Some people with cancer, HIV and multiple sclerosis have better access to high-cost specialty drugs in marketplace plans this year, yet a significant proportion of these plans still place many expensive drugs in cost-sharing categories that require the highest patient out-of-pocket costs.

The report released Tuesday by Avalere Health, a consulting firm, examined how silver-level plans handled 20 classes of medications that are used to treat complex and expensive diseases such as HIV, cancer, hepatitis C and bipolar disorder.

Health plans generally place covered drugs into tiers. Generics and preferred brand-name drugs are in lower tiers with lower cost sharing, while higher-priced drugs are often placed in tiers that require patients to pay a percentage of the cost of the drug rather than a flat copayment.

The study found that for five classes of drugs — two used to treat cancer, two for HIV and one class of multiple sclerosis drugs — fewer plans in 2016 placed all the drugs in the class in the top specialty drug tier with the highest patient cost-sharing requirements or charged patients more than 40 percent of the cost for every covered drug in the class.

For example, in 2015, 57 percent of silver marketplace plans put all cancer drugs called anti-angiogenic agents (which inhibit the growth of blood vessels) in the top specialty tier. In 2016, that dropped to 50 percent. Last year, a quarter of silver plans charged patients more than 40 percent coinsurance for every drug in that class. In 2016, 15 percent of such plans did so.

Likewise, 14 percent of 2015 silver plans placed protease inhibitors, a class of HIV drugs, in the top tier, compared with 10 percent in 2016. The percentage of plans charging more than 40 percent coinsurance for those drugs dropped to 6 percent in 2016 from 9 percent the previous year.

The changes are likely driven by protests and legal challenges from patient groups and from increased regulatory oversight, said Caroline Pearson, a senior vice president at Avalere. For example, California next year will prohibit insurers from placing most or all of the drugs for a specific condition in the highest cost tier. In addition, the federal Department of Health and Human Services has signaled in guidance to insurers that placing all or most of the drugs in a high-cost tier may be discriminatory.

“There’s been a lot of discussion about discriminatory drug benefits, and that attention has moved health plans to make changes,” said Pearson.

Carl Schmid, deputy executive director at the AIDS Institute, an advocacy group, said of the study results: “It does show some progress, which we are pleased to see.”

The organization drew attention to the problem in 2014 when it filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that the plan designs of four Florida health plans were discriminatory because they discouraged people with HIV/AIDS from enrolling. The Florida Office of Insurance Regulation subsequently set maximum limits on cost-sharing for HIV medications in marketplace plans.

“We can celebrate this,” Schmid said, but “our goal is zero, there should be no plans” that place all the HIV drugs in a class in the top tier and charge high coinsurance.

Please contact Kaiser Health News to send comments or ideas for future topics.

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Lowe’s home improvement company, like a growing number of large companies nationwide, offers its employees an eye-catching benefit: Certain major surgeries at prestigious hospitals are free.

How do these firms do it? With a way of paying that’s gaining steam across the health care industry, and that Medicare is now adopting for hip and knee replacements in 67 metropolitan areas, including New York, Miami and Denver.

Here’s how the program works: Lowe’s and other employers pay one flat rate for a particular procedure from any of a number of hospitals they’ve selected for its quality. And, under the agreement, the hospital handles all the treatment within a certain time frame — the surgery, the physical therapy and any complications that arise — all for that one price.

It was Bob Ihrie, senior vice president for compensation and benefits at Lowe’s, who came up with the idea in 2010. When he told managers at other companies about it, he says, “The first question was always, ‘Oh, this is just for executives, right?’ And I said no, absolutely not, this is for any Lowe’s employee in the Lowe’s health care plans.”

The program is optional for employees. They can still use their local surgeon, if they prefer, and pay out of pocket whatever their insurance doesn’t cover. But more than 700 Lowe’s employees have taken the company up on its offer, Ihrie says.

It’s a great deal for patients, he says, and for his company.

“We were able to get a bundled price, which actually enables us to save money on every single operation,” Ihrie says.

