Market Institute Unveils National #StopPriceFixing Effort

The Market Institute is informing voters around the country about a price fixing scheme that Republicans are considering in Congress.

Sign petition today at: https://action.stoppricefixing.org/

The awareness campaign is taking place in over 25 Media Markets across 7 States (North Carolina, Tennessee, Arizona, Utah, Idaho, South Dakota, and Wyoming). The effort includes Broadcast and Cable Television; Radio; Online and Social Media Advertising Campaign with a price tag of over $1,000,000.

The focus of the ad campaign is a bill that is currently under consideration in the United States Senate Committee on Health, Education, Labor, and Pensions (HELP) that includes price controls and will further erode the doctor – patient relationship, S.1895. 

Charles Sauer, President of The Market Institute, says, “Surprise medical billing is problem that must be solved. However, S.1895 will put more control of our healthcare decisions in the hands of government bureaucrats and the big insurance companies. This price-fixing-scheme is a prescription for fewer doctors, longer wait times, and less access to care. Government bureaucrats and insurance companies should not be standing between patients and their doctor.”

The team at The Market Institute is delivering signatures to elected representatives in Washington, DC. Organization volunteers are also reaching out to registered voters through phone calls and text messages encouraging members of Congress to oppose price fixing in S. 1895.


For more information, please visit:
Organization Website: www.MarketInstitute.org
Project Website: www.StopPriceFixing.org
Facebook: www.Facebook.com/StopPriceFixing

Encourage Senator Grassley to Investigate GPOs

Senator Grassley has introduced a good bill, S 1227, that would launch an FTC investigation into anti-competitive actions of Pharmacy Benefits Managers. The bill would be even better if it specifically required the FTC to also investigate similar practices by Group Purchasing Organizations (GPOs). Please call Senator Grassley’s office at 202-224-3744 and encourage him to add an investigation of Group Purchasing Organizations to S 1227, the Prescription Pricing for the People Act of 2019.

For more details, see the below letter from AAPS to Sen. Grassley, and this important video, from Physicians for Reform, explaining how PBMs and GPOs are driving the cost crisis while improperly interfering in patient care:

August 21, 2019

The Honorable Charles Grassley
Chairman, United States Senate Committee on Finance
219 Dirksen Senate Office Building
Washington DC, 20510

Dear Chairman Grassley:

We are grateful for your work to find market-based solutions to lower the cost to patients and taxpayers of medical care and medications.

Thank you for introducing S. 1227, the Prescription Pricing for the People Act of 2019 directing the Federal Trade Commission to investigate the middlemen who are driving up costs without adding value. The Association of American Physicians and Surgeons (AAPS) supports this bill, but we are writing to ask you to consider making one change.

Although you mentioned Group Purchasing Organizations (GPOs) in the Chairman’s comments about the bill, as we currently read S. 1227 it does not expressly require an investigation into the activities of Group Purchasing Organizations (GPOs).  We respectfully ask that you consider amending the bill to specifically name GPOs as entities that the FTC is charged with investigating.

In our view, GPO abuse of the rebate safe harbor they were granted to the Medicare anti-kickback statute is an under-appreciated culprit increasing the cost of critical drugs and medical supplies used in hospital settings, while simultaneously causing or exacerbating shortages.

While the impact on prices caused by Pharmacy Benefits Managers is now on Congress’ radar screen, the harmful impact of GPOs has been all but ignored. This may be because patients do not see the direct effect. However anesthesiologists and emergency room physicians know all too well how the anti-competitive actions of these middlemen are putting patients’ lives at risk. They have been compelled to use drugs that may not be ideal for the patient, adding unnecessary challenges to delivering quality patient care. 

It is unacceptable for the United States to be in short supply of saline and common anesthesia and emergency room drugs for any reason. It is particularly shameful when the shortages are caused by those who abuse the shield of government protection from market forces and laws that would otherwise curb their harmful actions.

Thank you for considering our request and please do not hesitate to reach out to us anytime for further discussion.

Sincerely,

Marilyn M. Singleton, M.D., J.D.
President, Association of American Physicians & Surgeons

What is the Major Contributing Factor to the High Costs of Your Prescription Medications?

By N. Lois Adams, Consultant Pharmacist, MBA, HHCS HEALTH GROUP OF COMPANIES, LLC.

Have you ever heard of the “PBMs”?  No?  Well join the huge group of people- seniors, employers, workers-who look at me with the thousand- foot, stare in their eyes when I mention that term. I almost always get the answer. NO, what is that.

They, my friend, are the Prescription Benefits Managers or PBMs.. entities who have taken over a great part of the delivery of health care and have caused the prices to escalate upwards dramatically.

These entities started out as companies which only processed pharmacy prescription claims for insurance companies for you, the employee, the consumer, and any other person who received medicine which had to be billed to an insurance company so that they would receive reimbursement. Now they have morphed into gigantic entities which make billions of dollars at yours, the employers, the government entities, and others expense. They are no longer in the background of medicine. They are running many parts of it. 

They started out by touting that they ( the PBMs) would save all of us money.  They convinced the insurers that they could save money by establishing drug formularies whereby they divided medical problems into categories and developed drug lists which allegedly would contain necessary drugs in each category so that the physician could choose one of those to treat his or her patient. This was a beginning in medical practice whereby the physician could only choose a drug that was on “their” formulary in “their” designated category- no matter if that was the drug of choice to treat the disease or not. And how, in many cases, did they choose the drug in each category? Well, simple. They selected those drugs from manufacturers who gave them the largest rebates. It may not be the best drug for that particular condition but it was the only one “their” formulary would permit.

Then came the “Prior Authorization” (P.A) debacle which is the bain of the physician’s office staff’s existence. As a practicing pharmacist for over 50 years and the owner of pharmacy entities, I have interviewed people for employment at my organizations who have told me that most of those people who are engaged with giving decisions as to whether you need the drug or not, have no idea what the professional is asking them. They are , in many cases, only following a script and do not have any knowledge or training in medicine, the disease, pharmacology, etc. regarding the question as to whether the drug should be approved so that the physician may prescribe it..And the insurer can pay for it. It became my practice, if I was denied, to ask to speak with their Medical Director because “he had to be licensed somewhere.” This was only because the ill-informed gatekeeper would end the inquiry there and not allow any further questioning.

Their “off shore” offices were another step in obstruction. I was told that they would get back with me-perhaps in 2 weeks. My patient needed the medication and that was not sufficient. The next step was to “demand” that I be transferred back to the United States and I allowed  to speak with their medical director.  That usually was successful. The issue here also is that many office personnel or health care companies do not understand the lengths to which one must go to get approval and then what happens in that situation.? You get improper or inferior medical treatment.

It is necessary to enlighten my readers to let them know that the entire system and quality is based upon the number and amount of the rebates given by the pharmaceutical industry to the PBMs. Your doctor can no longer practice medicine in the way that he knows best…he has to engage the PBMs for permission to use the drug of choice. That is where we are today. It is “medicine by rebate”. I sincerely hope that our President will understand who the real culprit of rising medication costs is and take action to rescind the “Safe Harbor” laws so that the PBMs can no longer hide behind laws and regulations that only serve as a “Safe Harbor” for them…and certainly not for you and me.

I will be giving you more insight on the high cost of prescriptions for you and your family in a following column.  Please address any of your questions to me at , “ASK YOUR PHARMACIST”   Newsletter @AmacFoundation.org

AOA commits DO member money to lobby for MOL requirements, but why?

A friend of IP4PI writes in:

The AOA just passed a resolution committing our membership dollars to lobby for Maintenance of Licensure requirements [overseen by the AOA].  I was not able to be in the committee hearing, but in our state meeting we voted against it.  On the floor of the house, when I expected our leadership to speak the will of the caucus, they did not speak at all. All states were silent as to the issue and it passed quickly without any objection.  In fact, it appeared that most delegates were not yet awake.  The only comment I got when I asked why we did not defend ourselves was that MOL is inevitable, and we have to vote for it if we want a place at the table. When will doctors learn that if they are told to advocate for their own destruction in order to make it less painful, it means they were never at the table.  We just helped by marinating ourselves for our place ON the table?

[Note from editor: Further demonstrating the AOA’s disregard for members, a provision in the resolutions directing the AOA to “make OCC more manageable and economically feasible was struck.]


H-627 MAINTENANCE OF LICENSURE (H638-A/14) Resolution No. H-627

Be it resolved: The American Osteopathic Association (AOA)

(1) supports the development of state level maintenance of licensure (MOL) programs to demonstrate that ALL physicians are competent TO provide quality care THAT INCORPORATES RELEVANT TECHNOLOGICAL AND SCIENTIFIC ADVANCEMENTS over the course of their career. Flexible pathways for achieving MOL should be maintained. The requirements for MOL should balance transparency with privacy protection and not be overly burdensome or costly to physicians or state licensing boards; 

(2) Continues to address and promote physician competency through the teaching of core competencies at the predoctoral and postdoctoral levels as well as ongoing physician assessment through Osteopathic Continuous Certification (OCC) and the AOA Clinical Assessment Program (CAP) or its equivalent;

(3) Continues to work with State Osteopathic Affiliates, the American Association of Osteopathic Examiners and other stakeholders to establish, AND implement MOL policies that promote patient safety and the delivery of high quality of care;

(4)WILL THROUGH ITS BUREAUS, COUNCILS AND COMMITTEES, CONTINUE TO ENSURE THAT OCC IS RECOGNIZED BY THE FEDERAL GOVERNMENT, STATE GOVERNMENTS AND OTHER REGULATORY AGENCIES AND CREDENTIALING BODIES AS EQUIVALENT TO OTHER NATIONAL CERTIFYING BODIES’ “MAINTENANCE” OR “CONTINUOUS” CERTIFICATION PROGRAMS.;

(5) WHILE SUPPORTING THE USE OF BOARD CERTIFICATION AS A  RECOGNITION OF QUALITY AND EXCELLENCE, SIGNIFYING THE HIGHEST PHYSICIAN ACHIEVEMENT IN A PARTICULAR SPECIALTY; OPPOSES ANY EFFORTS TO REQUIRE OCC AS A CONDITION OF MEDICAL LICENSURE.;

(6) THE AOA COLLABORATES WITH ENTITIES PROPERLY QUALIFIED FOR AND TASKED WITH DECISION-MAKING REGARDING INSURANCE PAYMENT, HOSPITAL PRIVILEGES, NETWORK PARTICIPATION, PAYMENT MALPRACTICE INSURANCE COVERAGE, PHYSICIAN EMPLOYMENT, TO DETERMINE THE ROLE OF PHYSICIAN BOARD CERTIFICATION AND OCC OR OTHER “MAINTENANCE” OF CERTIFICATION” PROGRAMS IN SUCH DECISIONS.;

(7) CONTINUES TO INNOVATE AND IMPROVE THE OCC PROCESS.

APPROVED

https://osteopathic.org/wp-content/uploads/2019-Ad-Hoc-Committee-Report-WITHACTION.pdf

Trust: The central issue in health care reform

Marion Mass, M.D. and Craig M. Wax, D.O.

$6.1 million per year represents an increase in 12% of the take home pay that Gene Woods received from public non-profit Atrium Health system last year.  During this 6.1 million dollar year the following remarkable events happened:

 A group of over 80 physicians accused Atrium of monopolistic and anti-competitive behavior and left, starting independent Tyron Medical Partners

Atrium terminated its 40+ year contract with anesthesiologist group Southeast, and replaced them with another.   This move spawned lawsuits now pending in North Carolina Business Court, and spilling into public view.   One Southeast anesthesiologist boldly wrote to the Charlotte mayor, “we think that this decision puts our community members at risk.” The anesthesiologists “believe that the community should know about this, and that they should be able to weigh in on the decision,” the physician wrote.

