JustCare

Tag: Veteran’s Administration

  • PhRMA fights states on drug pricing

    PhRMA fights states on drug pricing

    Drug prices are rising at crazy rates; in 2015, almost one in three brand-name drugs saw a price increase of 20 percent. In response, more than a dozen states are considering legislation that would call the drug companies to account. Of course, PhRMA is fighting states on drug pricing.

    On June 3, 2016, Vermont’s governor signed into a drug transparency law intended to make drug companies justify huge drug price increases. And, since then, the California Assembly’s Health Committee approved a similar drug price transparency bill, which its Senate has passed, intended to make drug companies justify huge drug price increases. That said, Stat reports that the bill has recently been gutted. 

    Now, a ballot initiative in California, Proposition 61, is designed to reduce the cost of drugs for state agencies. This would not only take a toll on drug company profits, it would set the stage for other states to pass similar initiatives. Not surprisingly, PhRMA has already put $70 million into fighting this initiative.

    Proposition 61 would keep California agencies like MediCal, (California’s Medicaid), which covers poor children, from paying any more for a drug than the lowest price paid by the Veterans’ Administration (V.A.). Ohio has a similar initiative, but PhRMA may successfully keep it from being voted on by bringing a lawsuit challenging it.

    California state agencies today spend $4 billion a year on drugs. If Proposition 61 passes, the state could  could save hundreds of millions of dollars. But, some argue that it would be hard to implement.

    Most drug prices, including discounts and rebates, are not transparent. So, it could be hard to know exactly what the V.A. is paying.  That said, the CBO reported ten years ago that the V.A. pays about 42 percent of the retail prices and Medicaid pays about 52 percent.

    California AARP supports Proposition 61 as does the California Nurses Association. But, according to the New York Times, some advocates oppose it for fear that it will lead drug companies to drive up prices at the V.A. and for others even further. It’s not clear whether some or all of these advocates take money from the drug companies and are therefore conflicted.

    As important as it is for states to be taking action on drug pricing, state action is not likely to succeed at reining in drug prices as much as needed. The pharmaceutical industry is too powerful. But, state activity keeps a spotlight on the pharmaceutical industry and that in turn keeps pressure on Congress to act. How long that will take, however, is anyone’s guess.

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  • The VA health system: Best in class and under fire

    The VA health system: Best in class and under fire

    Some might say with good reason that the Veterans’ Health Administration or the “VA” health system is best in class–indeed, Phillip Longman, senior editor at the Washington Monthly, has written extensively about the VA, calling it “The best care anywhere.” The VA offers a national health care system with the government owning most of its care facilities and employing its 311,000 doctors and other staff. What makes the VA system so good and why is it under fire?

    The VA system is the largest health care system in the U.S., covering 6.7 million veterans through a network of about 150 hospitals and more than 800 outpatient clinics. Different veterans are eligible for different levels of coverage, with veterans who were engaged in combat eligible to get the highest level of coverage. The VA does not charge a premium for coverage, but depending upon the nature of their service and injuries, veterans may pay copays. Copays tend to be low for veterans who sustained serious injuries while on active duty and are unable to find employment. Copays can be quite high for other veterans.

    The VA has been praised as a model for delivery of integrated care for people with complex and costly conditions. Doctors employed by the VA can rely on an electronic medical record system that allows them to coordinate care; they use data to drive good health care outcomes. Not surprisingly, the VA gets high marks on quality relative to the private sector. And, its doctors have the expertise needed to treat a population of people with very serious conditions.  Just one example of the V.A.’s expertise–a 2005 fall-prevention program has led to many fewer veterans falling and getting a hip fracture. By contrast, most hospitals don’t provide guidance to discharged patients who were hospitalized for a hip fracture resulting from a fall, let alone collect follow-up data.

    But, at the same time, the VA, like all health care systems in the U.S., is experiencing a doctor shortage. It has too few doctors and other providers to treat the growing pool of veterans, including both aging Vietnam War veterans and younger Iraq and Afghanistan veterans–and wait times to see primary care doctors are excessive. A 2014 report by the VA Office of the Inspector General documents the issues.  And, an April 2016 GAO report finds that wait times for primary and specialty care continue to be a serious concern and that the VA appointment scheduling policy needs upgrading.

    To address long waits for care, just a few weeks ago, a bi-partisan Congressional Commission has made a series of recommendations. Not surprisingly, the conservatives on the Commission, along with outsiders like the Koch brothers and Donald Trump, would like to privatize the VA over the next two decades. Veterans are strongly opposed.

