrative death records to investigate the relationship between Medicaid enrollment and mortality. Our analysis compares changes in mortality for near-elderly adults in states with and without Affordable Care Act Medicaid expansions. We identify adults most likely to benefit using survey information on socioeconomic and citizenship status, and public program participation.

We find a 0.13 percentage point decline in annual mortality, a 9.3 percent reduction over the sample mean, associated with Medicaid expansion for this population. The effect is driven by a reduction in disease-related deaths and grows over time. We find no evidence of differential pre-treatment trends in outcomes and no effects among placebo groups.

Sarah Miller Sean Altekruse Norman Johnson Laura R. Wherry, NBER WP Working Paper 26081

I’ve been waiting for this. ACA Medicaid expansion is a policy experiment. The states which did not expand Medicaid made it easy to see if Medicaid saves lives. Obviously it does.

Via Axios where Sam Baker wrote; “expansion states saw a mortality rate that’s about 0.2% lower than nonexpansion states, the authors write — which would translate to roughly 15,600 lives, had the expansion not been optional for states.”

So Republican reactionary idiots have killed roughly 15,600 people so far through refusal to expand Medicaid alone. For comparison “In 2017, the estimated number of murders in the nation was 17,284” (just a number for comparison, I am not saying Republican legislators are murderers).

I don’t read Axios. I clicked there from Steve Benen

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Back in April, I finished up an article for ConsumerSafety.Org called A Woman’s Right to Safe Healthcare Outcomes. The topics covered in this as given to me by ConsumerSafety.Org were Clinical Trials, Essure, and Maternal Mortality. All of the topics dealt with women’s healthcare. Of the three issues addressed, I found Maternal Mortality to be the most compelling.

I told the story of a white upper middle class couple, Lauren Bloomstein a nurse and her husband Larry a surgeon. They went to the hospital to have their first baby. Lauren was a healthy young woman who did everything right. Unfortunately Lauren’s OB before and during her delivery missed many of the signs she was suffering from preeclampsia or high blood pressure. Lauren died after giving birth to a healthy baby girl. It is not unusual for doctors failing to heed the warning signs a women or her symptoms are alerting them too.

The warning signs of life-endangering problems were there, were missed (pain in the kidney area), or ignored (abnormal high blood pressure for Lauren). Excuses for other causes of the pain (reflux) were made, and pain killers administered to dull the pain and other symptoms (blood pressure) not explored while she deteriorated in front of her husband who suspected preeclampsia. The missing part of this was the protocol to diagnose early on and prevent Lauren from slipping into late stages of preeclampsia. This is not an isolated incidence as the deaths of women giving birth keep increasing as evidenced in the chart.

Even with the PPACA, expanded Medicaid in place; and when compared to their Canadian sisters, American women are three times more likely to die from the start of a pregnancy up till one year after the birth of a child (defined by the Centers for Disease Control). The death rate for American women is 26.4 deaths per 100,000 as opposed to 7.3 deaths per 100,000 in Canada (Chart). The ratio worsens when compared to Scandinavia countries as American women are six times as likely to die as Scandinavian women.

There are two stories, one for economically secure women and another for minority, native American, rural, and lower income women.

The statistics worsens for women of color with their being more likely to die in pregnancy or childbirth and are nearly four times more likely to die from pregnancy-related causes than white women. In high-risk pregnancies, African-American women are 5.6 times more likely to die than white women. Amongst women diagnosed with pregnancy-induced hypertension (eclampsia and pre-eclampsia), African-American and Latina women were 9.9 and 7.9 times in danger of dying than white women with the same complications. Native American and Alaskan Native women experience similar discriminatory care. Half of all U.S. births are covered by Medicaid and covers women up to two months past delivery leaving a substantial gap after child birth when other issues can arise.

Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists; “We worry a lot about vulnerable little babies and we don’t pay enough attention to those things catastrophic for women.”