 In November,Atrium said that personal information for more than 2 million of it patientsmay have been compromised in a data breach of billing information, includingaddresses, dates of birth and Social Security numbers. Oops.

Continue reading

Is New York’s “Surprise Bill” Law a Model for Federal Legislation? Yes and No.

There’s a big fight brewing in DC. No, not the one between the “Squad” and President Trump, which will likely be forgotten as soon as the outrage addicts need a new fix. The fight we’re talking about will have a much greater impact on Americans and is occuring between insurers and hospitals over various proposals to combat “surprise bills.”

The bottom line: as these behemoths clash, patients and physicians — those who need medical care, and those who deliver it — are set to be further marginalized.


We interrupt this blog post for a quick, but important, Action Alert: The bill furthest along at the moment is the Senate HELP bill, S 1895, which is now eligible for a vote on the Senate floor after passing through committee on July 8. A favorable (but unrealistic) CBO score has also been issued, increasing its chances for a vote. CALL BOTH OF YOUR U.S. SENATORS and tell them to VOTE NO on S 1895 if it comes up for a vote. The fastest way to reach your Senators is by calling the Capitol Switchboard at (202) 224-3121.


A review of the the major problems with S 1895, and others like it, can be found here, here, here, and here. S 1895, while containing potentially a few helpful provisions, is for the most part, putting band-aids on top of existing failed cancerous policies — band-aids that will exacerbate the disease instead of excising the tumor causing it. Not to mention that insurance-company controlled “unsurprise bills” may be a significantly bigger problem than surprise bills, as disintermediator Dave Chase explains. In addition the bill imposes system-wide rules to address a problem that is not as widespread as advertised. “The cost of surprise bills is a small portion of all health care spending…,” reports the CBO in its score of the bill.

In the physician community, some are suggesting that legislation like S 1895 would be acceptable if arbitration provisions are included. There is also a suggestion that a competing bill over on the House side, HR 3502 (Ruiz/Roe) is the compromise bill that can be supported, because it includes an arbitration option, and is modeled after New York’s heralded surprise billing regulations. [Update: similar arbitration provisions have now also been added to the House E&C legislation (HR 3630) addressing surprise bills.]

As state regulation of market transactions go, NY’s surprise billing law seems to cut a reasonable path. It prohibits abuses by hospitals without swinging the pendulum too far in favor of insurers. It permits a reasonable level of flexibility for patients and physicians to interact on mutually agreeable terms.

But does HR 3502 really mirror NY statue? Both do allow for arbitration, but aside from that the similarities meaningfully end.

Here are some key differences:

1) The NY law kicks in only with charges above 120% of the Usual and Customary, defined to mean “the eightieth percentile of all charges for the particular health care service.” That’s a pretty high bar that helps contain overregulation.
https://www.nysenate.gov/legislation/laws/FIS/602
https://www.nysenate.gov/legislation/laws/FIS/603

Conversely, HR3502 sets a benchmark price at “the commercially reasonable rate, as determined by the plan or issuer.” That is drastically one-sided in favor of insurers and likely unconstitutional, argues a former U.S. Solicitor General.

Yes arbitration may help provide relief from this extreme price setting to hospitals, and health systems, and “Wall Street-owned doctor groups” who can afford the expense, but arbitration is not a meaningful option for small or independent practices in many cases. 

2) Also the NY law defines “Surprise Bill” in a way that allows patients and physicians some ability to voluntarily opt out of limitations, if both parties desire, i.e.: “a surprise bill shall not mean a bill received for health care services when a participating physician is available and the insured has elected to obtain services from a non-participating physician….” And under the NY law, patients have to take an affirmative step to trigger a prohibition on balance billing: ” When an insured assigns benefits for a surprise bill in writing to a non-participating physician that knows the insured is insured under a health care plan, the non-participating physician shall not bill the insured except for any applicable copayment, coinsurance or deductible that would be owed if the insured utilized a participating physician.” https://www.nysenate.gov/legislation/laws/FIS/608

