Corporate Giants and the government revolving door create costly and fragmented care

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

Insurers, Pharmacy Benefit Managers(PBM), advocacy groups  such as AARP, and others are using their amassed wealth and influence to game the over-complicated and burdensome healthcare system for their own profit on the backs of the American taxpaying patient while fragmenting their care.  Let’s follow one pathway of corporate profiteering that results in a poorer quality of patient care:

United Healthcare’s subsidiary Optum (the company formerly known as Inginex) is one of the three big PBM…  companies that control what drugs your insurance company pays for and how much, while having the government given right to receive kickbacks from pharma manufacturers (conflict of interest much?). These kickbacks are costing Americans $200 BILLION PER YEAR and a prime reason why Optum got so rich. Their 2018 profits put them at the 100 billion mark.

How did a company with a history of fraud get so rich? Round up the usual suspects of the government/corporate cronyism.

After the fraud charges,  Ingenix rebranded itself as Optum, it’s CEO Andy Slavitt left and in 2015 became the Head of Center for Medicare and Medicaid Services(CMS)  while the former head of CMS, nurse Marilyn Tavenner, left to become the president of the insurance industry’s  lobby group AHIP. Slavitt was able to cash out stock options TAX FREE, getting a $4 million windfall.

Curiously, in 2015, while Slavitt is running CMS, Optum seems to take over the publication and administration of the CPT and ICD coding, their logo appearing on the coding material.

As if kickbacks, and coding are not enough, Optum finds another revenue stream via home visits. They send clinicians to medicare advantage patient’s homes often incentivizing the patients with gift cards.  ( apparently they discovered that kickbacks work)  These “wellness visits” prevent patients from being able to see their primary care physician for an annual physical, thus fragmenting care, while failing to forward critical information to the patients’ physicians.

These visits seem designed for Optum to be able to increase risk scores, and thus collect more from Medicare. A possible scenario: order protein levels, often low in elderly patients, increase the patients risk score, and viola!  Optum collects more from Medicare, and thus from the pockets of TAXPAYERS. Apparently, someone in the Justice Department is paying attention, as United looks to be in the hot waters of fraud yet again.

All this money-making benefits the AARP, a formidable lobby force in DC. The AARP gets nearly 50% of its income from royalties the big insurance companies pay them to peddle Medicare advantage plans, the bulk from United/Optum. A mere  17% of AARP’s collections come from membership fees from its 37 million members.
https://capitalresearch.org/article/aarp-advocacy-group-or-crony-capitalists/

There you have it: big insurance and their PBM henchmen, hired by our government, teaming up with the AARP all getting rich gaming the system while Medicare patients get fragmented care and taxpayers pay more. Medicare advantage plans? They ought to call them “taking advantage of taxpayers plans. ”

Marion Mass, MD is co-chair of Practicing Physicians of America (PPA) and Craig M. Wax, DO is PPA’s VP of Health Care Policy.  Learn more: https://practicingphysician.org

American ingenuity and free markets can solve the problem of rising drug prices… if we allow it.

A couple of major threats to the health of the prescription drug supply chain are finally getting some long overdue attention.

  1. We are over-reliant on foreign production.

More than 90 percent of our prescription drugs are either manufactured in China or contain key ingredients that come from China, and China isn’t our best friend. Drugs on this Chinese-sourced list include antibiotics, birth control pills, cancer treatments, anti-depressants, statins (for high cholesterol), and HIV/AIDS drugs.

Why in the world are we outsourcing this mission-critical aspect of American medicine to countries hostile to our nation? (Not to mention the fact that countries like China are stoking the opioid epidemic by exporting deadly illicit Fentanyl to our shores).

Steve Jobs famously took the Obama administration to task over the main reason Apple had 700,000 factory workers employed in China, instead of the U.S:  D.C. is not business-friendly and it is impossible to build a factory in the United States due to regulations and unnecessary costs.

https://www.businessinsider.com/president-obamas-lack-of-resolve-frustrated-steve-jobs-2011-10

Unfortunately instead of cutting the red tape, Sen. Elizabeth Warren and colleagues are proposing exactly the wrong solution to bringing drug production back to the US of A. Instead of unleashing the market forces that built America into the #1 economy in the world, Warren hopes to import the same policies that sank behemoths like the U.S.S.R. and helped ignite the dumpster fires consuming Venezuela and Cuba: nationalized takeover of production.

Even the most profitable industries are not immune to the destruction that government-run production can bring. Case and point: Nationalization has driven Venezuela from oil powerhouse into the poorhouse:

So let’s look for proven solutions instead of dooming the drug industry to a fate of greater drug shortages, stagnation, and even higher prices.

Yes, there is already a sea of red tape and failed policies standing between American patients and inexpensive drugs. Thankfully, unlike Senator Warren, the Trump administration’s FDA Commissioner Scott Gottlieb MD and HHS Secretary Alex Azar seem truly interested in getting to work cutting through it by unleashing competition not warmed over communism.

Which brings us to the second major threat to the supply chain that is getting some overdue sunshine:

2) Kickbacks to Group Purchasing Organization and Pharmacy Benefit Manager Middlemen.

According to nomiddlemen.org:

GPOs and PBMs are perpetrating “a dangerous and unethical game of ‘pay-to-play.’ It’s the dirty little secret behind the outrageous cost of medications and the shortages of many drug and medical supplies. Unfortunately, a law was passed that allows these medical market “middlemen” to accept kickback payments from drug and medical supply companies in exchange for exclusive sales contracts! It created a government-sanctioned system of racketeering that would be illegal in any other industry.

 

The FDA along with HHS have signaled a willingness to end the kickbacks. And since the beginning of 2019 Senator Susan Collins and the new Chair of the Senate Finance Committee, Chuck Grassley have also stated they are going to take a close look at these shameful business practices

https://www.collins.senate.gov/newsroom/senator-collins-urges-administration-prioritize-reducing-drug-prices

https://www.grassley.senate.gov/news/commentary/grassley-top-priority-reducing-health-care-costs

Bottom line? American ingenuity can solve the problem of rising drug prices. If we will let it.

Take Action by Jan 11: Eliminate the #GPO #PBM Middlemen #Safeharbor Creating Drug Shortages and High Prices

“Drug shortages are pretty much a daily disaster right now for most hospitals,” reported Pharmacy Times on December 10. Meanwhile, “The US Food and Drug Administration (FDA) is not just seeing an increase in drug shortages but also a spike in the intensity and duration of shortages,” writes Zachary Brennan, summarizing conclusions from an FDA event last month.

This summer FDA Commissioner Scott Gottlieb, MD convened a Drug Shortage Task Force “to seek root causes of drug shortages and potential enduring solutions.”

The Task Force has issued a request for public comment as it prepares a report to Congress, and the deadline to submit solutions is January 11. Please help us, your colleagues, and your patients, take advantage of this opportunity to share a few key ideas with the Task Force.

Here’s how you can help! Continue reading

Be There! New Jersey Doctor-Patient Alliance Inaugural Summit

You will not want to miss this summit on February 8-9, 2019!

IP4PI’s own Craig M. Wax, D.O. will join an all star lineup as a featured speaker. Dr. Wax will share reform priorities that will help put doctors and patients back in the driver’s seat. It is time to put and end to the shenanigans politicians pull to hand advantages to their crony buddies in the hospital industrial complex. Patients and their physicians must team up to reclaim their rights, increase the availability, and slash the cost of high quality care.

Coming soon to an EHR near you: Downtime and Missing Patient Data

Electronic Health Records are often full of bloat and incorrect data, except when they are not accessible at all and/or relevant patient data isn’t even entered into the system. Here’s a frightening note from management sent to “providers” in one health system earlier this week:

Subject: Downtime Message to Providers
To the Health Network Medical Staffs :

On December 12 from approximately 7:30-10 AM the entire network experienced a EHR unplanned outage. It was due to a server issue in Kansas City and affected several customers. The Issue was identified quickly and remedied. We were back up in under 2 hours.

We identified the fact that data from the EHR had not transferred since Nov 16th. We failed to actively monitor that transaction so did not know that data transfer had failed. The data transfer issue has been fixed by our EHR vendor and we are putting a process in place to assure that the monitoring of the transmission of data happens without fail.

Your IS team understands that this impacted your workflow and we apologize. We continue to work toward no disruption in information flow at all times.

Chief Medical Information Officer

10 Reasons to ‘Refuse to Enroll’ in Obamacare

From our friends at Citizen’s Council for Health Freedom:

OPEN ENROLLMENT 2018: 10 Reasons to ‘Refuse to Enroll’ in Obamacare

‘Command and Control,’ ‘Claw Backs,’ ‘Narrow Networks’ and More Are Reasons to Stay Out of an Expensive, Privacy-Compromising Gov’t Plan.

Just a few days remain in the open enrollment period for the Affordable Care Act (ACA), and for those still on the fence, Citizens’ Council for Health Freedom (CCHF) is sharing the top 10 reasons to “Refuse to Enroll.”

“For more than eight years, the Affordable Care Act has been changing America’s health care landscape—and not for the better,” said CCHF president and co-founder Twila Brase. “Costs have skyrocketed because younger, healthier Americans wisely chose not to enroll, unlike the Obamacare architects thought they would. Health plans that were already making money hand over fist received bailouts for insuring older, sicker individuals, some with uninsurable conditions. With a new administration that’s making bold steps against the ACA way of doing health care, there are many reasons not to enroll in a flawed government system that compromises care, ties doctors’ hands and shares our private medical information.”

