Category Archives: Policy and politics

Paying for IVF

You paid how much for me?

You paid how much for me?

Advances in fertility treatment have greatly expanded the number of people who can become parents. But treatment is expensive and –in most states– is not covered by health insurance. Patients often pay tens of thousands of dollars out of pocket for in-vitro fertilization and surrogate pregnancies, and face tough decisions about whether to continue treatment when initial attempts fail.

Kaiser Health News (Infertility Patients Finding Creative Financing Help) documents the growing number of options available to fertility patients. Clinics and shared-risk programs provide full or partial refunds for customers who don’t end up with a baby, in exchange for paying somewhat more upfront. These programs look like a good way to hedge against the risk of multiple cycles or failure to conceive. Those offering the programs must like them, since they increase the addressable market and probably boost average revenues per patient.

So on balance I think these programs are good. But it’s worth stepping back to consider that a mediocre Reproductive Endocrinologist can easily make a seven figure income, especially in those states that don’t mandate coverage for fertility treatments. In the 15 states that do mandate coverage insurance companies use their negotiating power to pay more reasonable rates than what any individual could hope to negotiate, and there’s no need for the consumer to participate in shared-risk or similar programs. Insurers also get a break on the price of expensive fertility drugs.

The downside of the mandate is that it increases insurance premiums for everyone, although those increases may be partially offset by reduced costs for neo-natal intensive care (when self-pay patients push for more embryos and end up with twins and triplets).

I live in a mandate state and I’m glad that I do.

photo credit: Gonzalo Merat via photopin cc
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By healthcare business consultant David E. Williams of the Health Business Group

 

 

The Medical Marijuana Mess

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The thin veneer of “medical” marijuana has been stripped away in Colorado, where stores originally providing remedies for patients have been quick to plaster themselves with new signs touting recreational use for all adults. (The signs above are among those I spotted this month in just one small town.) And while federal regulations and public pressure have largely kept alcohol and nicotine out of candy and other child-friendly, sugary products, the marijuana industry is moving in the opposite direction by offering an ever-widening array of pot-infused “edibles,” complete with approving coverage from mainstream media.

There’s room for debate on just how harmful marijuana is, but it definitely is harmful, especially to the developing brains of adolescents. Here’s my bottom line: marijuana should be decriminalized so that those who consume it for whatever purpose are not subject to arrest and imprisonment, with all the personal and societal costs that brings, but the widespread use of marijuana should not be encouraged. And that’s roughly where Massachusetts was before voters decided to legalize medical marijuana.

I think we’re fooling ourselves in Massachusetts by going down the route of approving medical marijuana dispensaries. Early experience has already demonstrated that some unsavory characters and losers are drawn into the business. And with public opinion running toward legalization, we should expect these dispensaries to become outlets for recreational marijuana within a few years, maybe sooner.

Let’s be honest with ourselves and act accordingly:

  • If marijuana is a medicine it should be tested like any other drug and approved by FDA. If that’s the case, physicians could prescribe it and pharmacists could dispense it. In fact, such drugs are on the market and in development
  • If marijuana is so safe and effective that it doesn’t need a prescription, it should be sold wherever –like Tylenol
  • If marijuana is a recreational drug like alcohol, with known harms but where we’ve opted against prohibition, we should let liquor stores sell it. They already deal with age verification and physical security of the product

Sad to say but I think we’re going to see widespread legalization of recreational marijuana over the next few years and that we’ll look back in a decade or so and realize it’s been a serious mistake of the same magnitude as the addiction and abuse epidemic that’s resulted from the expansion of legal prescribing of drugs like OxyContin for pain.

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By healthcare business consultant David E. Williams of the Health Business Group

Consumer Reports lets us down with attack on Zohydro ER

Guess who's got acetaminophen

Guess who’s got acetaminophen?

Readers like me trust Consumer Reports to provide objective, unbiased recommendations on products and services. That’s why I’m so disappointed in the September cover story, The dangers of painkillers. The story rails against two products –Zohyrdo ER and acetaminophen– yet fails to mention that what differentiates Zohydro ER is that it is the only extended release version of hydrocodone that doesn’t contain acetaminophen.

The article urges readers to contact the FDA to ask that Zohydro ER be banned and acetaminophen be more tightly regulated. But Consumer Reports fails to inform us that Zohydro ER represents a partial solution to the problem of acetaminophen proliferation that Consumer Reports is so worried about. If I were at the FDA and someone called me to complain about Zohydro ER and acetaminophen on the same call I’d find it ironic, to say the least. Callers might be embarrassed when they realize they’ve been misinformed.

Here’s what the article says about acetaminophen:

Opioids aren’t the only painkillers that pose serious risks. Almost as dangerous is a medication renowned for its safety: acetaminophen (Tylenol and generic). Almost 80,000 people per year are treated in emergency rooms because they have taken too much of it, and the drug is now the most common cause of liver failure in this country.

And with acetaminophen, accidentally taking too much is all too easy. That’s because it’s the most common drug in the U.S., found as an ingredient in more than 600 OTC and prescription medications, including allergy aids, cough and cold remedies, fever reducers, pain relievers, and sleep aids.

Zohyrdo ER’s direct competitors such as Vicodin contain hydrocodone and acetaminophen. Until Zohydro ER came along, hydrocodone users ended up taking acetaminophen whether they wanted it or not. Incredibly, according to a 2010 study cited by Zohydro ER’s manufacturer, “63 percent of unintentional acetaminophen overdoses [are] attributed to the use of hydrocodone-acetaminophen combination products.” How can Consumer Reports have overlooked this?

There are legitimate complaints about Zohydro ER. The biggest is that it’s not tamper resistant, and is thus prone to abuse. Fair enough. But there are other narcotic painkillers on the market –like generic Opana ER– that are also not tamper resistant. And without getting into the details, it’s not all that hard to tamper with tamper resistant products.

I’m not saying Consumer Reports is necessarily wrong to want painkillers restricted. But I just can’t understand why an article that hits acetaminophen so hard wouldn’t mention that it’s the absence of acetaminophen that makes Zohydro ER different.

photo credit: Mike Licht, NotionsCapital.com via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

Whining about the thousand-dollar pill

Medicine is too expensive!

Medicine is too expensive!

When I saw Paying for the Thousand-Dollar Pill, an anti-Sovaldi op-ed in the Wall Street Journal by the health plans’ head lobbyist, it brought back memories from my childhood when I toured the FBI headquarters in Washington, DC. The tour guide started off by showing us a wall with pictures of the 10 most wanted fugitives in the country and asked for our help in tracking them down.

“If that’s their plan for catching these guys,” my dad whispered to me, “we’re in more trouble than I thought.”

The author, Karen Ignagni, complains that the prices charged for new drugs like Sovaldi don’t “reflect the cost of investment.” She worries that the government is giving drugs a monopoly through the patent system. And she fears that her cries for “transparency in the relationship between the price of a drug and the cost of its development” will lead to allegations of “price controls” –which the insurance industry doesn’t want. Boo hoo!

Rather than whining and complaining in the press, the insurance industry should do its job of containing costs and ensuring quality. The problem with Sovaldi, a novel drug that claims a high cure rate for Hepatitis C, is not that the per pill cost is $1000 or about $84,000 for a course of treatment. There are several drugs that cost a lot more than that and aren’t as effective against the diseases they target. The problem is that Hepatitis C is a common condition, and many, many cases that have accumulated over the years that can now be treated. That makes the total bill very high at least for the next couple years even though the total cost to the healthcare system as a whole may drop because there will be fewer transplants and fewer Hep C cases over time.

One way to deal with the problem Ignagni cites would be to move to a single payer system and global budgeting. Then the government could just dictate the price and be done with it. You don’t see the national health insurance systems in other countries quaking in their boots about Sovaldi. Instead, they’re negotiating prices and limiting the treatment to those with severe disease. Once competitors enter the market, access is likely to be expanded.

Clearly the US health insurance industry doesn’t want to put itself out of business so I don’t expect Ignagni to cheerlead for single payer. But I would expect closer scrutiny of the clinical claims being made for Sovaldi, which are not as airtight as they are typically presented. Plans could take a harder line on price negotiations, encourage some patients to wait for treatment, and more publicly critique the evidence beyond Sovaldi.

Meanwhile, I think it’s great that companies that come out with novel, useful drugs can make a ton of money.

The health insurance industry shouldn’t come crying to me or the rest of the American public if they can’t figure things out.
photo credit: ★ spunkinator via photopin cc

By healthcare business consultant David E. Williams of the Health Business Group

 

Health insurance premium increases in Massachusetts: More ways it can happen

Last week (ACA rollout hits some Massachusetts businesses harder than expected) I described how the implementation of Obamacare caused one small businesses’s Blue Cross Blue Shield of Massachusetts premium to jump by 29 percent for the upcoming renewal. The main issue was family size –previously only the first two kids were counted when calculating premiums, now it’s the first three kids. This group, with lots of kids, is paying the price.

After that I heard from two other BCBS MA customers who were experiencing big premium hikes. One is a two-family partnership where one family has two kids and the other has none. Their premium is up 17%. The second is a non-profit organization where the number of kids also shouldn’t be a deciding factor. Their premium increase is 26%.

Here’s what BCBS MA told me about these two:

The first group was a new customer entering its first renewal year. Initially, BCBS rated the company based on the expected –rather than actual– number of dependents. The rate was based on ~1.5 kids for one family and 0 for the other. (Something tells me they probably knew 1.5 was either too high or too low and not right on!) In any case, in a small group that is enough to make a significant difference in rates. With the ACA, health plans have to gather the dependent info even for new customers.

For the non-profit organization, the number of members covered declined from 12 to 7, which pushed them into a more expensive rate per member. (Even though rating based on group size is being phased out, it’s still a significant factor.) In addition, the group’s prior year increase had been tempered under a state law that limited the rates of increase for renewals. The ACA overrides the state’s rule and BCBS tells me they are unable to cap this year’s rate increase.

For what it’s worth, BCBS tells me that the median rate increase in the merged (individual + small group market) this year is 5-6%, which means these three examples are outliers. They also tell me that rate increases a year from now should be in the low single digits for all three of these customers and others like them.

I’d be interested in hearing from other Massachusetts customers of Blue Cross and other plans. Have your rates jumped? Are they steady? Did they fall? Do the explanations above seem to account for what’s happened to you?

Leave a note in the comments or mention on Twitter @HealthBizBlog.

By healthcare business consultant David E. Williams of the Health Business Group