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Drug Discount Plan Actually Lifts Costs

A new study by the Pacific Research Institute finds that a program to give discounted prescription drugs to poor Americans is riddled with abuse, has created a perverse incentive for providers to profit instead of effectively serve the poor and is hurting overall health care quality.

“The 340B Program is a well-intended effort to give America’s most vulnerable populations access to discounted prescriptions,” said Dr. Wayne Winegarden, author of the new study. “Over the years, it has evolved into a complicated mess, rife with abuse, and has encouraged health providers to put profitmaking ahead of serving the poor. Our study shows that Congress must reform 340B, so we can get back to the original mission — ensuring America’s poor have access to life-saving prescription drugs at a low cost.”

Under the 340B Program, Medicaid prescription drug discounts were extended to healthcare providers that largely serve the poor. Participating drug manufacturers provide 20% to 50% discounts for drug costs sold to qualifying clinics, hospitals and pharmacies.

See also: New Way to Lower Healthcare Costs  

In “Addressing the Problems of Abuse in the 340B Drug Pricing Program,” Winegarden found that:

  • With little guidance from the federal government, there is no requirement that hospitals provide the discounted drugs solely to people who are truly in need.
  • In practice, hospitals can prescribe discounted medicines purchased through the 340B Program to any of their patients, including those who have insurance and can pay full price – and pocket the difference. Many hospitals have taken advantage of this loophole and government-guaranteed profits.
  • Neglecting the program’s mission to serve the most vulnerable, more 340B hospitals have been set up in recent years to serve higher-income patients and secure more profit.
  • Exploiting this profit motive, the program encourages participating hospitals to prescribe high-priced medicines, as discounts are based on a share of the drug’s costs. They earn more revenue when prescribing the most expensive drug possible.
  • The program has also led to a rising trend of healthcare consolidation, as independent practices are not eligible for 340B discounts and are losing patients. In recent years, hospitals have increasingly acquired independent practices and set them up as hospital outpatient departments.

Winegarden concludes that the program has resulted in serious unintended consequences that are affecting the quality of the overall health care system, and must be addressed by policymakers in Washington. He argues that Congress should consider enacting reforms to the 340B program to ensure that the program solely benefits uninsured and low-income patients, while improving both oversight and administration.

See also: A Road Map for Health Insurance  

Watch PRI’s New Animated Video: Why Did The Government Swallow the 340B Fly?

Health Insurer Trickery Straps ER Patients

Millions of emergency room patients could face financial ruin — even if they deliberately seek care at hospitals covered by their insurers.

That’s the disturbing finding of a new study published in the New England Journal of Medicine. Conducted by two Yale professors, the study shows that one in five ER visits involve doctors who are not in the same insurance network as their hospitals. The patients treated by those out-of-network physicians are forced to pay for a portion of their care out-of-pocket. The average out-of-network ER charge is $600.

A bill that size spells disaster for many patients. About half of Americans wouldn’t be able to cover a surprise $400 bill without selling something or borrowing money.

It’s a travesty that, in the midst of medical emergencies, people who specifically head to hospitals covered by their insurance plans are still getting hit with huge bills. Unfortunately, these out-of-network ER charges are just the latest tactic that health insurers have devised to shift costs onto patients.

See also: Key Misconceptions on Health Insurance  

The contracts that hospitals establish with health insurers typically don’t cover ER doctors. Those physicians have to negotiate with insurers directly. Many insurers decide ER physicians’ fees are too high and cut them out of coverage networks.

Patients hardly ever suspect that the ER doctors at in-network hospitals could be out-of-network. Take Candice Butcher, a Salem, Va., mom who rushed her two-year-old son Logan to the ER after he cut his head on a dining room chair. Candice made sure to take her son to a hospital covered by her insurance. And Logan’s treatment — cleaning and suturing the wound — was relatively straightforward. So she was stunned when she got the news: Her out-of-network ER doctor was charging her $750.

Or consider Craig Hopper, who got hit with a $937 bill by his Austin, Texas, hospital for ER treatment for a sports injury. “It never occurred to me that the first line of defense … could be out of the network,” says his wife, Jennifer. “In-network means we just get the building? I thought the doctor came with the ER.”