The emphasis has been on safe baby care and safe birthing which lead to a significant decline in baby mortality. As reported in a Propublica, NPR report, the difference in “maternal mortality numbers contrast sharply with the impressive progress in saving babies’ lives.” Maternal death rates while giving birth and up to one year later has increased by an approximate 10 deaths per 100,000 since 2000 till 2015 or greater than the 9.2 deaths per 100,000 in the U.K, (Chart).

In my email account, I found my usual Health Affairs article with a lead off title “The Maternal Health Crisis: Policies of 2020 Candidates”

“Many of the Democratic presidential candidates met in Columbia, SC at the Planned Parenthood Women’s Health Forum to share their reproductive health proposals, including plans for maternity care. On Thursday, June 26th, they will engage in their first debate. Donald Trump launched his re-election bid on June 18th, 2019. While his campaign website does not include any specific reference to maternal mortality, members of his administration have recently brought attention to rural maternal health challenges.

This renewed focus on maternity care is desperately needed: U.S. rates of maternal mortality are the highest in the developed world and have been rising since the 1990s, with women giving birth today more likely to die in childbirth than their mothers. These adverse outcomes are also marked by significant racial disparities, with non-Hispanic black and American Indian/Alaska Native women at least 3 times as likely as non-Hispanic white women to die around the time of childbirth.”

About time.

run75441 (Bill H)

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Supreme Court to hear cases over ACA risk-corridor funds

“The U.S. Supreme Court said Monday it will take up cases over whether the federal government must pay billions of dollars to health insurers that sold coverage on the Affordable Care Act exchanges.

Letter to The Editor – Modern Healthcare Alert

If you are going to report on this particular incident with the Cromnibus Act which passed December 11, 2014, why not give the complete history of how the Risk Corridor Program was stymied?

Initially, then Budget Committee Republican Ranking Member Senator Sessions wrote a letter to the GAO asking whether the Risk Corridor payments were being appropriated correctly. In a letter back to Sessions the GAO said Agencies can only appropriate funds at the discretion of Congress. Funding had not been properly secured for the Risk Corridor Program. This effectively stopped any new funding from being used for the Risk Corridor Program; however, funding could be transferred from other healthcare programs.

With the aid of House Energy and Commerce Chair Fred Upton and House Appropriations Chair Jack Kingston, Section 227 was inserted into the Cromnibus Act.

“None of the funds made available by this act from the Federal Hospital Insurance Trust Fund or the Federal Supplemental Medical Insurance Trust Fund, or transferred from other accounts funded by this act to the “Centers for Medicare and Medicaid Services – Program Management “ account may be used for payments under section 1342(b)(1) of Public Law 111-148 (relating to risk corridors).”

This was far more nefarious than Congress as a whole making this budget neutral and its hides what Republican Senator Sessions, and House Representatives Upton, and Kingston did to sabotage the ACA, drive up premiums, bankrupt Coops, cause companies to leave the healthcare exchanges, and cause constituents to lose coverage.

Yes indeed, Congress did vote for the Cromnibus Act in the waning day(s) left before a government shut down. Section 227 was inserted during those last few days and more than likely overlooked in the process of passing a budget bill so the government would not shut down.

run75441 (Bill H)

Should these companies win at SCOTUS review, the costs and blame should be assigned to these three as their motives were “solely” party politics over country thereby penalizing citizens.

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It is doubtful Trump reads much beyond his own signature on Executive Orders and Twitter commentary. Someone is attempting to align him with current thinking creating a persona of his being a thoughtful and reasoning president as opposed to . . . ?

In “Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals ,” I had posted stats from a 2016 JAMA paper covering the period from 1996 to 2013. Healthcare costs had increased $1 trillion of which 50% was due solely to pricing. One significant factor in the JAMA report was the $66 billion increase in costs for diabetes treatment of which $44 billion was due to pharmaceuticals pricing. One impact to diabetes treatment was Eli Lilly’s increases for Humalog which was $21 per vial in 1996. By 2017, the price increased to $275 (700%) for a vial, a one-month supply. Humalog is a decades old drug and the manufacturing has not changed significantly.

