JustCare

Tag: Biden administration

  • Biden administration bent on privatizing traditional Medicare

    Biden administration bent on privatizing traditional Medicare

    There appears to be little light any more between corporate health care and government health care or even between government health care-speak and corporate health care-speak. In the latest government push to privatize traditional Medicare–“ACO REACH”–insurer and investor middlemen will responsible for assuming risk and paying claims. The Biden administration claims its goal is “value-based care,” though decades of evidence show that corporate middlemen drive up costs and do not deliver value for patients.

    What’s happening? The Biden administration is continuing a Trump administration experiment to pay middlemen–often entities with no meaningful medical expertise–a flat fee per patient to “manage care” for people in traditional Medicare. The administration just renamed the “Global Professional Direct Contracting” experiment–which works like Medicare Advantage–ACO REACH. It will privatize traditional Medicare by turning over “care management” read “money management,” to investors and insurers.

    Who will be in the experiment? People with Medicare whose primary care physicians are working for a middleman that contracts with the Centers for Medicare and Medicaid Services as part of “ACO REACH.”

    What’s the value to patients? If you look at the role insurer middlemen play in Medicare Advantage, it is hard to see that ACO REACH offers any possibility of value to patients and easy to see huge risk. Given the scant data available in Medicare Advantage, no one can demonstrate value in the care patients receive. MedPAC, the government’s Medicare oversight agency, has never been able to assess care quality in Medicare Advantage plans because the plans have never given it complete and accurate information that would permit MedPAC to assess value. At the same time, government agencies have found widespread and persistent inappropriate delays and denials of care and coverage putting patients at serious health risk.

    ACO REACH will offer “care coordination,” but what does that mean?  The Center for Medicare and Medicaid Innovation (CMMI) claims the ACO REACH model is somehow going to ensure people in traditional Medicare have their care coordinated in ways that improve health outcomes. But, there is no evidence that people in managed care plans have better health outcomes than people in traditional Medicare. In fact, “care coordination” is often a euphemism for delayed care, less care, and referrals to low-cost providers, none of which is by definition a good thing. Primary care doctors will have financial incentives to minimize costs.

    Will ACO REACH promote health equity? CMMI also says it is promoting health equity through ACO REACH, but there’s no evidence to support that claim. Participants will need to have health equity plans. But health equity plans are far different from results and, so long as cost is a barrier to care, it’s hard to see how participants can reduce health disparities. It’s also hard to imagine how CMS will ensure compliance by participants with model requirements.

    Here’s more from Just Care:

  • Biden administration will decide any day whether to reduce the price of Xtandi

    Biden administration will decide any day whether to reduce the price of Xtandi

    David Dayen writes for The American Prospect on the question of whether the Biden administration will to do what it can to reduce prescription drug prices. It has the power to reduce the price of Xtandi–a prostate cancer drug–from a list price of $188,900 a year to less than $38,000 a year if it wants, which would be inline with what other countries pay. The world is flat; it’s time for the Biden administration to do right by Americans.

    Today patients with prescription drug coverage often spend $10,000 or more a year out-of-pocket for Xtandi to treat their prostate cancer. Or, they are forced to forgo taking the drug. Many prostate cancer patients with prescription drug coverage cannot afford the copay, so cannot benefit from the drug.

    We should know very shortly whether the Biden administration will use march-in rights under Bayh-Dole to bring down the cost of Xtandi on the ground that the price of the drug is unreasonable. Xtandi is available in other countries for 20-33 percent of what we pay for the drug in the US. The NIH is scheduled to make a determination any day.

    To date, no administration has ever used its march-in rights to break a drug patent. If the Biden administration exercises march-in rights, two companies are prepared to distribute a generic version of Xtandi. The Canadian company says it would charge $3 for a pill about one-fiftieth of its typical price.

    In 2016, the NIH declined a request to use march-in rights on Xtandi. Its manufacturer responded by raising the price even higher. To date the drug has generated $20 billion in revenue.

    It’s not clear why NIH will take a different position this time round. Xtandi was developed with government funding and some senior staff at NIH profit from the drug every year. They receive royalties of as much as $!50,000. A decision to allow march-in rights could reduce their income.

    Although Bayh and Dole have said that their legislation was not intended to address unreasonably high drug prices. But, they did so when they were paid to work for the pharmaceutical industry.

    Why shouldn’t Americans pay the average of what other wealthy countries pay for their drugs? In fact, Pfizer agreed to charge the government no more than the lowest price it charges g7 countries for its Covid treatment, Paxlovid.

    Should the NIH grant march-in rights for Xtandi, Astellas, the drug manufacturer, could appeal. But, the government would automatically have royalty-free rights for people with Medicare, Medicaid and the VA. Older adults, people with disabilities, people with low incomes and veterans would benefit right away.

    Here’s more from Just Care:

  • Biden administration proposes greater accountability from Medicare Advantage

    Biden administration proposes greater accountability from Medicare Advantage

    For years, the federal government has paid Medicare Advantage plans and Part D prescription drug plans hundreds of billions of dollars to cover Medicare benefits, demanding little transparency and accountability regarding the amounts they spend on medical care and drugs and the quality of coverage they provide. HealthcareDive reports that the Biden administration has issued a proposed rule that, if finalized, would demand greater transparency and accountability from Medicare Advantage and Part D plans. But, it’s hard to imagine it’s enough to ensure these corporate health plans cover the care people need.

    If you are enrolled in a Medicare Advantage plan and you develop a serious condition, you might find unwarranted and inappropriate delays and denials of care. Please let us know if you do. And, fight back. Appeal the denials. It’s easy. Medicare Advantage plans are obligated to cover all reasonable and necessary care, and the vast majority of denials are overturned on appeal.

    The challenge is that Medicare Advantage plans can be engaged in all sorts of behaviors that are harmful to their enrollees and difficult, if even possible, to detect.

    For example, MA and Part D plans sold in the individual market are charging their enrollees (27 million and 24 million respectively) copays based on their negotiated drug prices at pharmacies, even though these plans sometimes pay pharmacies lower rates. The proposed rule would require the Medicare Advantage and Part D plans to disclose those lower prices and pass their savings along to their enrollees through lower copays.

    The proposed rule also recognizes the dangers of deceptive marketing by Medicare Advantage plans and the third parties they hire to get people to join their health plans. It aims to do a better job of protecting people. Nice to hear, but it’s hard to see how that’s possible. Scammers abound.

    The proposed rule is intended to require MA plans to behave in compliance with their legal obligations in disasters and emergencies. During COVID, many MA plans were slow to advise their enrollees that referral and network coverage requirements are waived, as required.  It’s a bit Orwellian that the proposal requires private MA plans to comply with requirements already in place.

    MA and Part D plans would also be required to disclose more information about their networks and how they report medical expenses. But, already these plans face requirements to disclose data that they have never disclosed completely or accurately, according to MedPac, the agency that oversees them. And, even if it appears they have an adequate network, who’s to know if the providers they list are seeing more than a handful of new patients.

    The proposed rule would enable CMS  to keep MA plans that have performed poorly in the past–which ones are those, you might ask–from growing their MA plans. CMS has always had tools to penalize plans. But, the punishment never fits the crime. And, of course, there is little if any way for CMS to protect all the enrollees already in the MA plan.

    So while the proposed rule sounds great in theory, it’s hard to see how it will lead to lower costs or better quality of care. How exactly will CMS hold MA plans to these new standards? What’s the punishment if they don’t comply?

    Here’s more from Just Care:

  • DCE “experiment” could mean total privatization of Medicare

    DCE “experiment” could mean total privatization of Medicare

    In 2020, the Trump administration launched a plan to hand traditional Medicare over to Wall Street. Inexplicably, the Biden administration is playing along.

    The overwhelming evidence demonstrates that the plan will drive up healthcare costs, inhibiting people from getting needed care. So-called Direct Contracting Entities, DCEs, must pay for the care of the people assigned to them. Here’s the sweet part for Wall Street: In addition to the normal profits from providing services, these firms can keep as much as 40 percent of the money they don’t spend on care. Talk about a financial incentive to deny treatments.

    In addition, a new safe harbor rule lets DCEs owned by the same investors shuffle money between them without risking civil or criminal penalties for paying kickbacks. That’s the kind of system that makes profiteering easy.

    In phase one of this healthcare experiment, the Centers for Medicare and Medicaid Services, CMS, pays 53 DCEs. They receive a fixed amount of money to cover care for each traditional Medicare enrollee whose primary care doctor signs up with that DCE. The government already auto-assigned hundreds of thousands of people to DCEs.

    Since people in traditional Medicare did not sign up for this, they likely do not know or understand what’s in store.
    Yes, they should have received written notice of their new status. But CMS treats the change as if it does not affect the quality of care provided to these older and disabled people.

    Astonishingly, CMS does not require DCEs to tell people that they have the right to opt out, let alone alert them that there is good reason to do so.

    Anyone enrolled in a DCE should worry that their primary care doctors will limit their access to costly necessary care. The DCEs are likely paying these doctors more to keep patients away from specialty care or providing them with guidance to delay and withhold care. We have seen this profit maximizing before, and it isn’t pretty.

    With Medicare Advantage, which corporate health insurers administer, the Office of the Inspector General found widespread and persistent inappropriate delays and denials of care and coverage.

    The Biden administration continues to mislead people about Medicare Advantage or Part C of Medicare with information claiming it offers people more than traditional Medicare without explaining its risks, including considerable financial and administrative barriers to care.

    Conflicts of Interest Abound

    These business models mean that providing quality health care and abiding by their legal obligations is at odds with profiting handsomely, reports by government agencies and independent researchers have shown again and again.

    Private equity firms and corporations that own or operate dialysis centers, hospice programs, long-term care programs and even dermatology practices put their own interests first, to the detriment of their patients, government watchdogs found.

    Similarly, the DCEs can deliver more for their investors when they avoid paying for costly care.

    How can they do that? Unlike other wealthy countries and large employers in the United States, our government pays a flat fee per person to insurers regardless of the amount they spend on care. Unlike other wealthy countries, our government does not dictate the terms for providing care. Instead, our government lets DCEs decide when to cover care and to do so without accountability. The DCEs don’t even have to make public their coverage policies.

    Covering Medicare benefits, which DCEs must do, is very different from providing people with the medically necessary services and treatments they need.

    For example, as far as a DCE is concerned, three physical therapy visits might be all that is medically necessary after a hip replacement, even though many more are needed. Likewise, a DCE may decide a plain old X-ray will suffice when the treating physician has determined that an MRI is required.

    What Wall Street Loves

    Why would the Biden administration want to give corporations control over the health care of the most vulnerable Americans?

    Wall Street loves it. And the Trump administration, which promised to drain the swamp and stop Wall Street predations, instead turned Washington into a prosperous paradise for the worst Wall Street predators.

    This move away from quality healthcare service to profit-oriented denials of care is worth hundreds of billions of dollars a year in taxpayer money flowing to private industry.

    The CMS description of the program shows how much it is directed at Wall Street, not to the quality of care.

    The DCE approach “draws upon private sector approaches to risk-sharing arrangements and payment with reduced administrative burden commensurate with the level of downside risk.

    “The risk-sharing options… also includes a reduced set of quality measures that focuses more on outcomes and beneficiary experience than on process.

    “By providing flexible options with regard to, for example, risk-sharing arrangements, financial protections, and benefit enhancements” they are expected to be attractive to people with Medicare but also to “organizations that have experience with risk-based contracts.” That’s a euphemistic way to refer to the DCEs financed by Wall Street.

    That description, interestingly, is contained in an announcement about a new rule that effectively exempts related DCEs from civil and criminal liability for paying kickbacks so long as they pay in accord with the new rule.

    If that sounds like a license to loot the Treasury, it’s because that is precisely what it can and likely will become.

    Basically, one DCE can make payments to a brother or sister entity, which can become a way for these related businesses to keep more of the money taxpayers pay them.

    These private business dis-Advantage plans are a far less cost-effective, quality-questionable arm of Medicare.

    Pilot Program Metastasizes

    Direct contracting is supposed to be a pilot program, yet Medicare has no plans to limit the number of people it enrolls in these new plans. Instead, Medicare has announced plans to enroll 100% of traditional Medicare members into DCE-like programs by 2030.

    This massive handover appears to violate the limited authority that Congress granted to conduct an experiment. Without any Congressional oversight, CMS is moving all people on Medicare into these private business plans by the Orwellian redefining of its direct contracting authority with providers and suppliers.

    Through the Medicare Innovation Center, Congress gave CMS authority to test new models for paying for care provided that they neither increase costs nor undermine quality.

    Our Congress did not authorize models that are known to be more costly, that are subject to large-scale inappropriate denials of care or to systems that involve private insurers and investors as intermediaries with complete control over people’s care.

    Our Congress did not authorize the wholesale overhaul of traditional Medicare, so why is this happening?

    The Biden administration should be held to account immediately and pressured to halt this dangerous and costly Medicare transformation. And members of Congress, especially on the committees that oversee Medicare, need to hold public hearings where people denied care would testify to their experiences.

    What You Can Do About It

    The Biden administration could stop this Direct Contracting pilot that is privatizing traditional Medicare.
    The Honorable Xavier Becerra, secretary, U.S. Dept. of Health and Human Services
    Washington, D.C. 20201
    The Honorable Chiquita Brooks-LaSure
    administrator, Centers for Medicare and Medicaid Services
    Baltimore, MD. 21244

    You also can sign this petition.

    Note: This article appeared originally on DCReport.

  • Biden administration aims to stop Pharma from preventing drug importation

    Biden administration aims to stop Pharma from preventing drug importation

    ABCNews.com reports on a Biden administration effort to ensure states can legally import drugs from abroad. You might have guessed that big Pharma is opposing drug importation by states. In this case, Pharma is trying to block Florida’s efforts to import drugs from Canada.

    The Biden administration is trying to dismiss a Pharma lawsuit against state drug importation. The administration argues that Pharma has no basis for filing a lawsuit to block state importation of drugs as the Biden administration has not approved importation to date. Interestingly, for once, the Republican governor of Florida, Ron DeSantis, is on the same side as the Biden administration.

    That said, DeSantis is quick to criticize the Food and Drug Administration for not approving state drug importation speedily. He’s a politician. And, he sees an opportunity to build political support around lower drug prices.

    Only Florida and New Mexico are currently seeking permission from the White House to import drugs from Canada. They believe it will save them and their residents tens of millions of dollars a year.

    Meanwhile, Pharma has only a couple of lame arguments against importation of drugs. Even though the US is able to import food safely and millions of Americans have already imported prescription drugs safely, it cries “safety” like the boy who cried “wolf.”  Of course, importation must be from verified pharmacies, but there are thousands of them around the globe.

    Here’s more from Just Care:

  • Will Biden expand Medicare benefits or strengthen the ACA?

    Will Biden expand Medicare benefits or strengthen the ACA?

    Jeff Stein reports for the Washington Post on health care reform proposals the Biden administration could include in the American Families Plan. House Speaker Nancy Pelosi is urging President Biden to invest in strengthening the Affordable Care Act. Senator Bernie Sanders wants him to add additional benefits to Medicare and make Medicare available to people 60 and older.

    Speaker Pelosi wants the next Congressional legislation to make greater subsidies to people under the Affordable Care Act permanent. In March, Congress expanded subsidies but they are  temporary. Her proposal would further entrench for-profit insurers in our health care system.

    Senator Sanders wants to shore up .the Medicare benefit package. He wants it to include dental, vision and hearing services. He also wants to lower the age of Medicare eligibility to 60 or 55. These benefits could bring down health care costs substantially for the 23 million people over 6o who are not eligible for Medicare today as well as for the 65 million people with Medicare.

    Biden, for his part, should recognize that pumping more money into our nation’s corporate health insurance system is going to drive up costs and keep us from having a sustainable universal health care system. Expanding public health insurance administered directly by the federal government is the only way to get a handle on health care costs and drive health care system improvements.

    The Biden administration is working on the American Families Plan. Right now, it appears it will cover child care, anti-poverty programs and health care. It could reduce prescription drug spending by $450 billion over ten years. Senator Sanders wants these savings, which are largely from Medicare, to benefit people with Medicare. Using the money on the ACA or any other health care initiative would take money out of Medicare.

    The savings on prescription drug costs should go to helping people with Medicare. The most up-to-date data show that older and disabled Americans suffer deeply as a result of not having comprehensive dental, vision and hearing benefits. Benefits available through Medicare Advantage plans appear to be theoretical and not meaningful. To the extent Medicare Advantage plans offer these benefits, they pay for only a fraction of the cost of treatment. Most people do not have the means to pay the substantial out-of-pocket costs.

    Consequently, nearly one in five people with Medicare over 70 have no teeth. An additional one in five of them suffer from tooth decay. Millions of people with Medicare also suffer from untreated severe or profound hearing loss. And millions suffer from lack of vision care. All of these services are prohibitively expensive. Lack of vision, dental and hearing care can lead to depression, increased risk of falls, social isolation, diabetes, cardiovascular disease and other co-morbidities.

    Whichever direction Biden goes, it will take enormous public pressure for Congress to pass the legislation. It will come after Congress passes an infrastructure package, which also will require a large public push.

    Here’s more from Just Care:

  • Biden administration acts to ensure people with disabilities keep their Social Security benefits

    Biden administration acts to ensure people with disabilities keep their Social Security benefits

    The Trump administration worked hard to destroy Social Security every which way it could. Among other things, it made it extraordinarily difficult for people to get the Social Security benefits to which they are entitled. Now, Jake Johnson reports for Common Dreams, that the Biden administration has withdrawn a Trump administration not-yet-final regulation that would likely have taken disability benefits from hundreds of thousands of Americans.

    The Trump administration tried to subject people receiving Social Security long-term disability benefits to constant reviews if they wanted to retain these benefits. The additional reviews would have posed challenging administrative hurdles for people receiving benefits. As it is, qualifying for Social Security disability benefits is not easy.

    Social Security Works led the advocacy effort. According to its executive director, Alex Lawson, the proposed regulation was “the Trump administration’s most brazen attack on Social Security yet.” “When Ronald Reagan implemented a similar benefit cut, it ripped away the earned benefits of 200,000 people. Ultimately, Reagan was forced to reverse his attack on Social Security after massive public outcry—but not before people suffered and died.”

    President Joe Biden has a history of proposing Social Security cuts. And, he was criticized for his record on Social Security during the 2020 presidential campaign. He is now holding true to his word during the campaign that he would protect Social Security.

    President Biden also promised during the campaign to increase Social Security benefits, which are not as high as they should be. For a wealthy country, Social Security benefits in the US are stingy relative to other countries. To increase Social Security benefits, it would be particularly helpful for President Biden to fire the Social Security Administration Commissioner Andrew Saul and Deputy Commissioner David Black. Donald Trump is responsible for putting these high-level anti-Social Security officials in charge of Social Security.

    Here’s more from Just Care: