Aetna and Cigna inked deals last month with drug maker Novartis that offer the insurers rebates tied to how well a pricey new heart failure drug works to cut hospitalizations and deaths. If the $4,500-a-year drug meets targets, the rebate goes down. Doesn’t work so well? The insurers get a bigger payment.

In another approach, pharmacy benefit firm Express Scripts this year began paying drug makers a special negotiated rate for some cancer drugs. The goal is to reward the use of medicines that are most effective for certain cancers.

Dubbed “value-based pricing,” these are the kind of private-sector efforts the Obama administration hopes to borrow to rein in drug prices for Medicare.

The results could lead to a profound shift in how the Centers for Medicare & Medicaid Services spends $20 billion a year for drugs under Part B, which are those given through doctors’ offices and hospital outpatient centers. Many cancer treatments are provided that way, as are some treatments for rheumatoid arthritis, macular degeneration and other medical conditions.

Under a proposed rule, different methods would be tried in selected geographic areas over a five-year test period. Some of these experiments would begin this year, with others added in 2017. The proposal faces two months of public comment.

“The goal is to test whether alternative approaches will lead to better value,” said Patrick Conway, chief medical officer for CMS, in announcing the proposal March 8.

“There is no perfect payment system, they all have upsides and downsides,” said Dan Mendelson of consulting firm Avalere Health, who lauded Medicare for considering new ways to pay even as he cautioned that it must be done carefully. “What we don’t want to do is create a world where doctors only prescribe the cheapest stuff even if not in the interest of the patient.”

Here are four concepts the government is investigating:

Cut add-on fees for doctors and outpatient centers.

Many drugs covered under Medicare Part B are first purchased by a physician office or outpatient center, then dispensed to patients. Once billed, Medicare pays the health care provider the average sales price plus 6 percent for costs associated with the purchase and storage of the medications. For example, a doctor or clinic would receive an add-on fee of $6 when a $100 drug is purchased, or $300 for a $5,000 treatment.

In the private sector, that practice – called “buy and bill” – is being reduced.

Instead, specialty pharmacies, often connected with pharmacy benefit management companies, purchase the drugs and deliver them to doctors’ offices. The management companies, paid by insurers for their services, negotiate prices with drug makers.

But the buy-and-bill approach still dominates Medicare Part B.

Oncology specialists and other proponents say add-on fees are an important revenue source needed to keep such centers open. But critics fear they encourage use of higher-cost drugs when equally effective products could be had for less. They also say the fees reward larger practices and centers that buy drugs at advantageous prices.

To counter that possibility, CMS would change the current reimbursement formula, cutting the add-on portion to 2.5 percent of the average sales price.

Recent industry surveys show that larger practices have resisted moving away from buy and bill. Smaller ones with less bargaining clout favor that. Drug makers and some physician specialty groups oppose this part of Medicare’s proposal, but patient advocacy groups express mild support mixed with caution.

Level payments.

In the private sector, insurers sometimes set caps on payments for services patients generally can shop around for, such as a hip or knee replacement or colonoscopies. The California Public Employees Retirement System insurance plans, for example, saw that the cost of joint replacements varied widely among hospitals, then set a cap of $30,000 for a joint replacement. If patients chose hospitals that charged more, they had to pay the difference. The move was credited with saving millions in its first two years. Most of it came from the more-expensive hospitals lowering prices.

Medicare plans to apply this model to its payments to doctors and outpatient centers for some categories of medicines. For example, it might select one price for all injectable treatments for knee pain caused by osteoarthritis. The same rate would be paid, even when centers use higher-cost products.

The question is how to set that price. While asking for comments, Medicare suggested a variety of options, including the average price for drugs in a category, the price of the most clinically effective drug or a rate developed some other way.

Medicare’s proposal would apply to some prescription medications, but not procedures. And unlike most private-sector models, Medicare patients who get drugs above a benchmark cost could not be billed for the difference. The goal is not to encourage patients to change drugs. Instead, Medicare said it will test whether grouping similar drugs into a single payment rate will give physicians incentives to use “products that provide the most value for the patient.”

Tie payments to effectiveness.

Under Medicare’s proposal, drug makers would agree to offer rebates that link the final price of their products results in patients. Just what those results would be – improved health, fewer hospitalizations or some other measure – would be spelled out up front. There are more than 300 such “risk-sharing” agreements currently in place in the private sector, according to a University of Washington School of Pharmacy database.

In a related test, Medicare would adopt an approach similar to that used by Express Scripts, varying the amount of payment based on a patient’s condition. Drugs are often approved for more than one condition – say, two different types of cancers – but may be more effective at treating one than the other. Under the proposal, Medicare would pay a physician less when a drug is less effective on that cancer.

Skeptics say the process can be complex, and savings might be eaten up by administrative costs or disagreements over whether drugs have met effectiveness targets. Moreover, these private sector efforts are so new that detailed results are not yet available.

Meanwhile, a report out Tuesday from the Institute for Clinical and Economic Review looked at similar efforts internationally. It found that such “indication-specific” pricing holds some promise, but cautioned that administrative complexity and other challenges are significant.

Cut patients’ out-of-pocket costs.

To get people to take essential medications such as statins after a heart attack, some insurers, including Aetna, have reduced or eliminated patient copayments. Other insurers have experimented with similar incentives for other conditions, such as asthma or diabetes. They generally found that reduced payments make patients more likely to continue taking their medications.

In Medicare Part B, patients are responsible for 20 percent of the cost of their drugs unless they have a supplemental insurance policy that covers such copayments. Medicare proposes to cut or eliminate those payments for certain drugs considered most effective or valuable.

Lower copayments might affect what doctors prescribe and could encourage patients to stay on needed treatments. Medicare itself would make up the difference, picking up the tab for the reduced or eliminated patient payment.

Medicare is soliciting suggestions in its public comment phase as to which drugs might be the best candidates for the test.

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Spending on prescription drugs in the U.S. rose 5.2 percent in 2015, driven mostly by increased costs of expensive specialty medications to treat conditions such as rheumatoid arthritis, according to data from the largest manager of employers’ drug benefits.

Spending on specialty medications rose 18 percent, while spending on standard prescription drugs rose less than one percent, according to a new report by Express Scripts. The report is based on the prescription drug spending for the company’s 80 million covered patients.

The measure — called “drug trend” in pharmaceutical industry parlance — includes increases in the use of medications and price hikes.

Still, in the health care industry, an increase that’s more than quadruple the rate of inflation — 0.7 percent in 2015 — still counts as a bit of good news. Why? In 2014, drug spending increased more than 14 percent.

“In a year when all the headlines were about the escalating price of drugs, overall costs rose only 5.2 percent,” says Glen Stettin, Express Scripts’ chief innovation officer.

The overall boost in drug spending was moderated by patients switching to generic drugs from brand names, whose prices rose 16.2 percent.

Stettin attributed that shift to pharmacy benefit managers and insurers exerting more control over the drugs their customers can get. Express Scripts and other companies have been more willing to refuse coverage of expensive medications than in the past.

The company pointed to its initial refusal to pay for Gilead Sciences’ hepatitis C drugs, which were listed at more than $90,000 for a course of treatment. Instead, Express Scripts opted to cover an alternative treatment, Viekira Pak made by AbbVie, for which it negotiated a 50 percent discount. Express Scripts has said it saved as much as $1 billion with the deal.

Brand name drug prices are more than 2 1/2 times as high as they were in 2008, while generic prices have declined by about two-thirds.

For traditional pills, “total costs are flat as result of generic and effective price negotiation by payors,” says Ronny Gal, a pharmaceutial industry analyst at the investment firm Alliance Bernstein. “For specialty drugs, there are more drug introductions, at very high price per patient per year, and we still don’t have effective alternatives on the market.”

The report says the surge in spending on specialty drugs was caused in part by the 29 new medications that were approved by the Food and Drug Administration last year, including 19 cancer drugs that are being used on a large number of patients. The prices of older cancer drugs also rose, including for example, the price of Gleevec, which is used to treat adults with leukemia. It went up 19.3 percent last year, the report says.

But drugs for rheumatoid arthritis, psoriasis and other inflammatory illnesses sucked up the largest share of cash. Express Scripts says treatments for such conditions cost every person with insurance about $89 last year. Insurers use a measure known as “per member per year” to show how spending is spread across population of insured people.

Diabetes treatments dominated the spending on nonspecialty medications, the report shows, with spending rising 14 percent last year. Three of the top five traditional prescription drugs were diabetes medications — Lantus and Humalog, which are both forms of insulin, and Januvia, a pill that helps control blood sugar.

People who bought insurance through the exchanges created by the Affordable Care Act spent an average of $777 on medications last year, about 15 percent higher than the year before.

The big increase “may be due to patients in this population filling a previously unmet need,” according to the report.

Since the exchanges have only been in place for two full years, Stettin says this is the first time there was good information available about people covered by those policies.

The spending increase “is consistent with the belief that people in the exchange plans, people with chronic conditions, are getting medications for the first time,” he says.

The Express Scripts report takes into account the effect of rebates that the company negotiates with drugmakers without disclosing the details of the arrangements. Rebates are considered trade secrets.

Bruce Stuart, executive director of the Peter Lamy Center for Drug Therapy and Aging at the University of Maryland School of Pharmacy, says the data are different from what he would have expected based on trends in retail prices.

“I have no reason to doubt their numbers,” he tells Shots. “If they say that they are getting better deals, there’s no way to validate that. “

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Hillary Clinton apologized on Friday after she called the late Nancy Reagan a “very effective, low-key” advocate on HIV/AIDS awareness.

The Democratic presidential candidate now says she “misspoke” when she told MSNBC during Reagan’s funeral that the former first lady and her husband, President Ronald Reagan, pushed for recognition of the disease in the national community.

“It may be hard for your viewers to remember how difficult it was for people to talk about HIV-AIDS back in the 1980s. And because of both president and Mrs. Reagan — in particular Mrs. Reagan — we started a national conversation,” Clinton said.

“When before nobody would talk about it, nobody wanted to do anything about it, and that too is something that I really appreciate with her very effective, low-key advocacy, but it penetrated the public conscious, and people began to say, ‘Hey, we have to do something about this, too.'”

However, it wasn’t until 1987 that President Reagan gave his first speech on the topic, calling for more testing (but not making it mandatory). At that time, according to the New York Times, there had been nearly 36,000 cases of AIDS and nearly 21,000 deaths. Reagan has been roundly criticized for not doing enough to educate the public and draw attention to the growing HIV/AIDS epidemic during his administration.

Clinton released a statement hours later, apologizing for her remarks.

Even Clinton supporters were up in arms over her ill-phrased comments.

Former Clinton White House aide and Human Rights Campaign President Chad Griffin, whose organization has endorsed Clinton, tweeted the former first lady was “no hero” on the issue.

Other LGBT activists, such as columnist Dan Savage, also pushed back on social media.

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California Gov. Jerry Brown signed landmark legislation last October that would allow terminally ill people to request life-ending medication from their physicians.

But no one knew when the law would take effect, because of the unusual way in which the law was passed — in a legislative “extraordinary session” called by Brown. The bill could not go into effect until 90 days after that session adjourned.

The session closed Thursday, which means the End of Life Option Act will go into effect June 9.

“We’re glad to finally have arrived at this day where we have a date certain,” says Sen. Bill Monning, D-Carmel.

“It’s a historic achievement for California, and for a limited universe of people dealing with a terminal illness,” Monning says. “It could indeed be a transformative way of giving them the option of a compassionate end-of-life process.”

Disability-rights advocates fought hard last year against passage of the legislative act, and they continue to voice concern.

Marilyn Golden, senior policy analyst with the Disability Rights Education & Defense Fund, says it would be impossible to know, for example, if a depressed patient went to many doctors — who all denied the request for lethal medication — before finding one who agreed to write the prescription.

“We are looking ahead at measures to protect people from abuse,” Golden says, “and to explore and inform doctors, nurses and pharmacists that they don’t have to participate.”

As written, the law requires two doctors to agree, before prescribing the drugs, that a patient has six months or less to live. Patients must be able to swallow the medication themselves and must affirm in writing, 48 hours before taking the medication, that they will do so.

California is the fifth state to permit this option at the end of life. It joins Vermont, Oregon, Washington and Montana.

Across the state, some patients with advanced cancer welcomed the news.

“It gives me a great peace of mind to know that I will not be forced to die slowly and painfully,” says Elizabeth Wallner, in a release from Compassion & Choices, an aid-in-dying advocacy group. Wallner, 52, of Sacramento, is a single mother with stage 4 colon cancer that has spread to her liver and lungs.

“It gives great comfort to know that the agonizingly traumatic image of me suffering will not be my family’s last memory of me,” she says.

Monning says he’s grateful to people who worked for passage of the law, some in their final days:

• Brittany Maynard, an Orange County, Calif., woman with brain cancer, moved to Oregon to take advantage of laws there that allowed her to get lethal medication. Before she died in 2014, she recorded a video that was shown during hearings on the End of Life Option Act in Sacramento.
• Jennifer Glass, of San Mateo, Calif., helped to launch the campaign in 2014, then died of lung cancer last year.
• Christy O’Donnell, 47, of Los Angeles, died of lung cancer last month.

“I really believe,” Monning says, “we use today to mark and dedicate the memory of some true champions.”

This story was produced by member station KQED’s blog State of Health.

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Medicare is going to test new ways to reimburse doctors for medications, in hopes they’ll choose less expensive drugs.

The plan would alter Medicare Part B, which pays for medicines administered in doctors offices or outpatient hospital clinics — to eliminate incentives for doctors to use the most expensive drugs.

The changes would have an outsize effect on cancer doctors and clinics. Medicare Part B shelled out about $7.8 billion on cancer drugs in 2014, or 42 percent of its total spending on drugs that year.

The program now reimburses the doctors or clinics for the cost of the medication plus a 6 percent fee. That means doctors and hospitals earn more money when they use pricier drugs.

As it is now, Dr. Patrick Conway, chief medical officer for the Centers for Medicare and Medicaid Services, called the reimbursement structure “perverse.”

“We’ve heard from oncologists who feel pressure from their health system to pick higher cost drugs even when they are not appropriate for a patient,” he said in a conference call with reporters on Tuesday.

The agency plans to test a reimbursement formula that would pay the cost of the drug, plus a 2.5 percent surcharge and a flat fee of $16.80.

Under the current system, a doctor earns just 60 cents for administering a $10 medication. An equivalent drug that cots $1,000, however, would bring in $60. Under the proposed formula, the cheaper drug in this example would generate a payment of $16.93 and the second one $41.80, according to CMS.

CMS officials say that change would mostly eliminate the incentive to choose a high priced drug over one that may be more appropriate. Medicare Part B spent about $20 billion on outpatient medicines last year.

“We’re trying to align the incentives to what’s best for patients and doctors,” Conway said.

The Medicare Part B plan would also reduce or eliminate the share of the drugs’ costs that patients have to pay.

Dr. Peter Bach, director of The Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center, says research shows doctors prescribe higher priced drugs when they bring in more profit.

“It is refreshing to see Medicare move towards an experiment where they pay for drugs using a flat fee reimbursement, where what doctors and hospitals make is related to giving the drug, not how much it costs,” Bach said in a statement to Shots.

But other cancer doctors aren’t so thrilled.

The American Society of Clinical Oncology opposes the CMS proposal. The proposal could have a major effect on oncologists because many cancer patients receive their chemotherapy treatments in doctors offices or clinics.

“It is inappropriate for CMS to manipulate choice of treatment for cancer patients using heavy-handed reimbursement techniques,” said ASCO CEO Allen Lichter in a statement posted on the physician group’s website.

ASCO, the Pharmaceutical Research and Manufacturers Association and about 100 other physician and advocacy groups sent a letter to Health and Human Services Secretary Sylvia Burwell last week opposing the payment changes.

“We believe that this type of initiative, implemented without sufficient stakeholder input, will adversely affect the care and treatment of Medicare patients with complex conditions,” the letter said.

The agency plans to field test the new reimbursement formula, as well as a handful of others ideas, in different regions of the country starting later this year. CMS will then compare the results to determine which changes are effective at reducing drug spending.

CMS is also planning to test a handful of so-called value-based pricing ideas. The first would pay for drugs according to how well they work.

For example, if a cancer medication is very effective in eliminating a specific tumor, but is also used on a second, different condition with less success, Medicare will pay less when it is used for the second condition than the first. Sloan Kettering’s Bach, who served as an adviser to CMS on cancer policy in 2005 and 2006, argued for varying payments for drugs this way in a 2014 paper published in JAMA, the Journal of the American Medical Association. The approach is called indication-based pricing.

The agency also plans to work with drugmakers to link prices to patient outcomes, perhaps paying less for medications when patients end up being admitted to a hospital.

Private insurers and pharmacy benefit managers have been testing similar ideas.

Cigna last month said it had agreed with drugmaker Novartis on a pay-for-performance deal for the heart failure drug Entresto. Under the agreement, Cigna will pay less if patients taking the medication are hospitalized for heart failure.

And Express Scripts, the biggest manager of pharmacy benefits, says it’s working with cancer drug manufacturers to pay indication-based prices that tie cost to how well the drugs perform.

The CMS proposal is open for public comment until May 9. Conway said the field tests will begin after the comment period is complete.

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The Dutch dentist was initially welcomed to the rural French town of Chateau-Chinon, which had been without a dental care provider for two years.

Then the horror stories started.

Now Jacobus Van Nierop is standing trial on charges of aggravated assault and insurance fraud, after scores of patients said he caused them injuries since arriving in town in 2008, Agence France-Presse reports. If found guilty, he could be sentenced to as many as 10 years in prison and fined up to $165,000, according to AFP.

The Associated Press has this account from a woman who said she was treated by the “Dentist of Horror,” as he has been dubbed in French media:

“One patient, Sylviane Boulesteix, has said she was unexpectedly summoned to the dental office in central-eastern France in May 2012. Without warning, the dentist pulled eight of her teeth out and immediately fixed dentures on her raw gums. For three hours, the elderly woman says she sat gushing blood.

“In the following days, she says Van Nierop refused to relieve her pain. A judicial expert later described a ‘cruel and perverse’ man whose incompetence made Boulesteix lose several health teeth, go through trauma and suffer irreversible damage to her mouth.”

According to AFP, some patients said they would wake to find notes asking them to come back for further treatment:

” ‘Every time, he would give us what he called ‘a little prick’ and we were asleep, knocked out,’ said Nicole Martin, a retired teacher who lost several teeth to abscesses caused by the horrific operations.

” ‘When it was over, we would find a Post-it note saying to come back for an appointment the next day or the day after,’ she added.”

Martin set up a victims’ group to press charges that grew to more than 120 members, according to AFP.

Van Nierop, 51, has said he “suffers from ‘psychological problems’ including gender identity issues and suicidal tendencies,” AFP reports.

He had a blanket over his head when he arrived today at the courthouse in the nearby city of Nevers, AFP reports. He has been incarcerated for the past 18 months.

“What my clients and I expect are explanations,” Charles Joseph-Oudin, who is representing some of the victims, tells AFP. “To understand how Mr. Van Nierop could have acted in such a way for so long, how things could have become so bad. Today, we have no explanations. Understanding is the first step of the victims’ healing process.”

According to the AP, the defendant has “refused to answer questions during the investigation, saying only that the oral health of the people in the region was ‘deplorable.’ “

Van Nierop was arrested in 2013 but was released and then fled to Canada, AFP reports. He was found in New Brunswick in 2014, extradited to the Netherlands and then sent back to France to stand trial.