“JAMA Network Open” has issued an end of May 2018 paper on pharmaceutical pricing trends covering the years from the period 2012 – 2017, “Trends in Prices of Popular Brand-Name Prescription Drugs in the United States.” The question it asks:

• What are the prices of top-selling brand-name prescription drugs in the United States and how have these prices changed in recent years?

answer:

• In this evaluation of 49 common top-selling brand-name drugs; 78% of the drugs have been available since 2012, have seen an increase in insurer and out-of-pocket costs by more than 50%, and 44% have more than doubled in price.

and concludes:

• Brand-name drug pricing associated with government-protected market exclusivity is likely to continue to increase and warrants greater price transparency.

Similar to what President Trump has proposed which “still” does not empower constituents to seek alternatives and typically the alternatives are just as costly.

Study Methodology

Data was obtained of 35 million individuals from the Blue Cross Shield Axis (data base) for the time period of January 2012 through December 2017. The researchers reviewed prescribed drugs exceeding $500 million in US sales or $1 billion in worldwide sales.

Within the identified parameters of 2012-2017 sales, 132 brand-name prescription drugs were identified. 49 of the 132 top-selling drugs exceeded 100 000 pharmacy claims, substantial cost increases among these drugs was experienced within the inclusion parameters with a 76% median cost increase, and 48 of the drugs had regular annual or biannual price increases.

Thirty-six of the 49 drugs were available since 2012. Twenty-eight had experienced an increase in insurer and out-of-pocket costs exceeding 50% and 16 more than doubled in price. Insulins such as Novolog, Humalog, and Lantus and tumor necrosis factor inhibitors such as Humira and Enbrel experienced highly correlated price increases coinciding with some of the largest growth in drug costs.

The results of the study revealed the median sum of out-of-pocket and insurance costs paid by patients or insurers for common prescriptions and presented both annually and monthly.
Pricing increases for 13 new drugs from January 2015 through December 2017) and entering the market in the last 3 to 6 years was not different than those (36) having been on the market longer, a 29% increase [median] from January 2015 through December 2017.

Nor did the study differentiate between drugs with or without a FDA approved therapeutic equivalent (number of drugs, 17 vs 32; median, 79% vs 73% price change).

Changes in prices paid were highly correlated with third-party estimates of changes in drug net prices (ρ = 0.55; P = 3.8 × 10−5), suggesting that the current rebate system incentivizes high list prices and greater reliance on rebates resulting in increased overall costs.

“The study concludes the growth of drug spending in the United States associated with government-protected market exclusivity is likely to continue. Greater price transparency is warranted.”

Interpretation? Pharmaceutical companies (and I will include companies such as Mylan [EpiPens]) are using the patent drug laws and resulting exclusivity time period to maximize profit margins ($14.50 for every $1 invested [WHO]) protecting their products from competition. A similar exclusivity holds true for generic products also (time periods for the introduction for a similar generic product). “Can You Patent The Sun (Jonas Salk)?”

I sat over dinner with one Exec. VP from a major pharmaceutical company who confirmed what I had said in an earlier post (Can You Patent The Sun?) and here. A new pricing strategy is being used by pharmaceutical companies which maximizes return based upon benefits achieved in treatment, life, healthcare system, and in society. It is a well thought out reasoning being delivered by intelligent purveyors of healthcare supplies portraying a modicum of caring or concern for societal welfare while pursuing the profit motive. Novartis CEO Vas Narasimhan (not the one I talked to);

“Cell and gene therapies are bringing about a new era of cancer medicines going beyond ‘just improving lives and are saving them.’ The new therapies are challenging the traditional model for paying for medical treatment and the industry is divided on this approach. Pricing for these one-time usage therapies are to be based on four key measures of value – the improvements they offer to patients both clinically and in terms of their quality of life, and the resulting benefits to the health-care system and society.”

The pricing application is not limited to new drugs, cancer meds and gene/cell therapies; it is also being applied to older drugs and also generic replacements.

