Category: Health Alerts

Are Insurers Prevailing Over Drug Makers?

Variety of Medicine in Pill BottlesLess than a year ago, it looked like health insurers were sending up trial balloons to see if they could get the federal government to regulate the research-based pharmaceutical industry as a utility. This was a reaction to high prices for new drugs like Sovaldi®. Today, the issue is being dialed back:

Express Scripts, the largest pharmacy benefits manager in the U.S. initially refused to put Sovaldi® on its formulary. Now, it looks like both sides might have come to a businesslike accommodation:

That taught Amgen and other drugmakers a lesson. Avoiding hostility with insurers and PBMs is now a paramount industry goal. “Every company is saying, ‘We don’t want to replicate what happened with Sovaldi. So let’s sit down and talk,’ ” says Steve Miller, chief medical officer of Express Scripts. “It’s very clear that it has changed the dynamic in the marketplace.” (Arlene Weintraub, “Big Pharma and Insurers Play Nice,” BloombergBusiness, May 28, 2015)

Insurers’ newfound power is extending beyond drugs for Hepatitis C and cancer:

Headwinds for Health Insurers as Obamacare Stumbles

Obamacare-protest-AP(A version of this Health Alert was published by Forbes).

You might think this headline is a gag, given how deeply health insurers are dug into Obamacare. Only a month ago, I wrote that health plans’ mastery of Obamacare poses challenge to repeal. Losses in Obamacare’s controversial exchanges are not yet apparent in the publicly listed insurers’ financial statements. However, exchanges comprise of a small (but not trivial) market of about 11 million people. Through 2016, health plans losing money in Obamacare can rely on taxpayers to help them out. After that, they are on their own.

Already, many plans are finding participation painful and increasing Obamacare premiums significantly for 2016. According to Louise Radnofsky of the Wall Street Journal,

In New Mexico, market leader Health Care Service Corp. is asking for an average jump of 51.6% in premiums for 2016. The biggest insurer in Tennessee, BlueCross BlueShield of Tennessee, has requested an average 36.3% increase. In Maryland, market leader CareFirst BlueCross BlueShield wants to raise rates 30.4% across its products. Moda Health, the largest insurer on the Oregon health exchange, seeks an average boost of around 25%.

All of them cite high medical costs incurred by people newly enrolled under the Affordable Care Act. (Louise Radnofsky, “Health Insurers Seek Healthy Rate Boosts,” Wall Street Journal, May 21, 2015)

Health insurers might not think the unravelling of Obamacare will hurt them too much. (Certainly, their investors do not). Nevertheless, these rate hikes increase the political risk of their participating in markets they do find profitable.

Price’s Empowering Patients First Act Gets Better with Age

220px-Tom_Price(A similar version of this Health Alert was published by Forbes.)

You’ve got to give credit to Congressman Tom Price, MD: He introduced his first post-Obamacare bill as early as 2009 and has reintroduced an updated version in every Congress since then. The latest Empowering Patients First Act (H.R. 2300), introduced this month, is the fourth iteration.

Many critics complain Republicans in Congress have taken too long to develop an alternative to Obamacare. However, President Obama is running the show until January 2017. It is responsible for Congressional Republicans to take all the time and space they need to develop their alternative for the next president’s consideration.

A fully baked repeal and replacement bill today would serve no purpose, while doing nothing until a president committed to patient-centered health reform takes office risks a confused mess of lobbyists’ priorities thrown together by politicians who barely know what they are doing – a Republican Obamacare, in other words.

The most important improvement is a universal tax credit, adjusted by age, to every American who chooses to buy individual health insurance: $1,200 for those aged 18 to 35, $2,100 for those between 35 and 50, $3,000 for those over 50 and $900 per child. Dr. Price’s previous bill had tax credits, which were not adjusted by age, but by income. Of course, Obamacare’s tax credits phase out by income, which causes very high effective marginal income tax rates at certain income thresholds.

Senator Cassidy Introduces King v. Burwell Alternative

Cassidy Official Headshot

(A version of this Health Alert was published by Forbes.)

Senator Bill Cassidy (R-LA) has introduced the Patient Freedom Act, in anticipation of the Supreme Court deciding for the plaintiffs in King v. Burwell, the lawsuit that seeks to force the administration to obey the law by not paying tax credits to health plans operating in states using a federal health insurance exchange (i.e.

Victory for the plaintiffs this summer would cause significant disruption in health insurance in the 34 to 37 states without their own exchanges because premiums for up to nine million people would increase significantly. Many would choose to drop coverage if and when they have to face paying full premium for their policies.

Congress must have an alternative to Obamacare ready because President Obama will immediately propose an amendment to change the law to accord with how he is executing it. That is: Let tax credits continue to flow through and just forget the money paid since January 2014 was illegal. It would be a very simple amendment – just a few sentences. The risk of Congress panicking and simply voting for that amendment, and finally surrendering to Obamacare, is unacceptable.

Americans have had their health coverage upended not only by the Affordable Care Act, but also by the allegedly illegal execution of the law by the administration. Congress has a duty to respond to a court victory with a new law. However, it has to be one that the president will sign, but will not leave the Republican-majority Congress’ fingerprints on Obamacare. This is a tricky needle to thread.

Dr. Cassidy believes he can achieve this by restoring federal funding to states that will lose tax credits, but freeing them from Obamacare. To be clear: If a state wants to restore the Obamacare tax credits, it would be free to do so by establishing a state-based exchange. However, state-based exchanges are a proven failure, which no responsible governor should institute in 2015. It would be an obvious choice to take Dr. Cassidy’s other option: Receive the federal dollars and use them in a way that empowers patients, rather than the federal government.

Medicare Fraud: Moratoria Miss the Mark

(A version of this Health Alert has been published by Forbes. A longer version of this Health Alert has been submitted to the U.S. House of Representatives Committee on Ways & Means, Subcommittee on Health, for the May 19, 2015 hearing titled, “Improving Competition in Medicare: Removing Moratoria and Expanding Access.)

Senior Man ThinkingMedicare fraud is a serious problem. The Medicare bureaucracy has the power to impose moratoria on new providers in geographic or program areas it deems susceptible to fraud. However, preventing new competitors from providing Medicare benefits reduces competition and cannot reduce fraud by incumbent providers. A better way would be to give Medicare beneficiaries a financial interest in combatting fraud.

Last February, the Government Accountability Office issued its annual report on federal programs that it identifies as high risk due to their greater vulnerabilities to fraud, waste, abuse, and mismanagement.  Medicare is a longstanding member of the list: “We designated Medicare as a high-risk program in 1990 due to its size, complexity, and susceptibility to mismanagement and improper payments”. A quarter of a century has gone by and Medicare is still on the list.

Successful Health IT Deals Are Obamacare Agnostic

(A version of this Health Alert was published by Forbes.)

Obamacare has definitely benefitted the health sector. My Forbes colleague Zina Moukheiber makes the case the Affordable Care Act (Obamacare) and the HITECH Act of 2009 (which channeled 30 billion taxpayer dollars into Electronic Health Records) deserve the credit (or blame) for the explosion of health information technology investments. That is undoubtedly true for traditional Electronic Health Record (EHR) providers like Cerner or Epic, which were boosted by the HITECH Act. In addition, the recently signed Medicare “doc fix” will likely ensure they continue raking in money for a while, because the law increases the EHR burden on physicians.

However, other successful new health IT ventures have prospects quite independent of Obamacare’s risky future. Rather, they appear robust in the face of a wide range of possible futures for U.S. health reform. Because health care is so dependent on government, it is not surprising that adoption of effective IT in health care has lagged behind other sectors, where suppliers have to rely on customers — not government — for revenue. Nevertheless, even a sector so politically protected from disruption as U.S. health care must eventually give way to change. Three examples show this change can come from different directions, despite Obamacare’s straightjacket.

Economic Growth Improved Health Coverage More Than Obamacare Did

05a941ec-8542-467a-97ad-fb1d4dc04d69_d1028errr(A version of this Health Alert was published by Forbes.)

The RAND Corporation has published a thorough analysis of Obamacare’s effect on health insurance that should have put an end to the Obamacare success narrative. Unfortunately, too many continue to confuse the effect of the delayed recovery with Obamacare. What the RAND study really shows is that employer-based benefits have been restored as jobs have started to come back.