HR 3502, on the other hand, makes no provisions for patients and physicians voluntarily opting out of the provisions of the legislation, and in fact levies fines and penalties on physicians who don’t comply: “if such nonparticipating provider holds such individual liable for a payment amount for such an item or service furnished by such provider that is more than the cost-sharing amount for such item or service … such provider shall be subject … to a civil money penalty of not more than an amount determined appropriate by the Secretary for each specified claim.
https://www.congress.gov/bill/116th-congress/house-bill/3502/text

So back to the question posed in the title of this post, is the NY surprise billing law a model for federal legislation? If it were actually being followed as a model, the answer might be “yes.” But given the existing bills on the table in DC, the answer is “no.” NY law is being followed as a model in name only, not in practice.

Ultimately, the phenomenon of surprise bills signals a more fundamental problem: past failed policies that tilt the playing field in favor third party payment and punish direct payment limit patient options and are impeding market forces from squeezing out costs that line the pockets of administrators and middlemen who add minimal or no value. It is past time to level the playing field and unleash innovations that will allow those who care for patients the freedom provide an abundance of lower cost, high-quality options.

President Trump’s Salute to Patients Promises Welcome Changes, But Special Interests Attack

The week before President Trump’s Independence Day “Salute to America” he gave a welcome Salute to Patients when he signed Executive Order 13877, “Improving Price and Quality Transparency in American Healthcare To Put Patients First.”

As free market champion Dr. Keith Smith of the Surgery Center of Oklahoma puts it, the “healthcare industry price gougers wore out their welcome” and were “kicked to the curb by President Trump.”

What does the order do? Its first priority is to end “opaque pricing structures,” that “benefit powerful special interest groups, such as large hospital systems and insurance companies,” but, “generally leave patients and taxpayers worse off than would a more transparent system.”

But there’s more: the order also aims to “enhance patients’ control over their own healthcare resources” by removing failed policies that impede patients from choosing to enroll in affordable Direct Primary Care practices or alternatives to big insurance like Health Care Sharing Ministries.

The bottom line is increasing patient freedom and choice is the centerpiece of President Trump’s order. However, make no mistake, it is also put a target squarely on the middlemen who have for too long taken advantage of backroom deals made with government cronies. And the middlemen are already fighting back with a vengeance and working to undermine the order.

Underestimating the special interests’ power to stop the good changes is not an option. Just last week the Pharmacy Benefits Manager (PBM) cartel killed a White House proposal that would begin to unwind corrupt kickbacks that result in out of control price hikes for life saving drugs through disingenuous propaganda that lower prices would somehow raise premiums.

And the fake news campaigns about the Transparency Order are already underway.

Thankfully physicians like Chad Savage, MD are debunking the industry lies:

No price transparency will not lead to higher prices. “This is akin to saying the best way to get a good price on a new Sony TV is to have no idea what it costs. If someone said that to you, you would rightly reject any future advice from that individual,” explains Dr. Savage.

Marni Jamison of the Association of Independent Doctors exposes another tactic of those who oppose transparency:

The cronies are “lawyering and lobbying up, busily working to undermine, narrow and water down the order. They are not going to give up the hundreds of billions of excess dollars flowing their way easily,” she writes and shares examples of weasel words insurers and mega health systems will attempt to use to corrupt the outcome.

Middlemen’s fingerprints are already evident on the order itself to some extent. For example the “Health Quality Roadmap” provisions empower the use of failed quality metrics that are already driving up the cost of care with out any benefit to outcomes. “Practitioners who practice according to the needs of their individual patients, not according to some standardized protocol approved by a third party whose only focus may be efficiency and cost-cutting, may be penalized,” warns Twila Brase of the Citizens’ Council for Health Freedom and award-winning author of Big Brother in the Exam Room. AAPS, while overall supportive of the order, flagged provisions as potentially harmful to privacy rights and urged that “patients’ right to consent to use of their data must also be respected.”

Winning these battles for patients and those who care for them will not be easy! But nothing worthwhile ever is. So let’s all Salute President Trump for taking these bold steps by stepping to help him fend off the special interests trying to thwart his welcome orders.