Findings:

Between 2012 – 2017, the study reveals an industry wide increase in costs for top-selling brand-name prescription drugs and less costly generic replacements. The increase in costs, biannual, and annually for 36 pharmaceuticals since 2012 can also be seen in newer drugs coming on the market after 2012. A pattern or practice of pricing determination based upon 4 values in the pharmaceutical market which will continue into the foreseeable future.

This particular chart depicts annual net price and annual paid price increases showing the percentage increases. This becomes more interesting where I cover “rebates” and whether the reduce costs.

Given median cost increases of 9.5% annually, the yearly increases will result in a doubling of costs for brand name drugs in this study every 7 to 8 years.

New and old brand-name competition does little to control rising costs of products which can be used interchangeably (hence this shoots transparency in the foot for constituents talking to pharmacists) such as Humira and Enbrel or diabetes drugs such as Humalog, Humulin, and Novolog. “Relative cost changes are highly synchronized” resulting in large increases over the last 6 years. As mentioned there appears to be a pattern or practice of pharmaceutical companies acting in concert.

There is little evidence of price changes associated with the existence of therapeutic equivalents such as generics, biosimilar drugs, or drugs entering the market later.

Legislated pricing transparency may lead patients to seek alternative drugs if available which may result in different pricing trends than what was observed over the six years of when the study was done. The impact of such is unknown as is the likelihood of those trends as they may already be in progress due to volume changes or speculation of volume changes due to expiration of exclusivity.

Neither was there evidence of products entering the market 3 to 6 years ago having different trends compared with other drugs in the first years of availability.

Transparency is need in the costing of drugs and the setting of prices by manufacturers. Only in the US, does the manufacturers of the product set the pricing. In Europe, pricing is influenced by governments.

Research and Development

There is a balancing act between reasonable pricing for consumers and the costs for bringing innovative drugs to market. The United States does provides strong patent laws globally. However, legal strategies by the pharmaceutical industry such as patenting the peripheral aspects of a drug (think EpiPen and its cap) extend protections beyond the original patent and delay generic and biosimilar versions. Furthermore, if a generic version brought to market by one company can not be used in the same manner by following the instructions of the brand name version; the company of the patented version can ask the FDA to block the generic version (again think Mylan’s Brand EpiPens and the TEVA generic [See; “Can You Patent The Sun?“]).

Healthcare and pharmaceutical companies can maintain exclusivity and pricing as set by the manufacturer much longer and well beyond the original patent limits with a range of new innovations. In similar countries as the US as found in western Europe, governments set pricing. The end result is a large discrepancy in pricing between the US and European countries for the same drug.

It is near impossible for private insurers to negotiate pharma pricing and Medicare is forbidden to do so. The Institute for Clinical and Economic Review’s value-based price benchmark is one approach to establish appropriate pricing. Using the four key measures the ICER assigned a cost effectiveness value of up to $1,688,000 for Kymriah for its use in children. This analysis takes into account all of the R&D cost in developing a drug, bringing it to market, and the cost save as measured against other therapies. Using the same ICER 4-point value-based analysis and understanding the range effectiveness determined by the ICER, Novartis set Kymriah list price for pediatric use at $475,000, well below the ICER’ cost effectiveness value, and $373,000 for adult cancers.

So, how is this drug paid for by the less financially endowed patients? Coupons by the manufacturer and rebates to the insurance payor set a net price for the patient which is price and profit neutral.

Rebates

Several points; Transparency of how rebates occur and affect net pricing is limited as to the impact of them on the pharmaceutical industry and healthcare insurance, rebates on list prices set by manufacturers are given by the manufacturers to commercial healthcare insurance and some government programs not including Medicare, and the rebates will vary by drug, by payer, and constitute “16% of all private insurer-branded drug spending returned as rebates in 2016.”

Whether rebates lower or increase costs is debated due to the lack of transparency of their application.

Due to the lack of data, this particular JAMA study used third party information or estimates of net price data on each drug. The observations did reveal a high correlation between increases in the rates of insurer and out-of-pocket costs paid for each drug and the net prices (ρ=0.55). The association suggests the offered industry supposition of higher list prices and greater reliance on rebates reducing costs may not be true.

Instead and a bit redundant by me, the paper offers an opposing supposition of increases in list prices, and the resulting increases in insurer and out-of-pocket costs paid, may coincide with increases in net prices, which in turn make these drugs more expensive overall. Seemingly biannual price increases should not be considered benign pricing strategies to offset paid against net price discrepancies in the current rebate system.

If true, this would be a façade making it appear rebates have an impact on final costs to the healthcare system and pricing to the patient. Rebates may only be a shuffling $dollars around.

Greater transparency of the process is needed to determine what is and what is not a cost save. The transparency is not for the purpose of patients deciding what to buy or pharmacists to recommend alternatives; although, it could be used by constituents to support healthcare proposals to bring prices down.

A healthcare system and its coverage without a foundation or mechanisms to control or account for costs is simply a blanket to pricing and hides its impact.

Run75441 (Bill H)

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Via Naked Capitalism:

Place based economic conditions and the geography of the opioid overdose crisis

By Shannon Monnat, Associate Professor, Syracuse University. Originally published at the Institute for New Economic Thinking website

Over 400,000 people in the U.S. have died from opioid overdoses since 2000. However, there is widespread geographic variation in fatal opioid overdose rates, and the contributions of prescription opioids, heroin, and synthetic opioids (e.g., fentanyl) to the crisis vary substantially across different parts of the U.S. In a studypublished today in the American Journal of Public Health, we classified U.S. counties into six different opioid classes, based on their overall rates and rates of growth in fatal overdoses from specific types of opioids between 2002-04 and 2014-16 (see Figure 1). We then examined how various economic, labor market, and demographic characteristics vary across these different opioid classes. We show that various economic factors, including concentrations of specific occupations and industries, are important to explaining the geography of the U.S. opioid overdose crisis.

1 in 6 hospital patients get a surprise bill for out of network care

By Rachel Bluth, Kaiser Health News reporter. Originally published at Kaiser Health News.

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

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Kevin Drum wrote a typically brilliant post on absurdly high estimates of the growth of the number of health care administrators. I was very interested in one little passage. My comment.

Dear Kevin

You used to work for a tech company and IIRC in public relations. Now your day job is as a blogger-journalist. Don’t quit your day job.

you wrote “Once you take into account the growth in health care generally, the share devoted to administration has gone up by 50-100 percent. That’s a lot! But it’s also not that surprising. In 1970, the health care industry spent approximately $0 on IT management. Today they spend a bundle, and all of that is admin overhead. ”

You are saying a huge improvement in information technology explains part of the increase in administrative costs. Better technology is supposed to be more efficient not less efficient. If IT weren’t a waste of money, it would cause lower not higher costs (I’m embarrassed to type a tautology but there it is).

You think it is obvious that IT is a waste of money. This might be excellent work for a blogger journalist (I wouldn’t be surprised if you are right). But it sure suggests you have more of a past than of a future in tech pr.

I am being sarcastic and am also totally serious. In fact, I am quite confident that you are right that IT has caused an increase in administrative costs, and that the use of IT in business administration has been a total waste of money. The reason is the 4th law of thermodynamics — work expands to fill the allowed space. Also known as Parkinson’s law.

I’m sure the number of administrative tasks which can be performed per person hour has increased enormously (this is counting the information techs’ hours too). But I think the amount of the cost of each unit of product which goes to pay salaries of administrators has gone up. The reason is that the number of administrative tasks which are assigned or required is not equal to the number which are necessary or even useful (which I would guess is a low number). Rather it is the number which can be done without hiring more people who have old job descriptions. So the non info techie administrators are kept and given more tasks. This means that the newly hired info techies are an added expense, unless the new tasks given to other administrators are actually useful in some way.

I am fairly sure that they aren’t useful.

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“Opioid Overdose Now Provides 1 in 6 Donor Hearts,” Ashley Lyles, MedPage Today

Overdose-death donors have accounted for a rapidly growing proportion of cardiac allografts, with a 14-fold increase from about 1% in 2000 to now 16.9%, “consistent with the rising opioid epidemic,” reported Nader Moazami, MD, of New York University Langone Health in New York City, and colleagues in The Annals of Thoracic Surgery. Earlier findings:

A total of 1,710 of 15,904 (10.8%) cardiac transplantations were from ODDs, approximately a 10-fold increase from 2000 (1.2%). ODDs were more frequently older than 40 years of age (87.2% vs 70.1%; p < 0.001), had higher rates of substance abuse, were more likely hepatitis C positive (1.3% vs 0.2%; p < 0.001), and less frequently required inotropic support at the time of procurement (38.4% vs 44.8%; p < 0.001). Overall survival was not different between the groups (p = 0.066). Discarded ODD allografts were more likely to be hepatitis C positive (30.8% vs 5.3%; p < 0.001) and to be identified as conveying increased risk by the Public Health Services (63.3% vs 13.2%; p < 0.001), but they were less likely to be discarded because of a diseased organ state (28.2% vs 36.1%; p < 0.001).

In many states, overdose-death donors comprised greater than 25% of cardiac allograft donors in 2018, with a high of 50% in Delaware.

While there have been concerns regarding allograft function and infectious risk, the researchers noted overall survival was the same between recipients of overdose-death and non-overdose-death donor organs (P= 0.066).

The discard analysis of donors who had at least one organ transplanted but not the cardiac allograft showed overdose-death donor hearts (7.4% of all discards) were: less likely to be discarded due to being in a diseased organ condition than those donors who died of other causes (28.2% vs 36.1%; P less 0.001), more likely deemed higher risk by Public Health Services (63.3% vs 13.2%; P less 0.001), and more likely to be hepatitis C positive (30.8% vs 5.3%; P less 0.001).

Even with the hazards of using a heart from an opioid abuse donor, survival outcomes of recipients of hearts that come from donors that have died from opioid overdose are equivalent to ones that we have traditionally been using, and because of this we believe that there are more donors out there that can be utilized.

STIs: ‘Hidden, Silent, Dangerous’ Global Epidemic, Molly Walker, MedPage Today

World Health Organization (WHO): “no substantial decline in global STI prevalence since 2012”

An approximate one in 25 people worldwide had at least one curable, sexually transmitted nonviral infection in 2016.

The incidence of gonorrhea, chlamydia, trichomoniasis and syphilis amounts to about one million new infections each day, and more than 376 million new cases annually. Additionally as Melanie Taylor MD and medical epidemiologist at the WHO Department of Reproductive Health and Research (and colleagues noted), “there has been no substantial decline in the number of new infections since the data was last updated in 2012.”

Also of the WHO Department of Reproductive Health and Research Teodora Wi MD; “We cannot sweep [sexually transmitted infections] under the carpet and pretend they don’t exist while we continue to stigmatize people living with STIs, neglect their care. and fail in prevention.”

STIs are a “hidden, silent, dangerous” epidemic, and are still “persistent” globally, despite an increase in education about the dangers of sexually transmitted infections. Dr. Taylor added that it’s not just stigma and shame that keep people from treatment — many patients do not realize they are infected.

In my first week of 4, the Grey’s Anatomy bunch swarmed my half of a hospital room and gayly announced, you do not have HIV, Hepatitis C, or any STD/STIs. Puzzled look on my face, “when am I getting out of here?”

Dropped From Health Insurance Without Warning: Was It Legal? , Julie Appleby, KHN

Those who qualify for a subsidy due to income being less than 400% of the federal poverty level (roughly $50,000 for an individual) have a 90-day grace period to make payment after missing a payment. The law requires insurers to notify those policyholders they have fallen behind and face cancellation. If a payment is made in full before the end of the 90-day grace period, they are reinstated. If not they are canceled and medical costs incurred in the second and third months of the grace period fall on the consumer.

This policy keeps federal subsidy dollars flowing to insurers during the grace period, even if a consumer has a financial wobble.

It’s different for people who are a part of the ACA; but, their income is above 400% and do not qualify for a subsidy. They are subject to state laws and they can be dropped much more abruptly. Most states have a 30 day Grace Period for payment; however, Prior Notification law differs state to state.

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Robert Kocher and Donald M. Berwick “While Considering Medicare For All: Policies For Making Health Care In The United States Better,” Health Affairs

Dr. Donald Berwick is the former Director of Medicare and Medicaid who talked about waste in Medicare and Doctors knowing such waste exists.

“It is unlikely that the United States will move quickly to a full publicly financed health insurance when Congress next considers health policy after the 2020 presidential election. Despite its theoretical advantages, passage of Medicare for All would require a massive political battle to make feasible the shift from private to public funding, to develop enough public trust to expand an entitlement program for all Americans, and to mitigate the disruption for many of substituting public insurance for familiar, existing health insurance policies. The transition will take time.”

Improving Affordability

Donald Berwick’s direction on Medicare was this: While US health care can and should be made more affordable by attacking waste, innovating in delivery system design, and improving productivity, these mechanisms are unlikely to achieve affordability quickly. He comes back with other comments which can be quicker in implementing.

• Lower the cost of health insurance for more Americans: Two types of financial assistance were implemented in the form of premium and cost-sharing subsidies. Sliding-scale premium subsidies reduced the monthly cost of insurance substantially when they phase in for people with incomes at 133 percent of the federal poverty level up till 300% FPL and phased out at 400 percent of poverty. 400% of income was $100,400 for a family of four in 2019. With an average silver-level insurance plan, the costs for healthcare insurance were $15,855 or 16 percent of income. It is recommended, no American should spend more than 10 percent of income on insurance premiums.

Cost-sharing subsidies were available to those with incomes up to 250% of poverty, average deductibles have risen to $3,000, and total out-of-pocket costs are capped at $7,900. The deductibles and out-of-pockets was done so as to give patients some skin-in-the-game and not abuse insurance. “Skin-in-the-game,” are regressive actions which disproportionately penalize people with chronic diseases. The authors recommend eliminating all cost sharing for people with incomes below 250% of poverty. For people with incomes from 251 percent to 1,000% of poverty, the authors suggest a sliding-scale of subsidies similar to the current program. Instead of annual appropriations, we would make these subsidies mandatory expenditures to replace annual appropriations and prevent an Executive Branch from using the funding of these benefits as a political weapon.

• Reduce insurance premium growth rates by limiting hospital prices. As I wrote in Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals, the biggest driver of healthcare cost is simply “pricing” increases reflected in hospitals and pharmaceuticals. These increases are reflected in insurance premiums. As the authors also point out, the biggest driver of premium increases has been in hospital price increases which have risen 42% between 2007 to 2014 and far greater than physician prices.

The ACO strategy has allowed hospitals to exploit the market through consolidation thereby eliminating competition to raise prices and enabling the employment of specialist doctors, making them “must haves” in insurance networks. As planned, the consolidation should have generated administrative cost synergy and quality benefits instead of enabling healthcare to consolidate and control prices. The authors believe no hospital should be able to charge prices that equal more than Medicare prices plus 20 percent, which is far less than many charge today (plus 89% on average) also far, far less than the 200 to 240% for hospitals in Michigan for catastrophic automobile accidents recently signed into law. The authors claim the plus 20% is enough revenue to offset Medicaid underpayments and provide incentive to be more productive. Indexing hospital prices to the Consumer Price Index rather than medical inflation, hospitals are not perversely rewarded for lower levels of productivity improvement than the rest of the economy. It is recommended, hospitals with greater than 40% market share in a given area would be required to contract with all health plans so that they cannot limit choice and competition.

• Make medications more affordable. As I noted in “ Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals,” from 1996 to 2013 in one JAMA study, healthcare costs increased by ~$1 trillion of which 50% was due solely to pricing increases. The big issue is the change in pricing for in and out patient hospital stays/care and pharmaceuticals. Hospital/clinic consolidations leads to the former even though insurance has been fighting for a reduction in stays. Pharmaceutical has instituted new pricing strategies which we have all read about in the news. Old drugs such as Humalog, Vimovo, and the infamous EpiPens as well as others are now vastly more expensive. This study points to pricing for pharma and service as one of the issues.

