Making American Medicine Great Again in 10 Simple Steps #MAGA

1. Price transparency for all healthcare services and supplies.
2. Site neutral payments (no hospital advantages).
3. Legislation to open and eliminate closed insurance networks. Networks are the third parties strangle-hold noose on healthcare.
4. Care must not be limited by insurance red-tape “referrals,” pre-certifications of imaging tests, and prior authorizations of medicines.
5. Reconsider tax exempt status of hospitals. They should have no advantage over physician offices or other services.
6. Patients should shop for all non emergent healthcare services and supplies and keep their savings.
7. Repeal 1987 GPO PBM anti-kickback safe harbor. Enable freemarket competition.
8. Define DPC as healthcare service contract between patient and facility or physician, not insurance. Keep DPC simple, direct, third party and government free, and patient empowered.
9. HSA expanded for DPC and OTC meds.
10. Legislation to permit physicians to see charity patients in return for either tax deduction or  malpractice insurance.
Two supplementary short editorials:
To solve U.S. healthcare crisis, think small, not big
The American hospital: from volunteer charity to tax-exempt patronage pit
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AT RISK: Bill to Let Patients Use HSAs for DPC

Earlier this week we heard the good news that H.R. 365 was finally going to be considered by the House Committee on Ways and Means, bringing the use of Health Savings Accounts (HSAs) for Direct Patient Care (DPC) one step closer to reality.

Then we learned “a few small changes” had been made to the bill. Unfortunately the “few small changes” have greatly damaged the legislation.

You can read a copy of the latest bill here: https://goo.gl/B6imgQ.

Under the new language, DPC practices would have to comply with several federal requirements in order to become HSA-eligible. One provision limits the care provided under the agreement to specific CPT codes.  Another would prohibit DPC arrangements priced over a certain threshold from being HSA-eligible. Others further limit how the pricing can be structured and what care can and cannot be included. Specialists would be blocked from offering innovative HSA-eligible monthly membership payment arrangements.

To us, these changes are unacceptable and might be worse than no bill at all. If the bill passes in this form it would put practices that don’t comply with the federal rules at a competitive disadvantage to practices that align their model to satisfy DC instead of their patients.

One more problem:  these changes were tucked in at the last second barely a day ahead of Wednesday’s mark up session of the Bill in House Ways and Means.  That’s right, the new bill is headed to be pushed through committee with little chance for public input.

Today, AAPS sent a letter to every Ways and Means Committee member, and the committee staff, expressing our concerns about this bill and a few other bills the committee will consider on Wednesday, July 11.  Overall, we like a number of the bills under review, because they do expand HSA flexibility. But there are several key problems that tilt the playing field to the advantage of corporate medicine. Read more in our letter here: https://goo.gl/XYutr5.

What can you do?  Please send the committee a message ASAP before Wednesday at 2pm Eastern.  Here are the steps:

1) Copy the following text:

Dear Chairman Brady, Ranking Member Neal, and Members of the House Committee on Ways and Means,

Tomorrow you will be considering replacement language to H.R. 365, the Primary Care Enhancement Act. The addition of improper requirements means the new bill will not accomplish the goal of allowing patients to use their Health Savings Accounts to see the Direct Patient Care physicians of their choice.  I encourage the committee to consider adopting H.R. 365 as written, while rejecting the recent changes. In addition I encourage you to please consider AAPS recommendations about this bill and others you are considering today. The AAPS letter to the committee is available at https://goo.gl/XYutr5.

2) Visit https://waysandmeans.house.gov/contact/ and paste the comment in to the appropriate field and modify as desired.

2a) You can also fax your comment to the committee: (202) 225-2610

3) If your representative is on the Ways and Means Committee, email the note to the Health Legislative Assistant for your Member of Congress. A list of committee members and their health staff contact information, sorted by state, is available here: https://goo.gl/8iqw3u.

Thank you for speaking out!

Talking to Patients About Guns. A physician says “yes” and “no”

Should doctors routinely talk to patients about gun use?

That was a question my colleague Paul Hsieh MD addressed in the Wall Street Journal over the weekend.

Here’s another slant:

“Yes, physicians should ask about patient gun issues for their health and safety but No, no one should use EHR electronic health records or any data sharing mechanisms for that ultimately private discussion!” – Craig M. Wax DO

What do you think?

One Easy Hack @RealDonaldTrump Can Use to Ignite a Consumer-Directed Revolution in American Medicine

Options are about to multiply for 12-million Americans trapped in ObamaCare plans, the 12% uninsured, and others ACA victims, with coming new proposals from the Trump administration.  After signing “Right to Try” into law Wednesday, President Trump hinted that these changes are mere weeks away.

Once the new policies are in place, new lower cost and flexible insurance alternatives will be unleashed, freeing Americans from disruptive (in a bad way) ObamaCare rules that drive up costs and decrease patients’ and workers’ choices.

Here are the two expected policies plus one hack that will floor the accelerator on their impact:

First, the Department of Labor is set to expand the availability of Association Health Plans. These will give Americans with common connections the ability to join together in plans they control.  Less regulation is not the only advantage of AHPs, although savings will be significant: an estimated $9,700 a year less compared to the individual market by 2022, reports Avalere.  Escaping state-based mandates is another advantage; these plans can be sold across state lines. In addition, association plans will allow employees to more readily keep their plan if their work situation changes.

The second anticipated policy, this one from the Department of Health and Human Security, will increase access to short term health insurance plans that are almost completely free of failed ACA requirements. Under President Obama, these plans were limited to 90 days of coverage, but Secretary Azar is expected to extend the limit to 364 days.  Coverage in such a plan would costs on average $342 a month, vs. $619 per month for an exchange plan, reports Michael Cannon of CATO. Mr. Cannon also suggests the administration should allow short term plans to offer guaranteed renewability or even sell the guarantees separately (he estimates the average cost at $86/month).  Renewability options would not only help consumers retain these plans long term, but would also inhibit expensive enrollees from being pushed back into the ACA exchanges.

Both of these proposals are going to help Americans; however the Trump administration could turbo-charge these good ideas with one simple hack. One sleek additional change to federal policy would lower costs even further, while increasing patients’ access to high quality care.

What else should the Trump administration do immediately? It’s simple: let patients use Health Savings Accounts (HSAs) for Direct Primary Care (DPC).

Most people already know about HSAs but, perhaps aren’t yet familiar with DPC, a direct arrangement between doctors and patients, that cuts the red tape out of health care, kicks the bureaucrats out of the exam room, and is set to sweep across the U.S.   Dr. Marilyn Singleton explains DPC like this: “The Direct Primary Care (DPC) model is burgeoning as patients yearn for quality time with their doctor at an affordable price. Here, all primary care services and access to basic commonly used drugs at wholesale prices are included in a fixed transparent price,” often around $50 to 75 per month.

The bottom line is DPC saves money for patients and downstream payers (like Medicare), increases quality of care, and it relieves physicians of counterproductive red-tape hassles that are driving them out of practice. DPC is a win-win-win.

You’d think everyone would agree that encouraging the use of DPC is a no-brainer. Shockingly, the Internal Revenue Service is blocking the use of this innovation for the 30 million Americans with HSAs. Thanks to a letter issued by Obama’s IRS commissioner, John Koskinen (yes the same one who stonewalled efforts by Congress to investigate IRS retaliation against conservatives) patients are prohibited from contributing to their HSA if they are in a DPC practice. To add insult to injury, HSA funds cannot be used for DPC.

As the public becomes aware of this flawed IRS decree —deserving of a blue ribbon in the Health Policy Hall of Shame—momentum grows for change. Just last month, Senators Ted Cruz and Ron Johnson wrote Treasury asking for a reversal.  In addition 1,125 patients and doctors have asked Congress to pass the Primary Care Enhancement Act (HR 365/S 1358) and force the IRS to change its misguided interpretation of law.

Disrupting (in a good way) Koskinen’s obstruction of patient freedom must be a priority for the Trump Administration as it moves forward with other reforms to remedy past policy disasters.  Allowing patients to use HSAs for DPC will turbo-charge the ability of patients with short term and Association-based plans to make their health care dollar go even further and get the best care from the physicians of their choice.

Need one last reason, President Trump? DPC will boost your plans to lower prescription drug costs.  A 72-year old female patient with multiple chronic conditions purchases all nine of her medications through a Direct Primary Care office in Allentown, Pennsylvania for $14.63 per month. Through Medicare “coverage” her cost would be $294.25 per month.

There is simply no legitimate reason for blocking patients with HSAs from DPC physicians … unless you are a middleman profiting off the status quo.

Can a Former Pharma Insider Solve Sky High Rx Costs?

HHS Secretary Alex Azar talked a good game in a Rose Garden ceremony and subsequent press conference—held Friday, May 11—on Trump Administration efforts to lower prescription drug costs for American patients.

Azar is, of course, a former executive of Eli Lilly. Can he be trusted to champion the interests of everyday Americans?

We will soon find out.  President Trump stated that Sec. Azar’s insider knowledge about the complex schemes to raise prices, perpetrated by industry middlemen, is exactly what makes him the right person for the job.

Watch the video of the Rose Garden Ceremony:

Although groups like Physicians Against Drug Shortages have been sounding the alarm for years, industry-led smoke and mirrors have, until recently, largely flown under the radar of the main-stream-media. Thankfully, respected outlets like the Wall Street Journal and Washington Times are now beginning to shine needed light on this malfeasance.

