Governor Brown signs California’s Drug Price Transparency Act and Big Pharma Kills Ohio’s Drug Price Reduction Referendum

Last month, California adopted a law that requires drug makers to explain and justify price hikes, making it only the third state in the country to demand some transparency in response to rising medicine prices. While this act does not control pricing, the pharmaceutical industry vigorously fought this effort over concerns that other states will take similar actions.

California’s action is a response to the failed leadership of congress and the president to control the outrageous growth of prescription drug costs. Other countries with national healthcare such as Canada, Germany, England, France, Italy and many others require financial accountability and transparency from pharma companies and then negotiate drug prices based on the value produced and the best interest of their country.

By comparison, the United States Congresses and presidents have developed a hands-off policy with Big Pharma and have legitimized excessive drug prices by prohibiting Medicare from negotiating drug prices, like the VA does. They have also prohibited Americans from reimporting prescription drugs from Canada, England and other countries at a fraction of the prices charged in the US.

It should also be noted that Big Pharma spends hundreds of millions of dollars in the US on: direct marketing of prescription drugs to consumers and healthcare providers; and campaign contributions and lobbying congress and state legislatures to oppose any change in pharma’s dominant position with federal and state governments.

Unknown

Big Pharma’s Success in Killing Ohio’s Referendum to Reduce Drug Prices

On Election Day, Big Pharma scored another victory by crushing a grassroots initiative to reduce the inflated pharmaceutical drug prices paid by the State of Ohio down to the rates paid by the VA for the same drugs.

Big Pharma spent more than $75 million to kill recent Ohio ballot initiatives that threaten pharma’s massive drug revenue. They flooded Ohio television with negative, misleading and deceptive ads with the intent of creating confusion and opposition to change and were successful in defeating this consumer initiative.

In the absence of any congressional or presidential leadership on controlling drug prices, federal, state and local deficits will continue to rise due to outrageously high drug costs along with rising employer, individual and family debt.

Winners and Losers in the Repeal of the Affordable Care Act (aka Obamacare)

ryan_trump_mcconnell3-620x412.jpg

With the election of Donald Trump as president, Congressional Republicans are scrambling to come up with a repeal and replace plan that is acceptable to their various factions and president-elect Trump.

House Republicans have a lot of experience in successfully approving bills to repeal the ACA more than 60 times (without a replacement plan) over the past 6 years knowing that the Senate lacked the necessary votes to approve their bill.

While Republicans have labeled the ACA a disaster since it began 6 years ago, they have opposed every opportunity to work with the President and Democrats to design and improve the health insurance legislation. They have also been successful in arm-twisting Republican members of Congress and Republican governors to oppose the establishing state insurance exchanges, expanding Medicaid and providing tax credit subsidies to eligible low-moderate income uninsured Americans. Their actions have had had a negative impact on the large percent of workers who’s employers do not offer health insurance and the 40% of workers who are treated as “contingent” with no employer commitment to a work schedule or any benefits including health insurance.

However, the ACA has succeeded in enrolling more than 20 million people in exchange plans and another 14 million people have enrolled in expanded Medicaid in 31 states. This includes 16 Republican governors.

TrumpCard.jpeg

The Trump Wildcard

Now that Trump has been elected after campaigning on repealing and replacing the ACA, the fun really begins. While many people have jumped on the repeal bandwagon, the vast majority of people opposing the ACA don’t know what the impact will be on their ability to buy health insurance and receive services at a reasonable cost in the future.

The repeal and replacement of the ACA will also affect small businesses, state and local governments, health care providers and facilities, insurance companies & brokers, employees of large businesses and national and regional economies. The great uncertainty that remains is what specifically will be lost and gained.

Trump has campaigned as an independent, populist who is the “peoples’ choice” who is not indebted to any special interests. Time will tell.

Winners:Losers.jpg

Who are the Winners of the ACA Repeal?

Career Republican Politicians

The obvious, big initial winners from the repeal of Obamacare are career Republican politicians who have opposed all forms of tax-supported social supports including Social Security, Medicare, Medicaid and every universal health insurance proposal presented over the past 100+ years, including those proposed by various Republican presidents.

It should be noted that the US spends more than double what every other country spends for health care and prescriptions drugs and has poor health outcomes. Our system is a patchwork of multiple insurers, providers, payers that is costly, inefficient and ineffective that leaves millions uninsured with chronic and costly medical conditions.

From a political standpoint, opponents want to kill, not improve or replace, “Obamacare”. They want to obliterate President Obama’s landmark legislation from the history books.

Higher Income Individuals and Business Owners

Other winners are higher income individuals, who have experienced an increase taxes as a result of the ACA and employers who have experienced increased costs associated with compliance and implementation of the ACA. What is unknown is the cost of repercussions resulting from the repeal of the ACA.

Insurance Companies

Large, national for-profit insurers have to make the most changes to comply with and participate in selling uniform ACA insurance policies in both state and the federal insurance exchanges. Some insurers chose not to participate, others entered the exchange market late after millions were already enrolled and others, such as Aetna, United Healthcare and Humana dropped out of exchanges for 2017 as federal subsidies for catastrophic claims were expiring and their plans for merging with smaller companies were being scrutinized by federal regulators.