The authors recommend; a ban on rebates to all insurance markets and not just Medicare; reducing the period of market exclusivity for biologic drugs from 13 years to 7 years to enable generic competition sooner since biologic drugs are the most expensive drugs accounting for 70 percent of spending growth from 2010 to 2015; and adopting the Trump administration’s proposed international market basket pricing approach to set the upper limit for drug prices.

Improving Access

Improve the risk pool of people buying coverage and make Medicaid more universal.

• Create larger, lower-cost, healthier risk pools to reduce premiums. Reimpose the Individual Mandate to create larger, lower-cost, and healthier risk pools thereby reducing premiums. Since subsidies would be more generous, the penalty for not buying insurance would be larger. Short-term three-year plans would be eliminated. Reinstate the coverage of essential health benefits in all plans.

• Expand the use of reinsurance. Reinsurance lowers premiums by reimbursing plans for medical expenses for the most expensive patients These expenses do not have to be offset by premium increases from healthier patients.

• Improve Medicaid access. Medicaid provides comprehensive insurance for 74 million Americans and in some states, coverage is dropping as a result of work requirements besides other barriers to enrollment and reenrollment. The authors would eliminate Medicaid cost sharing as even small amounts of cost sharing can reduce the use of necessary services and increase wait times for enrolling in Medicaid coverage after losing commercial insurance. We would encourage the 14 states that have not expanded Medicaid to accept federal funds to expand their programs and urge the administration to accept waivers from these states, with the exception of work requirements, cost sharing, or other policies that undercut the core mission of Medicaid.

Improve Health Care Quality

The provisions in the ACA were designed to switch “volume” (fee for service) to “value” (getting paid for better outcomes). Accountable care organizations and bundled payments were two such innovations put in place to do such. They appear to have had mild and directionally desirable impact on both quality and cost. There is still more to learn.

The Institute of Medicine has categorized six defects in the quality of care resulting in excess cost. Problems in patient safety, unscientific variations in care leading to ineffective treatment, lack of patient-focus, unwarranted delays due to poor system designs, excessive prices due to lack of transparency and open competition, and fraud all of which lead to wasted resource, bad patient outcomes, and decreased value. The switch from volume to value will alleviate these defects.

The authors endorse the creations of the Center for Medicare and Medicaid Innovation to sponsor tests of new payment models and delivery system designs such as home and community-based alternatives to hospitalization, telemedicine, and the integration of behavioral health into the care mainstream. Renewed efforts to improve patient safety through innovations in training, equipment, and job roles.

Stakeholders have become enthusiastic in spending health care dollars to mitigate the power of “social determinants of health” such as housing, food availability, exercise patterns, precursors of substance abuse, early childhood trauma, and more. The authors strongly favor action and funding in that direction.

Other Issues

• Reform medical malpractice policy. Eliminate the excuse medical malpractice necessitates wasteful extra tests and treatments encouraging doctors to adopt risk-based payment models and more parsimonious approaches to care. I do have a problem with this as many states have put in place limits to malpractice. The authors have suggested a safe-harbor when doctors adhere to clinical guidelines and evidence-based care. Is malpractice a big issue? Public Citizen’s “ The Medical Malpractice Scapegoat;” details the data from 2015, (most recent full year for available data) the medical malpractice payments on behalf of doctors amounted to about 0.2 percent of costs for hospital and physician services and about 0.1 percent of all healthcare costs. The number of payments on behalf of doctors in 2015 was the lowest on record and is lower than what it was during Clinton or Bush.

• Protect Americans from surprise bills. The authors would require all doctors who provide care at in-network hospitals or outpatient facilities to bill patients at average in-network prices.

The authors believe this portfolio represents a set of policies that could be supported at least somewhat on a bipartisan basis and believe are likely to be effective and in the short term more politically viable than Medicare for All.

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