CCHF’s “10 Reasons Not to Enroll in Obamacare” include the following:

  1. Obamacarecoverage is a government program; not private insurance.
  2. It’s “a second Medicaid-style program,” said former CBO director Douglas Holtz-Eakin.
  3. The Affordable Care Act (ACA) exchanges facilitate redistribution of American’s wages, reported Fox News in 2010, just days after the law was signed.
  4. User fees added to premiums fund operations of these ‘command and control’ exchanges, according to an “Overview of Health Insurance Exchanges” from the Congressional Research Service.
  5. ACA exchanges may automatically enroll you in Medicaid, such as this story in Minnesota.
  6. If you underestimate your income, the IRS can ‘claw back’ premium subsidies you received.
  7. Your choices are limited, as a result of “narrow networks” of doctors and hospitals.
  8. Federal law and most states no longer penalize you for refusing to buy insurance.
  9. Health care sharing is a more affordable, cash-based option for coverage.
  10. The federal exchange database (“Health Insurance Exchange Program” System of Records) collects, stores and shares private information from all enrollees.

For many years, CCHF has also shared a list of wise—and legal—alternatives to signing up for costly government coverage:

  1. Buy private insurance outside the government exchanges, such as a private policy, employer-sponsored coverage or a private insurance exchange.
  2. Claim one of several general exemptions to the mandate or one of its many hardship exemptions. The Trump administration added several hardship exemptions in April, including one related to abortion, and also announced earlier this month that documentation is not required for those who take these exemptions.
  3. Become a member of a health care sharing ministry, a viable, affordable option for some families that is skyrocketing in enrollment—and the second of the nine general exemptions.

“Americans also need to understand that although the mandate and penalty are gone in a practical sense, they are technically still in place,” said Brase. “While Congress zeroed out the penalty tax starting in 2019, Congress did not repeal the ACA mandate to be insured or the penalty itself. It only zeroed out the penalty for going uninsured. The language for the mandate and the penalty are still in law, but the cost of the penalty is now zero dollars. While this provides welcome relief to many, a future Congress could turn around and easily reinstate the penalty for being uninsured because the penalty language is still in law. They could simply go from zero to whatever penalty they wish to impose for going uninsured.”

Americans should also know that the individual penalty was zeroed out beginning in 2019, so those who went without coverage in 2018 may be still on the hook for penalties—and may still be able to claim exemptions to avoid those penalties.

For more information about CCHF, visit www.cchfreedom.org, its Facebook page or its Twitter feed @CCHFreedom. Also view the media page for CCHF here. For more about CCHF’s initiative The Wedge of Health Freedom, visitwww.JointheWedge.comThe Wedge Facebook page or follow The Wedge on Twitter @wedgeoffreedom.

Federal Judge Ends Mandatory AOA Membership Tied to Board Certification

“A federal judge in Camden has granted final approval to an $84 million settlement of an antitrust class action against the American Osteopathic Association,” related to the tying of AOA membership to the ability to maintain specialty certification through Osteopathic Continuous Certification, reported the New Jersey Law Journal on December 4, 2018.

The lawfirm leading the case, Duane Morris, LLC, earlier reported on what is in the settlement:

In addition to agreeing to end its practice of conditioning AOA board certification on purchasing annual membership in the AOA, which was at the center of the lawsuit, the AOA has also agreed to provide a host of other economic benefits to the more than 45,000 class members, such as:

  • for three years reducing its annual dues by $90 and
  • waiving a $90 board certification fee;
  • for two years offering AOA members two free CME courses of up to 12 aggregate credits;
  • contributing not less than $2 million to an osteopathic awareness campaign;
  • eliminating distinctions between online and in-person CME for purposes of AOA membership;
  • lifetime board certification is restored for all those certified prior 1997;
  • committee of independent private practice physicians will be created to represent independent practice considerations to the AOA board; and
  • physicians will not lose membership in the AOA as a result of failing to meet the CME requirement, provided that the physicians meet the CME requirements for the state(s) in which they practice.

Weighed against the uncertainty and expense of protracted litigation, the valuable benefits the AOA has agreed to provide to resolve the claims against it demonstrate that the settlement is in the best interest of the class and sub-classes, as well as the AOA, stated Duane Morris.

https://www.duanemorris.com/pressreleases/osteopathic_physicians_class_action_settlement_0718.html

For a full copy of the settlement agreements, see:
https://www.duanemorris.com/site/static/AOA_joint_motion_for_certification_0718.pdf

For a full history of the suit, see:
https://www.duanemorris.com/site/osteopathclassaction.html

Here is the wording from the motion on the key items: