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Wither healthcare reform when one host extends a hand and the other the finger?

House Energy and Commerce Chairman Henry Waxman (D, CA) said this morning that the $80 billion deal reached last month by PhRMA with Senate Finance Chairman Max Baucus does not have House support and is losing the White House's backing. "The White House is not bound. They told us they're not bound to that agreement," Waxman said at a National Journal breakfast. "We're certainly not bound by that agreement."

I suppose that goes for hospitals as well -- and doctors.

And what about Teddy?

In response to a question from Senator Gregg in the HELP hearing, CBO Director Douglas Elmendorf just expressed strong skepticism that the Kennedy/Dodd bill would bend the cost curve for health care.  In fact, quite the opposite.  Elmendorf said, “This bill will add substantially to the long-term spending burden for health care on the Federal government.”

This appears to pose a significant problem since President Obama said in his most recent press conference,  “And I've said very clearly: If any bill arrives from Congress that is not controlling costs, that's not a bill I can support.”

No laughing matter.

House majority leader Steny Hoyer (D, MD) said Tuesday that the healthcare reform bill now pending in Congress would garner very few votes if lawmakers actually had to read the entire bill before voting on it.

"If every member pledged to not vote for it if they hadn't read it in its entirely, I think we would have very few votes."

Mr. Hoyer was responding to a question on whether he supported a pledge that asks members of the Congress to read the entire bill before voting on it and also make the full text of the bill available to the public for 72 hours before a vote.

In fact, Hoyer found the idea of the pledge humorous, laughing as he responded to the question. “I’m laughing because I don’t know how long this bill is going to be, but it’s going to be a very long bill,” he said.

Cliff Notes.  Not acceptable in high school.  Not acceptable in Congress.  Not acceptable for healthcare reform.

Americans hear a lot about the UK and Canada, so much that it sometimes seems like there aren’t any other countries out there. Sure, others pop up from time to time, often as mere entries on a list of nations that have single payer health care or, more ambiguously if more correctly, “national health care,” but real discussion of their ins and outs is thin.
 
However, given the broad agreement that uninsured Americans should be covered and the leeriness of many about letting government run health care, there is a lot we can learn from a country that has made use of both market competition and government regulation to produce a system where costs are under control, wait times and rationing are prevented, and coverage is universal: the Netherlands.
 
Presently, the Netherlands achieves universal coverage with a mandate that all resident buy health coverage. Those who don’t, receive a fine. To make sure everyone is financially able to participate, subsidies are given on a sliding scale up to a fairly high income threshold. Nonetheless, enforcement of the mandate has been limited and approximately 1.5 to 2 percent of people have not bought coverage.Another 1.5 percent joined an insurer but failed to pay their premiums.
 
The government sets the requirements for a basic (but quite comprehensive) health insurance package that is open too everyone, regardless of age, sex, or current health status. The companies can offer different types of further coverage on top of the basic plan and can take into account age and other variables on these packages. Competition is vital and insurers have come up with a variety of creative strategies to lure customers, reduce costs, and improve health. Premiums are also actually lower than anticipated, largely due to competition among insurers.
 
To compensate for the fact that the basic package is open to everyone at the same cost, insurers with more sick members get government funds to make up the cost difference. However, only 30 conditions are on the list used to pay out compensation, leaving some companies carrying increased costs and some patients with difficulty getting coverage above the basic plan.
 
Health coverage in the Netherlands is still mostly obtained through work. Each person pays an “income-related contribution,” 7.2 percent of income up to €31,200 for 2008, which is reimbursed by their workplace. On top of this, the Dutch pay a premium per adult (children are free) and taxes that are used to subsidize people who cannot afford health insurance on their own.  
 
Health care is cheaper than in many countries, a basic package cost around €1,100 per adult in 2008 with a deductible of €150. Those willing to accept higher deductibles can get lower premiums. But one must beware that around 90 percent of people in the Netherlands opt to get further coverage so the actual typical cost is higher. Some companies also give higher reimbursement for in-network doctors than out-of-network ones.
 
Despite its successes, many doctors in the Netherlands dislike the new system. They feel that bureaucrats are watching over their shoulders and fear that there will be pressure to use cheaper treatments. Indeed, some insurers encourage the use of generics over brand name medication and given doctors bonuses for complying. Prices are set partially through negotiation between doctors and insurers but only about 20 percent of procedures are subject to such negotiation. Generic drug manufacturers have to accept a 40 percent price cut at the introduction of the new system.
 
A number of people in the US have seen the Netherlands as an interesting model for American health care and November 2007 from US Health and Human Services Secretary Michael Leavitt traveled there and spoke with a variety of people, from leaders to patients, about the health system there. The HHS said, however, that it “would not endorse a system like the Netherlands.”
 
As a warning, however, the system in the Netherlands is quite new; the law creating it was passed at the end of 2004 and was implemented only at the beginning of 2006. So while the news so far is largely good, we need to wait a while before more concrete conclusions can safely be drawn.

Canadian Re

  • 07.08.2009

In all the tumult over healthcare reform, we haven’t heard that much about “drugs from Canada.”  There are clearly bigger fish to fry. And (not to go metaphor-crazy) those in the frying pan know just what I mean.

Witness PhRMA panjandrum Billy Tauzin, who, according to a report in today’s edition of the Wall Street Journal told a White House meeting Tuesday that “if the larger health-care bill passes, the cost savings will be big enough to make reimportation unnecessary.”

A White House official confirmed the meeting took place and said, "As a political matter there may be less pressure" to pursue reimportation after a health bill passes.

(Meanwhile, Bernie Sanders -- the Senator from Ben & Jerry's -- disagrees with "any move to drop the importation idea."  Yawn.) 

Two things.

First, it’s amazing that this issue is even being mentioned. Why? Because, according to the Congressional Budget Office, importing drugs would lower costs by less than 1% -- decimal dust when you compare it to the $80 billion “deal.” And that’s not even factoring in the significant safety questions.

Second, there is no such thing as “reimportation.” The various schemes under discussion (most recently Senator McCain’s amendment that got voted down in committee the other day) call for the importation of drugs from a variety of nations around the globe – including Canada.  This isn’t about getting “the same drugs” as our neighbors to the North.  The drugs that would be imported aren’t even legal for sale in Canada. The only reason to “pursue” is for pharma-bashing politics.

(It should also be noted that on-patent medicines represent about 8% of our national healthcare expense.  The rhetoric may be great for headline-seeking pols, but is trivial when it comes to lowering health care costs.)

There is no such thing as “reimportation” and no financial incentive for importation.  But the most important issue of all is safety. And that should be what stops this absurd notion from going even one step forward.

The Pink Sheet reports that ...

Hamburg's FDA Reorganization Merges Budget And Policy Functions


FDA Commissioner Margaret Hamburg is reorganizing her direct staff reports to streamline the development and tracking of the agency's budget.

As part of the proposed reorganization, the Office of Policy, Planning and Preparedness is being dissolved and a new Office of Policy, Planning and Budget will be created, housing the Office of Policy, the Office of Planning and a newly created office, the Office of Budget. It will be headed by an associate commissioner for budget. Currently, the budget functions are handled in the Office of Operations, which is being trimmed down and re-launched the Office of Administration.

The new structure will be accompanied by new faces at FDA. It may also involve departures:  Randall Lutter, the current deputy commissioner for policy, planning and preparedness, and John Dyer, the chief operations officer are absent from the proposed organizational chart included in a memo outlining the proposed changes.

The departure of Lutter and Dyer would noteworthy because they are the last members of senior leadership team tapped by the Bush administration. Former Chief of Staff Susan Winckler departed June 19.

In the memo making the case for the new organization, Hamburg states, "Our program directors have been concerned for some time that we must be more successful in aligning our budget commitments with measurable outcomes."

"I intend to make the development and presentation of the agency's funding needs and performance goals among my highest personal priorities," Hamburg notes.

A focus on planning and budgeting has been one of the requests of congressional appropriators, and FDA's reorganization may help address the concerns of the purse string holders on Capitol Hill.

Appropriations and authorizing committees have expressed willing to provide FDA with more resources, and even as the agency's budget has gone up in recent years, the increases have been accompanied by comments that FDA needs a better plan for spending the funds.

Among the other features of the reorganization is a new deputy commissioner for foods, who will oversee the Center for Food Safety and Applied Nutrition and the Center for Veterinary Medicine. "There is no higher priority than assuring the public that we intend to make the food safety program at FDA successful," Hamburg said.

Former FDA Deputy Commissioner for Policy Michael Taylor is seen as the likely candidate for the post.

He is an experienced former FDA leader and recognized food safety expert. His resume includes posts as the administrator of the Food Safety and Inspection Services at the U.S. Department of Agriculture; vice president for public policy at Monsanto Corp.; and a senior fellow at Resources for the Future, where he focused on food safety. He is currently a research professor at George Washington University's Health Policy Department.

Also as part of the reorganization, the Office of Chief Scientist will be streamlined to focus on innovation and integrity issues, and a new Office of Special Medical Programs will be created. The proposal also adds an Office of External Affairs and elevates the agency's crises management functions.
Uwe Reinhardt tries to claim that critics of a public option on the grounds a government plan might lead to rationing are also blindly loyal supporters of everything health plans do to keep down costs that drive down utilization.  
 
Read more here

Rationing to save money without regard to health or value is dumb.  Doing so without the consent of the doctor or patient and the use of population based information as Reinhardt has relentlessly proposed for a decade is inefficient and does not contain costs or improve improve health. 

Further, Reinhardt stumbles en route his leap to logic, as do other single payer supporters, in assuming that administrative controls can tamp down costs.  They do not and cannot.  All they do -- take note Dr. Krugman -- is ration more completely and destroy innovation.  

Then again, Reinhardt who believes America is NOT a democracy but an aristocracy, also believes in massive redistribution of income.  

Which is why he continues to charge and take nicely sums from corporate and investor groups to talk about health care.   

I wonder if Reinhardt will also pledge to enroll in Medicaid to help drive down health care costs and create social solidarity?  Will Krugman? 



HELP Math

  • 07.07.2009
HELP at 8+2+2?

More details to follow (on).

Follow-onwards

  • 07.07.2009

CMPI TO HOST HILL BRIEFING ON FOLLOW-ON BIOLOGICS WITH REP'S ESHOO AND ROGERS 

Event Focused on Ensuring “Patient Safety” is Top Priority of Follow-on Biologic Legislation Being Debated on Capitol Hill

Next Wednesday, July 15th, on Capitol Hill, the Center for Medicine in the Public Interest will host a briefing for Congressional Staff and the media entitled: “A Follow-On Biologics Legislation Update; Congressional Leaders and Medical Experts Discuss Patient Safety.” The event will be co-hosted by two high-ranking members of the House Energy and Commerce Committee, Congresswoman Anna Eshoo (D-CA) and Congressman Mike Rogers (R-MI). The Representatives are lead sponsors of bipartisan legislation to modernize the regulatory pathway for Food and Drug Association approval of follow-on biologics.

Representative Eshoo's legislation: H.R. 1548, the Pathway for Biosimilars Act, ensures that new standards for testing will make certain that follow-on biologic drugs are both safe and effective. The bill currently has 108 cosponsors and has the broadest bipartisan support of any legislation designed to regulate follow-on biologics.

“CMPI applauds Representatives Eshoo's and Rogers' commitment to ensuring patient safety is the top-priority for follow-on biologics legislation,” said Robert Goldberg of CMPI. “The next few weeks are going to be a pivotal time in Congress as health care takes top billing in the House and the Senate. It is critical that advocates for safe and effective follow-on biologics do all they can to support Representative Eshoo's legislation. Representatives Eshoo's and Rogers' dedication to ensuring FDA takes the appropriate steps to ensure the safety of patients could mean the difference between health and illness for millions of Americans.”