The Hoppers are in a particularly unfriendly state. Fully half of the Texas hospitals covered by the state’s main private insurers have zero — yes, zero — in-network ER physicians, according to work from the Center for Public Policy Priorities. Emergency patients all are getting hit with huge, unexpected bills. “There’s little consumers can do to prevent it and protect themselves” says Stacey Pogue, an analyst at the CPPP.

This out-of-network trickery is largely a response to Obamacare’s crippling mandates on insurers. The outgoing president’s signature legislative accomplishment straps coverage providers with invasive, costly regulations, squeezing bottom lines and forcing insurers to cut expenses and boost revenues anyway they can.

The obvious insurer response is to ratchet up premiums. The average premium for plans available on the Obamacare exchanges in 2017 jumped 22% over the 2016 rates.

But insurers also have resorted to subtler tactics.

That includes raising deductibles, the amount that customers have to spend out-of-pocket before benefits kick in. The average health insurance deductible for individual plans shot up 42% in Obamacare’s first year — and that figure continues to climb. Today, the average deductible for the “bronze” plans in the exchanges — the cheapest possible coverage — is a whopping $6,000 for individuals and $12,000 for families.

See also: The Basic Problem for Health Insurance  

Insurers also are restricting their official networks — limiting the doctors and hospitals that their customers can use. This strategy enhances insurer bargaining power in negotiations with healthcare providers, but it hurts patients by denying them access to convenient care. People get stuck traveling long distances to unfamiliar caregivers for vital treatments. McKinsey calculates that about four in 10 exchange plans exclude more than 70% of hospitals in the plan’s coverage area, and a further three in 10 plans exclude at least 30% of hospitals.

Insurers are feeling the squeeze under Obamacare, and they’re resorting to devious tactics to cut costs. Too often, that straps patients with staggering, unforeseeable medical bills. That should all change when Obamacare is repealed and replaced — which is why lawmakers must move with all due haste in the new year.

It’s Time to Embrace Telemedicine

At hospitals and clinics across New Jersey, thousands of new doctors could soon be on call — literally.

In Trenton, lawmakers are considering two bills that would enable doctors and patients to skip the office visit and conduct appointments using video-conferencing tools like Skype.

They’re right to embrace this kind of technology. The increasing use of “telemedicine” promises to improve patients’ access to doctors and slash healthcare costs.

Virtual medicine makes it a lot easier — and cheaper — to see the doctor. By first consulting with a patient by video, doctors and nurses can determine whether a costly in-person trip to the emergency room or to the doctor’s office is necessary — or whether two aspirin and plenty of rest will do.

See Also: 5 Questions on Telemedicine Coverage

For patients who end up in the hospital, telemedicine can facilitate faster and cheaper convalescence.

Consider a patient recovering from heart surgery. His doctor may want to continuously monitor his blood pressure and pulse. Telemedicine can accomplish that remotely and automatically. That saves the patient the trip and the doctor the time measuring those vital signs.

Telemedicine can also save money. Take a program called Health Buddy, which asks patients daily, tailored questions about their health through a handheld device at home. After reviewing the answers, doctors know when and how to offer care. A study published in Health Affairs found that Health Buddy reduced Medicare spending by as much as 13% per patient.

Other programs offer patients hospital-level care inside their own homes. Doctors and nurses visit one to two times a day while other providers monitor vital signs remotely. Participating patients often require fewer tests and less time under observation, so these “hospital at home” programs can cut costs by 19% compared with conventional inpatient care.

Telemedicine can also alleviate the mental stress of being sick. Someone diagnosed with heart disease, for instance, may understandably worry about his prognosis. That can take a toll on his physical health and jeopardize his chances of recovery.

Healthcare providers can ease these concerns with remote counseling. One such telecounseling program helped cardiovascular disease patients deal with anxiety and depression through video sessions. Over six months, the program reduced hospital admissions by 38% compared with a control group, according to a report published by the American Journal of Managed Care.

Telemedicine can improve healthcare providers’ ability to communicate with one another, too. By connecting doctors with health workers in emergency rooms, for example, telemedicine can prevent 850,000 unnecessary transfers between ERs each year. The savings? More than $530 million.

There’s even evidence that telemedicine can offer care that’s superior to inpatient care. Take Teladoc, a videoconferencing technology that allows patients to consult with a doctor around the clock. According to one study, those who used Teladoc were less likely to need to see the doctor again for the same illness than patients who actually went to the doctor’s office.

Finally, telemedicine may also decrease wait times. American Well, for example, offers a mobile app that allows patients to send out a request for a doctor — much like one does for an Uber — and the first to respond does the consultation via videoconferencing. Over the last three years, the average wait time has been three minutes.

See Also: Questions to Ask on Telemedicine Risk

New Jersey’s lawmakers seem to be paying attention to all this research, particularly Sens. Joe Vitale, D-Middlesex, and Shirley Turner, D-Mercer, and Assembly representatives Pamela Lampitt, D-Burlington-Camden, and Daniel Benson, D-Mercer-Middlesex. One of Lampitt’s bills (A-2668) would establish parity for insurance coverage of telemedicine with conventional in-patient care. A bill sponsored by Vitale (S-291) would allow patients to seek telemedicine services from out-of-state doctors. This latter measure would also permit New Jersey’s Medicaid program to reimburse for telemedicine.

Thus far, the Garden State has been slow to adopt telemedicine. Insurers in many other states already cover it. The American Telemedicine Association recently gave New Jersey six Fs on crucial telemedicine issues, including allowing for the reimbursement of remote patient monitoring and videoconferencing.

State leaders now have the chance to raise those grades. Telemedicine controls costs and improves patients’ health. It’s time for New Jersey to take advantage.

Healthcare Costs: We’ve Had Enough!

Healthcare is consuming an ever-greater share of corporate America’s balance sheet. According to the latest Kaiser Family Foundation survey, today’s employers spend, on average, $12,591 for family coverage—a 54% increase since 2005.

Some companies have finally had enough. Twenty of America’s largest corporations—including American Express, Coca-Cola and Verizon—recently formed a coalition called the Health Transformation Alliance. They’re planning to pool their four million employees’ healthcare data to figure out what’s working and what’s a waste of money.

Eventually, they could leverage their collective purchasing power to negotiate better deals with healthcare providers.

It’s a worthwhile experiment. The government has largely failed to rein in spiraling healthcare costs; in fact, by over-regulating the healthcare marketplace, it’s largely made the problem worse.

The private sector will have to take matters into its own hands and find ways to creatively deploy market forces to its benefit.

Collectively, U.S. employers provide health coverage to about 170 million Americans. Because many pay part—if not all—of their workers’ premiums, they’ve borne the brunt of the upward march of healthcare costs. According to the Kaiser Family Foundation, premiums for employer-based family insurance have increased 27% over the last five years, and 61% over the last 10.

Unfortunately, this growth won’t slow any time soon. The Congressional Budget Office estimates that average premiums for employer-based family coverage will reach $24,500 in 2025—a 60% increase over premiums today.

Understandably, companies are desperate to find ways to curb their healthcare spending.

Last year, one of every three employers reported increasing cost-sharing for employees, through higher deductibles or co-payments. Another 15% said they cut worker hours to avoid falling afoul of Obamacare’s employer mandate, which requires firms to provide health insurance to anyone working 30 or more hours a week.

See Also: Radical Approach on Healthcare Crisis

But shifting costs elsewhere simply masks employers’ health-cost problem. They’ll have to address inefficiencies in the way healthcare is delivered to bring about savings that will actually stick.

The Health Transformation Alliance sees three primary ways to do so.

First, companies will have to mine their healthcare data for insight, just as they analyze the numbers for sales, operations and other core business functions.

The Alliance will examine de-identified data on employees’ health spending and outcomes. The hope is to determine which providers are delivering the best care at the lowest cost and to then direct workers toward these high-performing providers.

The U.S. healthcare sector today is awash with ambiguity and a lack of transparency. A knee replacement can cost $50,000 at one hospital but $30,000 at another. Two hospitals may offer the same price on a procedure, but one may have a higher rate of infection.

Such differences matter. According to a 2013 report in the Journal of the American Medical Association, an infection can add, on average, $39,000 to a surgery’s price tag.

Second, employers will have to use their combined buying power to secure better deals on healthcare. Tevi Troy, the CEO of the American Health Policy Institute, the organizing force behind the Alliance, said, “If you brought together multiple employers, you would have more leverage, more covered lives, more coverage throughout the country in terms of regional scope.”

In other words, there’s safety—and potentially lower healthcare costs—in numbers.

Third, employers will have to educate their workers about how they can secure better care at lower costs.

Most consumers are clueless about where they should seek healthcare. They may welcome a gentle nudge from their employer toward a high-quality, low-cost clinic or provider. If it saves their bosses some money, all the better.

See Also: What Should Prescriptions Cost?

And as the Alliance hopes to prove, it’s a lot easier to borrow another company’s successful strategy for executing those nudges than to create one from scratch. An educational campaign that resonates with Verizon’s 178,000 employees, for instance, may do just the same with IBM’s 300-some-thousand staffers.

As Marc Reed, chief administrative officer of Verizon, explained, “What we’re trying to do is to make this sustainable so that kind of coverage can continue.”

Corporate America has been saying for years it cannot afford the healthcare status quo, with costs rising ceaselessly. But if employers use their healthcare data wisely—and capitalize on their collective bargaining power—they may discover that salvation from their health-cost woes lies within.

Little-Known Loophole Inflates Health Costs

The rising cost of insurance is putting a squeeze on American families. And this problem could get even worse if lawmakers don’t fix a little-known federal drug program called “340B.”

Created by Congress in 1992, 340B was originally intended to provide low-income people access to needed medications. This program allows hospitals, clinics and other healthcare providers
serving large numbers of poor and uninsured patients to buy drugs at a deep discount. The idea was that these facilities would pass along those savings to their patients.

But 340B is not working as intended. Instead, it’s being manipulated by hospital systems to increase profits. It isn’t helping the poor. And this exploitation is driving up health insurance costs for all Americans.

Price Disparity

The program’s major flaw is it doesn’t actually require healthcare providers to pass along those drug discounts to low-income patients. Participating facilities are free to buy huge volumes of cheap medicines and then sell them at full price to insured patients — and pocket the difference.

That’s exactly what many participants are doing. Duke University Hospital has accumulated $280 million in profits from 340B over the last five years. The drug chain Walgreens is projected to make a quarter of a billion dollars off the program over the next half decade.

Established hospital systems have increased their revenue from 340B by buying up specialty clinics. These smaller practices often use a high volume of expensive drugs. By acquiring these clinics, hospitals can purchase even more discounted medicines through 340B and further boost profits.

In 2012, hospitals enrolled more clinics in 340B than in the previous 20 years combined. A new University of Chicago study shows that most of these clinics are located in relatively affluent areas. In other words, they aren’t even pretending to serve the low-income and uninsured populations 340B was intended to help.

Unfortunately, lawmakers have not responded to these abuses by fixing 340B’s structural flaw. Instead, they’ve blindly expanded the program. Back in the early ’90s, just 90 health care facilities participated in 340B. Today, that figure is more than 2,000.

The acquisition of smaller clinics, precipitated by 340B, will seriously drive up insurance costs for average Americans. Large, established health providers tend to charge more than smaller, independent clinics. And insurance companies respond to these higher treatment expenses by raising premiums.

Indeed, a study from three Duke University researchers published in the October issue of the journal Health Affairs looked into the price disparity between key cancer drugs provided at both corporate hospitals and clinics. Researchers noted that, between 2005 and 2011, the proportion of cancer services administered at independent clinics dropped by 90%. They found that the price gap between the two settings can be as much as 50%.

Pharmaceutical manufacturers are now incurring heavy losses from 340B abuse. In 2010, this program cost the industry $6 billion. By 2016, that’s expected to more than double, to $13 billion. Simple economics forces firms to compensate for losses by raising their prices, leading to higher medical expenses for average patients.

Noble Purpose

340B has a noble purpose. But it’s not fulfilling its mission to provide vulnerable patients with discounted drugs. Instead, 340B is being exploited by rich hospitals to boost their bottom lines. And these abuses are leading to higher insurance costs for everyone else.