As these articles explain, a safe harbor to Medicare anti-kickback law is the major policy failure enabling the bad actors to line their pockets by driving up costs. The safe harbor legalizes kickbacks paid by manufacturers to Pharmacy Benefit Managers (PBMs) and their cousins-in-crime Group Purchasing Organizations (GPOs).

TownHall.com reports: Repealing the GPO/PBM safe harbor to Medicare anti-kickback law “would open the drug and medical supply segment of healthcare to free market competition and foster innovation. In addition, it would result in cost reductions estimated at $100 billion [actually more like $200 billion], including savings for the Medicare and Medicaid programs.”

Congress initially enacted the GPO safe harbor in 1986. Then in 1987 Congress reaffirmed the measure, instructed HHS to implant the the safe harbor into regulation, and granted HHS authority to create additional safe harbors. In 2003 HHS OIG issued guidance clearing the way for PBMs to piggyback on the GPO safe harbor. Such guidance could theoretically be revised or rescinded by the HHS Secretary, without needing action by Congress.

And in their remarks today, both Trump and Azar mentioned that they will be looking at reining in such abusive practices.

Later in the press room, Azar explained that there are perverse incentives at play: “These big price increases are actually a good deal for pharmacy benefit managers, who are supposed to keep prices down.”

Video of White House Press Conference With Sec. Azar:

What is HHS going to do? They put out a 44-page blueprint of their plan:

https://www.hhs.gov/sites/default/files/AmericanPatientsFirst.pdf

One step HHS announced it will implement immediately is a prohibition of Part D gag clauses, “preventing pharmacists’ telling patients when they could pay less out-of-pocket by not using insurance.”

Great words but let’s hope HHS doesn’t stop there. The blueprint is less clear about other action HHS will take related to PBMs, although it states HHS is considering:  “Measures to restrict the use of rebates, including revisiting the safe harbor under the Anti-Kickback statute for drug rebate.”

Rebates? Why does CMS use that euphemism? They are not rebates, they are legalized kickbacks.  Furthermore, rebates do not go to the patients, they flow to the PBM and insurance companies.

Unfortunately, HHS has a poor track record when it comes to using it’s existing authority to stop PBM abuse. The Government Accountability Office reports: “since 2004, [HHS] has not routinely exercised its authority to request and review disclosures” that PBMs are required to make available to comply with the safe harbor.

HHS promises there will be an opportunity for the public to comment through a “Request for Information.”

HHS appears to be asking the right questions, including:

“Do PBM rebates and fees based on the percentage of the list price create an incentive to favor higher list prices (and the potential for higher rebates) rather than lower prices?”

and

“Should PBMs be obligated to act solely in the interest of the entity for whom they are managing pharmaceutical benefits? Should PBMs be forbidden from receiving any payment or remuneration from manufacturers, and should PBM contracts be forbidden from including rebates or fees calculated as a percentage of list prices? What effect would imposing this fiduciary duty on PBMs on behalf of the ultimate payer (i.e.,
consumers) have on PBMs’ ability to negotiate drug prices?”

When details become available about the comment opportunity we will ask that all patients and doctors demand that HHS take strong action to stop the PBM and GPO kickbacks.

Ultimately, as Trump stated in his comments, Congress will need to do it’s part in concert with administration actions.  One priority for Congress must be to repeal the GPO/PBM safe harbor and end legalized kickbacks.

In the meantime HHS can lead the way to educate Americans on how such repeal will save $200 billion dollars/year and prevent dangerous drug shortages.

Americans are depending on you to do the right thing, Secretary Azar.

Don’t get stuck in ER surrounded by flu victims. Joining a concierge practice is a no brainer.

Dr. Tom LaGrelius writes in:

Joining a concierge practice is a no brainer, unless you want to sit surrounded by coughing masked flu victims in a packed ER unable to treat you with antivirals anyway. The hospitals are using Tamiflu only on patients so sick they are in the ICU. And in most of those cases they need not have bothered. They got their first dose long long long after the effectiveness window had closed. They should save it for the ones ill less than two days when it actually works!

The hospitals are currently swamped with flu victims and have no beds or ER space.  Continue reading

CMS wants your comments on market-based Healthcare innovation. Deadline Nov. 20.

CMS has caused quite a stir this week by announcing they are shaking up their CMMI “Innovations” office.
They are looking for input on “Consumer-Directed Care & Market-Based Innovation Models”  that might be beneficial to Medicare and Medicaid patients.
“What options might exist beyond FFS and MA for paying for care delivery that incorporate price sensitivity and a consumer driven or directed focus and might be tested as a model and alternative to FFS and MA?”
Here’s a link to the full request:
The deadline for submitting comments is November 20 and the link to their webpage on this is here:
And the response form is here https://survey.max.gov/429625