Also speaking at the event will be former Congressman Mike Ferguson; Dr. Geno Merli, Director of the Division of Internal Medicine and Vice Chairman of Clinical Affairs, Thomas Jefferson University; and John F. Crowley, President and Chief Executive Officer of Amicus Therapeutics. All three will help highlight the importance of balancing cost reduction and the well-being of patients in the follow-on biologics debate, bringing their unique experiences and perspectives directly to Hill staffers.

WHO: Representative Anna Eshoo (D-CA), Representative Mike Rogers (R-MI), Leading Medical Experts

WHAT: Briefing for Congressional staff and the media

WHEN: Next Wednesday, July 15th, 12-1pm

WHERE: Cannon Caucus Room, Cannon House Office Building 3rd Floor, Washington, D.C.

WHY: A Follow-On Biologics Legislation Update; Congressional Leaders and Medical Experts Discuss Patient Safety

Those interested in attending this event can RSVP via email to Meryl Reichbach at mreichbach@cmpi.org or by calling her at 212-417-9169.

My Facebook friend, Senator Charles Grassley (R, IA), has asked eight leading medical journals to describe their policies and practices regarding ghostwriting.

Grassley said his inquiry is part of his broader effort to establish transparency with regard to financial relationships between the pharmaceutical industry and medical professionals.

The text of the letter (sent to the American Journal of Medicine, the Annals of Internal Medicine, the Annual Review of Medicine, the Archives of Internal Medicine, Nature Medicine, PLoS Medicine, The Journal of the American Medical Association, and The New England Journal of Medicine) can be found
here.

But inquiring minds want to know … who drafted the letter onto which Senator Grassley affixed his signature?

The Senate Health, Education, Labor and Pensions Committee's health reform bill establishes a public insurance option administered by HHS, which would negotiate rates directly with providers, including drug firms, according to senior committee staff.

The bill states that "the [HHS] Secretary shall negotiate rates for the reimbursement of health care providers for benefits covered under a community health insurance option."

Direct negotiations?  Some things to consider:

"It is not obvious that allowing the government to negotiate with pharmaceutical companies will lead to lower prices than those achieved by private drug plans. Private plans like Kaiser or United are able to negotiate deep discounts with pharmaceutical companies precisely because of the plans' ability to say no – the ability to include some drugs and to exclude others, allowing the market to judge the resulting formulary. On the other hand, when the government negotiates, its hands are tied because there are few drugs it can exclude without facing political backlash from doctors and the Medicare population, a very influential group of voters. Neither economic theory nor historical experience suggests government price negotiation will achieve lower drug prices. Congressional Democrats need to be careful in making the logical leap from market share to bargaining power. Empowering the government to negotiate with pharmaceutical companies is not necessarily equivalent to achieving lower drug prices. In fact, neither economic theory nor historical experience suggests that will be the outcome. Members should think carefully before jumping on the bandwagon – this promise may bring just the opposite of what was ordered."

Stanford Business School's Alain Enthoven and Kyna Fong


"Both the non-partisan Congressional Budget Office and Medicare actuaries have said they doubt the government could negotiate lower costs than the private sector. The theory behind Part D is that market forces and competition among drug plans, overseen by government, can achieve better results than a government-run program. The multitude of plans allows seniors to pick one that best meets their needs. Government price negotiation could leave people without drugs that manufacturers decide aren't sufficiently profitable under the plan. Medicare recipients account for half of all drug prescriptions. With that kind of clout, government might try to dictate prices, not just negotiate them. This could leave people without drugs that manufacturers decide aren't sufficiently profitable under the plan. The VA plan illustrates the point. It offers 1,300 drugs, compared with 4,300 available under Part D, prompting more than one-third of retired veterans to enroll in Medicare drug plans."

"Our View On Medicare Part D: Put Brakes On Drug Plan 'Fix,'" USA Today, 11/13/06

The bottom line here is that Part D is a tremendous success – due in no small part to the Non-Interference Clause.  Consider:

* The projected cost for Medicare Part D is $117 billion lower over the next decade than experts estimated just last summer. This means that over the 10-year period from 2008 to 2017, the estimated $915 billion cost of Part D fell to $798 billion.

Why?  Marketplace competition.

* And, according to a study published in the Annals of Internal Medicine, the Medicare drug benefit led to a 17 percent decrease in out-of-pocket expenses, or $9 a month, for seniors who enrolled in the new Medicare Part D benefit in 2006, the first full year prescription coverage became available in the federal health insurance program for the elderly and disabled.

* And the savings amounted to an extra 14 days of medicine for those who signed up, or a 19 percent increase in prescription usage.

Can Part D be made even better? Absolutely. But this is good news worth sharing -- and not because it helps any particular partisan political agenda but because it means that more Americans -- tens of millions of more Americans -- are getting access to the medicines (largely chronic medicines) that will help them live healthier lives. And this, in no small measure, significantly reduces more drastic medical interventions -- which in turn reduces our overall national health care spending.

We shouldn’t interfere with success.

By revoking the Non-Interference clause, Uncle Sam will be able to "negotiate" prices for Part D drugs.  That's kind of like negotiating with your hands tied behind your back and a gun pointed at your head.  There's also the potential for Uncle to dictate that Part D prices be tied to prices in other countries -- a kind of Medicare reference price.

“Direct negotiations” means price controls.  And price controls = choice controls.

The HELP committee will resume markup of the health reform bill on July 7th.

Did you watch the President on ABC talking about healthcare reform last week?  Don’t worry – neither did anyone else.

For the best recap, have a look at what Tobin Harshaw wrote in the New York Times' “Opinionater” column:

“It was a bit like planning the dream wedding only to have a hurricane rip away the chapel roof as you make your way down the aisle.”

He also offers useful links to what other reformacenti had to say:

Jeff Poor of the Business and Media Institute gives a “thoughtful, respectful and probing” analysis:

 “Call this a teachable moment, but even with ABC’s best-laid plans to kickstart the debate about health care reform and not allow the “Prescription for America” special to become an “infomercial,” as many have complained – the president spent more than twice as much time as his questioners vaguely answering or not answering the questions asked of him. But the network consistently presented the event as part of the need to fix a “broken system.” When asked, every one of the 164 hand-picked audience members said they felt that health care needed to be changed.”

And further …

“While Obama had to field some difficult questions — from the audience and ABC — he faced no Republican critics of his proposals. The network also allowed him to dominate the program with long-winded and vague answers. Out of the 75 minutes the network dedicated over the two programs (commercials excluded), the president managed to take 60 percent of that time: 45 minutes to give 19 vague responses – not exactly the “dialogue” advertised by ABC …”

Scarecrow at FireDogLake’s Oxdown Gazette, however, thinks the network lured the president into a devilish trap:

“For its part, ABC insisted on having Charles Gibson and Diane Sawyer, instead of informed, qualified health care experts, guide the conversation. That was a mistake, but not the worst of ABC’s offensive conduct. Sawyer’s main contribution was to introduce her own uninformed biases/opinions in framing issues and introducing questioners. Gibson’s primary role was to reveal his own misconceptions and then literally read talking points from a Republican letter — an obvious ransom extracted after days of Republican whining about giving the President air time on a critical public issue.”

And as far as trading "Good Morning America" for "Healthcare at Night" ...

“Gibson’s other role was to interrupt the President every few minutes to announce a commercial break. The all too frequent commercial interruptions served as an apt metaphor for how private commercial interests demand our attention and extract their profits while limiting our ability to discuss critical public policy issues.”

Harshaw’s full column can be found
here.
CMPI

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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