    The Commission made many recommendations around infrastructure. Its biggest recommendation was to establish a new VHA Care System, expanding the pool of doctors and hospitals treating veterans with additional health care providers, from both government and the private sector. However, back in 2014 to address the long waits for care, Congress passed the Choice Act, which allowed veterans coverage for care from private doctors in certain situations. While this may sound good in theory, it did not work in practice. Indeed, wait times increased.

    For sure, more doctors and hospitals are needed to treat veterans. But, why would relying on the private sector be a solution now, when it did not work back in 2014? We all experience long wait times to see doctors. Moreover, most primary care doctors outside the VA are not trained to treat war veterans And, commercial care brings with it large out-of-pocket costs. As Philip Longman says, “Offering unlimited, unmanaged choice of doctors and treatments would not only lead to dangerously fragmented care, it would also cost so much that in the real world, it would be a political non-starter and thus limit choice.”

    There are other ways to reduce wait times for treatment. Some propose that the VA allow nurses with special expertise to practice without supervision from doctors, which is already permitted in 20 states. Or, as Longman proposes, in places where it lacks capacity, the VA could identify and contract with skilled outside doctors in an integrated fashion that allowed these providers to use the same electronic medical system as the VA doctors.

    Longman sees the VA as our opportunity to move the U.S. towards a better, more cost-effective health care system. In his words, “The VA model of care, with its emphasis on integration, prevention, and evidence-based, cost-effective care, is also in the forefront of where the rest of the U.S. health care needs to go. If we lose the VA, the cause of real healthcare delivery system reform will be set back by at least another generation, with incalculably dire consequences health and finances of the American population.” Of course, moving towards a VA system for all threatens Aetna, Blue Cross and UnitedHealthcare among other big stakeholders in our health care system. And, that’s precisely why the VA system is at risk.

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  • Should you care whether a hospital employs its doctors?

    Should you care whether a hospital employs its doctors?

    A recent Kaiser Health News article notes that doctors who once practiced on their own are increasingly working for hospitals. The idea, at its best, is that doctors who practice in a group setting, like a hospital, can better coordinate care and improve quality of services for patients. At its worst, the hospital sees the doctors as a means to generate more revenue. Should you care whether a hospital employs its doctors?

    In September, Broward Health, a non-profit hospital system based in Florida that employs its doctors, paid $70 million to settle charges that it was improperly kicking back money to doctors for making patient referrals to the hospital. For decades, policymakers have tried to prevent such arrangements on the theory that they can encourage doctors to deliver more care than necessary, driving up costs and potentially harming patients.

    The question remains whether promoting good care has anything to do with how doctors are paid? Or, is it about the goals of the people directing and providing care. Broward’s goals appear to have been revenue-based. But, not all hospitals who hire their doctors share those goals.

    The Veterans Administration (VA) doctors are employees. Based on many studies comparing patient safety and health care quality under different payment systems, the VA offers “the best care anywhere.”  The VA has been lauded for giving systematic attention to appropriate treatment in ways other hospitals do not. It encourages a team-based coordinated care approach to care.

    That said, not only is there huge quality and safety variations among hospitals, but there can be large variations within a hospital or a hospital system. The Wall Street Journal reports that patient care varies widely at VA hospitals.

    So, how is a person to choose among health care providers? For good reason, the public is not focused on health plan quality.  And the various hospital ratings will at best tell you a piece of the hospital quality story. A lot of data is still not available. But, make sure you look at hospital infection rates.  Moreover, keep in mind that the quality of care delivered turns in significant part on the doctors who are providing care. For more information about the different provider ratings available through Medicare and elsewhere, visit the Informed Patient Institute.

  • Americans are more satisfied with Medicare than with private insurance

    Americans are more satisfied with Medicare than with private insurance

    According to a new Gallup poll, people with government-provided health insurance, including people with Medicare and VA coverage, are more satisfied with their health care coverage than other Americans.  Almost four out of five people 65 and older are satisfied with their treatment by the health care system (79 percent of people with Medicare, Medicaid and VA coverage) as compared with about three out of five people between 18 and 45 (61-66 percent).
    More specifically, people without health insurance are the least satisfied with the health care system (36 percent). People with military or veterans coverage are the most satisfied (77 percent) and people with Medicare or Medicaid are the next most satisfied (76 percent).

    For this survey, Gallup was not able to separate out satisfaction rates for people newly insured in the health insurance exchanges.  They plan to do so in future polls as soon as practicable.

    The survey also does not speak to the reasons why people over 65 are more satisfied with the health care system than the rest of the population.  Joe Baker, president of the Medicare Rights Center, speculates it’s because Medicare and Medicaid coverage are easier to use than private insurance and in most cases provides better protection against financial risk.  “For sure, Congress can improve Medicare.  But, compared with the hassles of referrals and huge copays and deductibles with private insurance, Medicare is relatively simple.”

     

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