According to Vice, the Van Nierop case highlights the problem of France’s 192 ” ‘medical deserts’ — areas where the authorities have failed to find successors for retiring doctors.” Vice says some 2.5 million people live in these areas.

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Depression prompts people to make about 8 million doctors’ appointments a year, and more than half are with primary care physicians. A study suggests those doctors often fall short in treating depression because of insurance issues, time constraints and other factors.

More often than not, primary care doctors fail to teach patients how to manage their care and don’t follow up to see how they’re doing, according to the study, which was published Monday in Health Affairs. Those are considered effective tactics for treating chronic illnesses.

“The approach to depression should be like that of other chronic diseases,” said Dr. Harold Pincus, vice chair of psychiatry at Columbia University’s College of Physicians and Surgeons and one of the study’s co-authors. But “by and large, primary care practices don’t have the infrastructure or haven’t chosen to implement those practices for depression.”

Most people with depression seek help from their primary care doctors, the study notes. That can be because patients often face shortages and limitations of access to specialty mental health care, including lack of insurance coverage, the authors write. Plus there’s stigma: Patients sometimes feel nervous or ashamed to see a mental health specialist, according to the authors.

Meanwhile, physicians and researchers have increasingly been calling for mental health conditions such as depression and anxiety to be treated like physical illnesses. Historically, those have been handled separately and not always with the same attention and care as things like high blood pressure and heart disease.

The researchers compared strategies for treating depression with those used for asthma, diabetes and congestive heart failure. They surveyed more than 1,000 primary care practices across the country to determine how often doctors’ offices used five steps considered best practices to manage chronic conditions. These include employing nurse care managers; keeping a registry of all patients with a condition that requires regular follow-up; reminding patients to comply with their treatment regimens; teaching them about their illnesses; and giving doctors feedback. Those approaches track with guidelines from the Department of Health and Human Services Agency for Healthcare Research and Quality.

On average, the practices surveyed were least likely to follow those protocols when treating depression. About a third kept registries of patients with depression; the other steps were less commonly used. Less than 10 percent of practices, for instance, reminded patients about their treatments or taught them about the condition.

Doctors were most likely to use those best practices for treating diabetes. Most practices followed at least one of the strategies for managing chronic illness.

Effectively treating any chronic illness requires working with patients beyond single visits, said Dr. Tara Bishop, an associate professor of health care policy and research at Weill Cornell Medical College and the study’s main author. For depression, that means things like following up to see if medication is working or if a dose should be adjusted.

“When we treat high blood pressure, the blood pressure may start at 150 over 95, and then it’s monitored over time until it gets to a level that’s being aimed for,” said Dr. Jeffrey Borenstein, president of the Brain and Behavior Research Foundation. The foundation funds mental health research but was not involved with this study. “If somebody has depression, their symptoms need to be monitored until it gets to a level that the depression is lifted.”

Depression can contribute to other health problems, like pulmonary disease or diabetes, Bishop said. It can make people less productive at work, or less able to have healthy relationships. Unchecked, it can result in suicide.

“If we actually treat depression as a chronic illness and use the level of tools we’re using for diabetes, then we’ll be able to better treat patients — and help them live healthier lives and more productive lives,” she said.

The study didn’t delve into why the gap exists between depression and other medical conditions. But the authors pointed to potential explanations. One is that there’s been a decades-long push to improve how doctors treat diabetes — an effort that has almost been “the poster child” for how to monitor and treat a long-term illness, Pincus said.

And there are time pressures. Diagnosing a patient with depression and following up regularly can take more time than a diabetes blood test or insulin check. Cramming that into a 15-minute visit can get difficult, Bishop said, especially as doctors are increasingly asked to do more with less time.

Plus, she said, while there’s been an effort nationally for the medical profession to better address mental wellness, individual physicians may still struggle.

“It’s almost like a subconscious divide of mental health issues versus physical health issues,” she said.

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