The Pacific Business Group on Health negotiates that price for Lowe’s, Walmart and a number of other large employers. Associate director Olivia Ross oversees these deals, and says her team is able to negotiate rates that are 20 to 30 percent below what the companies used to pay for the procedures.

“We’re seeing savings at the front end,” she says, because Lowe’s pays less for the surgery. And, because the hospital is responsible for all that care, the institution has a strong incentive to be careful and thorough, Ross says.

That means “huge savings on the back end,” she says, “from things like reduced re-admissions, reduced return to the O.R. and lower rates of blood clots. Those are hugely expensive, preventable complications.”

Lowe’s comes out ahead, even after paying for the patient’s travel, Ihrie confirms.

Participating hospitals win, too, by attracting more patients, says Trisha Frick, who handles such negotiations on behalf of Johns Hopkins Medicine in Baltimore.

“It’s new business for us,” Frick says. “And, for the most part, the reimbursement is acceptable; we believe that we can provide that, within that amount of money.”

Medicare, the health insurance program for people 65 and older, started using bundled rates for hip and knee replacements this month in Miami, Los Angeles and 65 other metro areas. Medicare had some early evidence from pilot programs that “the model works well,” according to Rob Lazerow, a health care consultant with The Advisory Board Company.

“Medicare is saving something like $4,000 on orthopedic cases,” he says.

Medicare’s deal is somewhat different from the one at Lowe’s. Patients may pay something out of pocket, depending on the type of Medicare policy that insures them. And while the few hospitals selected in Lowe’s program can bank on increasing their revenue and the number of surgeries they’ll get, the rates established by Medicare’s bundled payment system hold for every hospital in a participating market.

“Entire markets are selected for participating,” Lazerow explains. “If you’re in the San Francisco market or you’re in the New York market, all of the hospitals are actually participating in the program.”

But there are similarities, too, and Medicare may learn some lessons from Lowe’s experience. Lowe’s initially had trouble wrangling all a patient’s medical records from local doctors. And the company found that patients who had questions weeks or months after an operation sometimes had trouble following up with the out-of-town doctor who had performed the surgery.

“You have some setbacks, and things happen, and you just have questions,” Ihrie says. “So what we give every patient now is a little card with the doctor’s name and direct phone line and the nurse’s name and direct phone line. And all of a sudden, things were a lot better.”

Another lesson was startling, Ross says. In addition to cutting the cost of procedures, another chunk of savings to the companies came from avoiding surgeries that probably shouldn’t happen in the first place.

“We’re seeing up to 30 percent — close to 30 percent of cases — who should not be moving forward with the joint replacement,” Ross says.

What typically happens in these cases, she says, is that employees get a recommendation from a local doctor that they should have surgery, only to have physicians at the selected hospitals deem the operation inappropriate.

In some cases that may be because the employee hasn’t first tried less invasive treatments, such as physical therapy, Ross says. Or the employee may need to lose weight first, to make the surgery safer.

Ihrie says what heartens him most about his company’s program is that Lowe’s employees are now taking a more active role in decisions about their care.

“What treatment you receive is not always very black and white,” he says. “The mere fact that people now think about what they’re doing helps us control costs across the board.”

This story is part of NPR’s partnership with WFAE and Kaiser Health News.

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White women are dying at a slightly younger age than they used to. That’s according to a report released Wednesday by the Centers for Disease Control and Prevention’s National Center for Health Statistics.

The life expectancy for non-Hispanic white women in the United States declined by one month — from 81.2 years to 81.1 years — from 2013 to 2014. Though just one month may not seem like much, demographers worry — it’s the first time since the government began keeping records that white women saw their life expectancy decline, according to the report.

The numbers don’t include cause of death, but demographer Elizabeth Arias, who wrote the analysis, decided to dig deeper. She looked at cause of death among white people in the U.S. over the last 15 years. And the changes she found troubled her.

“For the age group 25 to 54, suicide went up,” she says. ” ‘Unintentional poisonings,’ which is mainly alcohol and drug poisoning, and chronic liver disease — those went up by quite a bit.”

Those underlying factors affected men and women, Arias says, but affected women more. The life expectancy of white men over the same time period did not change.

Many other causes of death declined, she says — including heart disease, cancer and stroke. But those health improvements were offset by the increases in drug overdose, suicide and chronic liver disease.

The report comes just a few months after a separate study by Princeton economists Anne Case and Angus Deaton showed that middle-age mortality among white people is on the rise. The authors of that study also said the increase in deaths was likely due to suicides, drug overdoses and alcoholism.

Ellen Meara, a professor at Dartmouth’s Institute for Health Policy and Clinical Practice, said the numbers are surprising because mortality has been in decline for so long.

“There are people for whom life expectancy is falling — and that’s happening at a time where everywhere else and for every other group we’re seeing all these amazing gains in survival,” Meara says.

The NCHS report does have some good news: The average life expectancy for non-Hispanic black men increased by about a half year — from 71.8 years to 72.2 in that same time period. Arias says that improvement seems linked to declines in cancer deaths, homicides and heart disease.

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Starting today, 155 countries and territories will start switching to a different polio vaccine.

The shift, which is expected to be completed by May 1, is the “largest and fastest globally coordinated rollout of a vaccine into routine immunization programs in history,” according to the Global Polio Eradication Initiative.

“We’re closer than ever to ending polio worldwide, which is why we are able to move forward with the largest and fastest globally synchronized switch ever,” Michel Zaffran, Director of Polio Eradication at the World Health Organization, said in a press release.

According to The New York Times, it’s the “first worldwide vaccine change ever attempted.”

The progress towards complete eradicating polio shows in the numbers. Last year, 74 cases of wild poliovirus were reported, exclusively in Pakistan and Afghanistan, according to the initiative. In 2016, 10 cases have been reported so far — also in those two countries. By comparison, when the initiative started its work in 1988, “more than 350,000 children were paralyzed every year.”

As health officials strategize about how to rid the world of the disease, which can cause paralysis, “one important step is to gradually withdraw the oral polio vaccine, starting with the type 2 component,” Jackie Fournier-Caruana from the initiative explains.

The old oral vaccine (tOPV) protected against three strains of poliovirus, while the new oral vaccine (bOPV) protects against two of the strains. According to the initiative, the transition is possible “because type 2 wild polio has been eradicated.”

It stresses the importance of closely synchronizing this transition globally: “if some countries continue to use tOPV it could increase the risk of the spread of type 2 poliovirus to those no longer using tOPV.”

This “massive undertaking” will involve deploying thousands of monitors to make sure tOPV is no longer in use.

The New York Times details the disposal methods during the switch:

“Approved disposal methods include incineration, boiling, autoclaving, bleaching or burying in concrete-sealed containers. Each has drawbacks, like the possibility that glass vials will explode.

“Adding to the possibility of confusion, the old and new vials and boxes are almost identical. Warehouse managers are supposed to mark the old vaccine with an “X” and bag it for disposal.”

Dr. Walter Orenstein, who is the associated director of the vaccine center at Emory University School of Medicine, tells the Times, “This is going to be hard. …For a long time, we’ve driven people to think of vaccine as valuable. Now we’re asking them to destroy it.”

The initiative says there’s a global stockpile of type 2 vaccines, ready to be used in the unlikely case of an outbreak. Type 2 was last detected in the wild in 1999, according to the initiative.

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Doctors know it’s important to talk with their patients about end-of-life care.

But they’re finding it tough to start those conversations. When they do, they’re not sure what to say, according to a national poll released Thursday.

Such discussions are becoming more important as baby boomers reach their golden years. By 2030, an estimated 72 million Americans will be 65 or over, nearly one-fifth of the U.S. population.

Medicare now reimburses doctors $86 to discuss end-of-life care in an office visit that covers topics such as hospice, living wills and do-not-resuscitate orders. Known as “advance care planning,” the conversations can also be held in a hospital.

Payment for such discussions was initially included in the Affordable Care Act, but removed because of the controversy over so-called death panels. Medicare ultimately changed its policy, independently of Obamacare, to allow reimbursement for the end-of-life planning sessions.

The poll of 736 primary care doctors and specialists, including 202 in California, examined their views on advance care planning and end-of-life conversations with patients. Among the findings:

• While 75 percent of doctors said Medicare reimbursement makes it more likely they’d have advance care planning discussions, only about 14 percent said they had actually billed Medicare for those visits.
• Three quarters also believe it’s their responsibility to initiate end-of-life conversations.
• Fewer than one-third reported any formal training on end-of-life discussions with patients and their families.
• More than half said they had not discussed end-of-life care with their own physicians.

The survey was commissioned by The John A. Hartford Foundation, the California Health Care Foundation and Cambia Health Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.)

The general survey has a margin of sampling error of plus or minus 3.6 percentage points. For the internist/primary care provider sample, margin is plus or minus 4.5 percentage points. For specialists, plus or minus 6.0 points.

Patients and their families increasingly want to talk about end-of-life care with their physicians well before facing a terminal illness, studies have shown. Most also want to die at home rather than in a hospital, although cultural differences influence end-of-life preferences.

Policy analysts are urging more end-of-life conversations not just to accommodate patients’ desires, but to save money on aggressive medical interventions that patients and their families don’t want and that won’t prolong life.

A recent study found nearly 40 percent of American patients dying with cancer received at least one chemotherapy treatment in the six months before they died, more than in six other countries studied. An average of about $18,500 was spent on U.S. hospital costs for patients in their last six months.

Nearly a quarter of the physicians in the national poll said that the electronic health records they’re required to use don’t have a place to include patients’ end-of-life preferences. Even when electronic health records signaled that a patient had an advance care directive, nearly a third of doctors reported they couldn’t access its actual contents.

And doctors who received their medical training years ago say they rarely focused on how to talk to patients about end-of-life care, although medical education is improving in that regard.

Physicians in large medical systems may find more support than those in private practice. At Kaiser Permanente in Northern California, physicians receive training in end-of-life discussions and have time to carry them out, said Dr. Ruma Kumar, the HMO’s regional medical director of supportive care services.

Kaiser Permanente looks to nurse practitioners, registered nurses and social workers to work with patients on various stages of what the HMO calls “life care planning.” The HMO also offers a website to guide people through the process.

Kumar said Kaiser encourages both doctors and patients to think of end-of-life planning “as a routine part of care, just like you’d get a mammogram or colon cancer screening.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation. Follow Barbara Feder Ostrov on Twitter: @barbfederostrov.

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An injured worker featured in an NPR/ProPublica investigation of the opt-out alternative to workers’ compensation has settled with the company that denied her medical care and wage-replacement payments after an incident at work.

Rachel Jenkins, 33, was injured last March while protecting a mentally disabled man who was attacked by another client at an Oklahoma City shelter operated by ResCare, which claims to be the nation’s largest provider of services to people with disabilities.

ResCare had opted out of state-regulated workers’ compensation in Oklahoma by developing its own workplace injury plan. The company initially denied Jenkins any benefits for her painful and persistent shoulder injury because she had missed a 24-hour reporting deadline by just three hours. Jenkins said she reported late because she had been heavily medicated after emergency treatment.

The 24-hour reporting rule is one of the most contentious elements of opt-out plans in Oklahoma and Texas. Critics say the rule gives employers the ability to deny benefits for legitimate workplace injuries that they would otherwise have to provide if they hadn’t opted out of workers’ comp.

Jenkins and other workers in Oklahoma sued their employers and state regulators over that provision and others in the state’s opt-out law.

ResCare and Jenkins agreed not to disclose the details of this week’s settlement, but Bob Burke, Jenkins’ attorney, says the monetary settlement gives Jenkins enough money to get her shoulder treated, recover lost wages and provide the same type of disability payments Jenkins would have received if ResCare had remained in the workers’ comp system.

“ResCare was reasonable in providing monetary compensation for medical care and for permanent disability,” Burke says.

He adds that Jenkins is planning to get treatment and find another job.

Jenkins says the settlement negotiations “went great.” But she noted that she expects to be “dealing with my shoulder the rest of my life.”

A spokeswoman for ResCare says the company does not comment on pending or past litigation.

Burke says the settlement resolves the Jenkins lawsuit but other clients still have ongoing cases.

ResCare initially denied benefits for the injury despite the fact that her supervisor witnessed the incident. Jenkins endured 16 days of pain while unable to afford treatment and worried about getting back to work.

“I went through hell, a whole lot of pain where I was in tears,” Jenkins told NPR and ProPublica last year. “I was just thinking … ‘How am I going to take care of my kids?’ “

ResCare reversed the denial after pressure from Jenkins’ colleagues.

The settlement follows a recent ruling by the Oklahoma Workers’ Compensation Commission that declared the state’s opt-out system unconstitutional. The issue is now headed to the state Supreme Court.

U.S. Labor Secretary Thomas Perez told NPR last month that the agency is investigating opt-out plans. Agency investigators are trying to determine whether the plans violate workplace benefits provisions required by federal law. Perez said the opt-out alternative to workers’ comp creates “a pathway to poverty” for injured workers.

ProPublica’s Michael Grabell contributed to this report.

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Are you ready for some more uncertainty about blood pressure treatment?

Decisions about blood pressure have gotten more difficult over the past couple of years as experts in the U.S. have failed to reach consensus on recommendations about when drug therapy should be started. Now there’s new evidence that could make the decisions even more challenging.

Let’s review first where there is agreement. Around the world, high blood pressure causes a lot of harm. Your risk of health problems — such as heart disease, stroke and kidney disease — increases with higher blood pressure. Your lifestyle can influence your blood pressure. A healthful diet, at least moderate physical activity and weight control can bring down your blood pressure. Those are good habits for everyone, in fact.

Medicines can help reduce the risk for people with higher blood pressure, say 150 millimeters of mercury and above for systolic pressure, the top number. Too many people have untreated and uncontrolled marked elevations of blood pressure and many devastating health problems could be prevented if we could help people get proper treatment.

What about medicines for people whose blood pressure is high but less than 150? Most doctors agree that people younger than 60 would do well to keep their blood pressure less than 140. The consensus is that the benefit of drugs for those who didn’t respond to lifestyle changes exceeds the risks of treatment.

Some believe that for older patients, who may be more sensitive to medications, the recommendations should be more permissive and not push for treatment that brings blood pressure below 140. Then there’s the SPRINT trial, whose results were released last November and suggested that people without diabetes, even older people, would benefit by seeking to get their blood pressure down to around 120.

Another study, called HOPE-3 for short, added important evidence about the treatment of blood pressure that will further unsettle the field. The findings were published April 2 by in The New England Journal of Medicine.

The researchers in the study randomized 12,705 people with at least one cardiovascular risk factor (like high cholesterol) to get blood pressure medication or placebo. At the time of randomization, the average systolic blood pressure was 138. Some people’s pressures were higher and some were lower, or course. In fact, a third of the people had a beginning blood pressure less than 132.

So what did HOPE-3 find? The blood pressure medications worked. Study participants in the group that got blood pressure medicine had their systolic blood pressure lowered about 6 points more than those in the placebo group. However, after almost six years of follow-up, the investigators determined that lower blood pressure didn’t translate into lower risk. The risks of death from cardiovascular causes, heart attacks, strokes and other problems weren’t different between the groups.

The investigators explored the data further and found some evidence that the group in the highest third of blood pressure at the start (an average top number of 154) seemed to have a lower risk, while the group in the lowest third at the start (average of 122) seemed to do worse. These analyses were planned at the outset of the study, so we tend to give them a bit more weight.

So what happened?

HOPE-3 used common antihypertensive medications, an angiotensin receptor blocker called candesartan and a diuretic called hydrochlorothiazide. Could the results be explained by something about these medications?

Participants in the study had an average age of 65 years, about half were women, a quarter were smokers and almost all were overweight. Was there something special about them?

Or could it be that pushing blood pressure to ever-lower levels, even in a group at modest risk of heart disease and stroke, is just not producing benefit?

We don’t know for sure.

The field is waiting eagerly for the next version of national guidelines about blood pressure. A group of experts in the field will look at all the evidence and give its opinion about whom to treat and when.

But how useful will general guidelines be for individual patients, given the conflicting evidence? How confidently will the experts be able to recommend strategies for people in the middle range of blood pressure?

The ultimate decision about treatment for each person should be informed by the fact that a definitive benefit hasn’t been consistently shown for lowering blood pressure below 140 in people without known disease (we call this primary prevention). The results of the HOPE-3 indicate that the lower your blood pressure is, the less likely you are to benefit from starting drug therapy.

As always, if your blood pressure is in the range where there is controversy and you want to lower your blood pressure, your best first move is to adopt a healthful lifestyle and see what happens — and, of course, talk with your physician. Meanwhile, experts will be poring over the recent studies to try to reconcile the disparate results.

In medicine, we like it when the latest data bring clarity to personal decisions about treatments. But the reality is that studies often go in different directions and leave us even more uncertain about what to do next. That uncertainty, though, is still important information as you consider your options.

The disappointing conclusion about blood pressure is that we need more studies and more evidence. We also need better evidence — information that is more precise about what is likely to happen to us personally if we take medications for blood pressure.

We need to move faster to get the knowledge that is attuned to our personal characteristics and that can guide our decisions about the blood pressure number that’s best and also the drug that would work best for each of us, if we need one. This is the hope of President Obama’s Precision Medicine Initiative. Given the mixed evidence we have, this new era of knowledge cannot come fast enough.

Harlan Krumholz is a cardiologist and the Harold H. Hines Jr. Professor of Medicine at Yale School of Medicine. He directs the Yale-New Haven Hospital Center for Outcomes Research and Evaluation and is a co-director of the Robert Wood Johnson Foundation Clinical Scholars Program.

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The Obama administration is recruiting as many as 20,000 primary care doctors for an initiative it hopes will change the way physicians get paid and provide care.

The program, which was announced Monday, will be run by the Centers for Medicare and Medicaid Services. The aim is to stop paying doctors based on the number of billable services and visits provided to Medicare beneficiaries and instead to tie payments to overall patient health and outcomes.

“We think there will be a high level of interest across states and regions among primary care providers,” said Dr. Patrick Conway, the chief medical officer at CMS. “The model aligns with how doctors and patients want to practice medicine.”

Under the five-year project, CMS will recruit primary care doctors into two separate payment tracks. Both will include a monthly payment to doctors for each Medicare beneficiary, but the amounts will vary.

The fee for doctors in the first track will average $15 a beneficiary; the physicians will also still be paid for each service they provide. The fee for the second track will average $28; doctors will receive lower fees than those in the first track for each service. (In both tracks, the monthly payments will be higher for patients with more complex health problems.)

The idea is that doctor groups will use the payments that aren’t tied to specific services to develop different ways to provide care, including telephone and video consultations. They might also use care managers to help patients with their medications and chronic illnesses.

The payment change “really allows them to move away from a visit-based, fee-for-service structure,” Conway said on a conference call with reporters.

Doctors who want to participate in the program have to commit to offering patients preventive care, support for chronic illnesses and 24-hour access to health care and health information.

Conway says CMS expects the second track, with lower fees for itemized services, to save Medicare about $2 billion over five years.

The project is based on a pilot program set up under the Affordable Care Act to test new ways to deliver and to pay for health care. The goals are to improving care and cut costs.

Fee-for-service systems encourage too much medical intervention, says Robert Berenson, a fellow at the Urban Institute who has written about medical payment systems. But, he adds, programs that only pay a flat fee for care and result in physicians or hospitals cutting back too much.

“This is an attempt to balance paying for visits at a reasonable rate and then reimbursing substantially for all the other activities that are necessary to provide care,” he says, such as phone calls and coordinating with other doctors.

The CMS program is similar to successful health care payment systems in Denmark and the Netherlands that combine fees for itemized services and flat fees per patient.

Berenson says, however, that CMS’s goal of including 20,000 doctors may be too high. CMS would be better off working out the glitches in the approach with a smaller number of physician practices before rolling it out more widely.

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