The headline is that 172.7 million people, ages 18-64, are covered in 2015, versus only 155.8 million in 2013. The number of uninsured dropped by 16.9 million from 42.7 million to 25.8 million, falling from 21.5 percent to 13.0 percent of the population in that age group.

However, the RAND survey examines people insured or uninsured at a point in time, reporting changes from September 2013 through February 2015. The good news is the number of people with employer-based benefits increased by 8 million, from 111.9 million to 119.9 million (The total population is adjusted for death, aging and migration over the period.)  Digging deeper, it looks like this improvement would have been much higher, but for Obamacare.

Financing Breakthrough Medicine: Opportunities and Obstacles

(A version of this Health Alert was published by Forbes.)

Variety of Medicine in Pill BottlesResearchers at RAND Corporation have given a clear and precise description of a new financing mechanism for medical breakthroughs. The proposal would address a problem recognized about a year and a half ago, when healthcare payers launched high-profile complaints about the price of Sovaldi®, a miracle drug that effectively cures a strain of Hepatitis C.

In a nutshell, the problem is that Sovaldi® costs up to $84,000 per course, administered over a short period of 12 to 24 weeks. However, its benefits are lifelong: Hepatitis C patients live for decades with diseased livers. Transplantation is a $300,000 procedure followed by expensive drugs to prevent rejection of the new liver. However, payers with annual budgets do not have adequate incentives to pay in one year for savings that accrue over decades.

Sovaldi® was quickly followed by another Hepatitis C wonder drug, Harvoni®. More generally, the previous generation of blockbusters (now mostly generic) were targeted at chronic conditions like high blood cholesterol. Drugs designed to be taken regularly over many years demand a different pricing model than those designed to be taken only for a short period and lead to a clean cure.

Protecting Small Business from the Effects of Obamacare: Opportunities after King v. Burwell

(A version of this Health Alert was submitted as testimony to the hearing, “King v Burwell Supreme Court Case and Congressional Action that can be taken to Protect Small Businesses and Their Employees,” held on April 29, 2015, by the U.S. Senate Committee on Small Business and Entrepreneurship.)

A number of independent sources confirm Obamacare is harming small businesses. According to a paper published by the American Action Forum last September, the increased burden of regulations and rising health insurance premiums have reduced pay in firms with 20 to 99 employees by at least $22.6 billion annually, and has led to 350,000 job losses. Employees who kept their jobs have seen a decrease in pay of just under $1,000 annually.

Intellectual Property Rights for Global Health

(A version of this Health Alert was published by Forbes.)

patent-pendingRepublican congressional leaders are eager to give President Obama Trade Promotion Authority, or “Fast Track.” Proponents argue that Fast Track will break the logjam holding up important international trade agreements like the Trans Pacific Partnership (TPP), which includes countries as diverse as Australia, Canada, Peru and Vietnam.

Fast Track would allow the president to finalize the agreement before sending it to Congress for a straightforward up-or-down vote within a limited time. However, the likelihood of Fast Track resulting in TPP getting a “thumbs up” from Congress is limited by potential differences between the president and the congressional majority on intellectual property rights.

In a recent Wall Street Journal op-ed, Representative Paul Ryan (R-WI) and Senator Ted Cruz (R-TX) asserted that the administration must pursue a number of negotiating objectives, including “beefing up protections for U.S. intellectual property” if it wants Congress to approve the TPP.

It is uncertain the president is as committed to intellectual property as Mr. Ryan and Mr. Cruz hope, especially with respect to patents for medicines. Although the text of the TPP is not yet available to the public, the U.S. Trade Representative, who negotiates in the president’s name, insists that “TPP countries have agreed to reflect in the text a shared commitment to the Doha Declaration on TRIPS and Public Health.”

The 2001 Doha Declaration was an attempt to limit international trade agreements’ commitment to patent rights that were accepted in the World Trade Organization’s 1995 Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement. It insists that low and middle-income countries should have broad latitude to allow generic drug makers to make copies of patented medicines through a legal mechanism called “compulsory licensing.”