With potentially millions of insurance subscribers displaced as a result of the ACA repeal, it will likely cause a “death spiral”, state and federal insurance exchanges and plans for individuals who are not covered by group insurance plans. If it does, insurers will be losers of both subscribers and income. If insurers can negotiate positive changes for them with rate-setting, regulations and federal subsidies for high-need subscribers and regulator support for planned insurer mergers, they will be big winners.

Who are the Losers with the ACA Repeal?

  • The majority of Americans who have indicated in polls, that they only want improvements, not repeal, of the ACA.
  • Individuals who have pre-existing conditions may return to paying between $15,000 (ind.) and $30,000 (fam.) a year for private policies with increased co-pays and deductibles.
  • 14 million low-income individuals may lose their expanded Medicaid eligibility in 31 states
  • Young adults may find their new health insurance costs are unaffordable and chose to go uninsured.
  • Individuals with pre-existing conditions, chronic diseases and those that require costly medical & surgical treatment may find insurance & health care unaffordable and file for a medical bankruptcy.
  • Families with young-adult children, less than 26 years old, who have been covered on their employers’ family plans, may have significant new costs.
  • People who are at risk of serious diseases that may not be able to afford preventative screening tests that have been free.
  • Employees and employers who will require more education and support to understand differences in new  regulations, plans, coverage, benefits and true costs. This will have a negative effect on employee morale and productivity.
  • Insurance companies will lose up to $20 million existing ACA insurance plan subscribers along with up to $16 million in subsidies for low-middle income individuals.
  • Loss of federal tax revenue from select taxes and closed loopholes included in ACA to pay a portion of insurance costs.
  • Loss of brand-name prescription drug discounts and higher out-of-pocket expenses. for seniors.
  • Small employers, who have purchased or directed low-moderate income employees to insurance exchanges for subsidized policies, may face higher health insurance expenses and/or higher employee turnover.
  • Hospitals and health care professionals will likely face loss of insurance income, an increase in bad debts and increased administrative expenses to manage changes.
  • Health care quality and cost containment standards and strategies will be lost.
  • Loss of consumer protections and assistance in navigating a very complex and costly insurance/healthcare system

CBO.png

CBO Report on the Impact on Repealing the ACA

The non-partisan Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) just released a report on the impact of repealing the ACA on insurance coverage and premiums.

Without any replacement plan in place, the impact will be devastating including:

  • Increasing the number of uninsured by 18 million in the first year and rising to 32 million by 2026.
  • Premiums for individual policies would increase by 20%-25% in the first year and increasing by 100% by 2026
  • Eliminating subsidies to insurers and the individual mandate will destabilize the insurance market and reduce the participation of insurers in selling policies.
  • In the first year after subsidies are repealed, about 50% of the nation’s population lives in areas that would have no access to insurers participating in the individual policy market.

Final Thoughts

The first 100 days of the Trump administration should be very interesting. There will be a major transformation of The White House and management personnel.

And, the repeal and replacement of the ACA is just one of many domestic and foreign promises that Trump has made, but will be implemented by people who have largely not had any similar responsibilities or experience.

The public expects the positive results that Trump has promised and we will soon see the public’s reaction to the new administration’s performance.

With Congressional midterm elections scheduled for 2018, Republicans, who are up for re-election, have their political survival at stake.

 

 

 

Four Strategies for Reducing your Medicare Drug Costs

Why is the Cost of Medications so High?

Medications are a major out-of-pocket expense, especially for anyone with acute or chronic medical conditions. Unlike other countries with national health insurance systems, our Congress has supported the financial interests of Big Pharma and themselves and over interests of citizens to have access to affordable health care.

In return,Big Pharma has been a major source of more than $10 million a year in political contributions. In addition, they spend more on marketing to health care providers and  consumers than they spend on research and development of new medications to safely treat serious health conditions.

Medications that are critical to individuals’ health and well-being, are substantially more expensive in the US than in Canada, Europe and other countries.

Pharmaceutical companies are free to establish high prices for their government-protected patented drugs and this results in high consumer and government debt due to taxpayers subsidizing Big Pharma.

The US spending on pharmaceuticals is approximately $300 billion dollars a year. Political efforts to reform these  out-of-pocket expenses for medicare recipients have been very limited primarily to pharma companies agreeing to offer discounts to Medicare patients once they exhaust their initial Medicare coverage limits.

However, there are some strategies that consumers can use  to reduce and control their  medication expenses.

Strategies for Lowering Your Drug Costs

1. Know The Differences in Medication Cost and Coverage Before you a Select a Plan.

Medicare Advantage (MA) and stand-alone Prescription Drug Plans (PDP) are difficult to compare and can be very confusing for most people. However, not knowing the consequences of the plan that you select can be very costly.

Use Medicare’s Plan Finder at http://www.medicare.gov to compare the cost of medications among the different plans available in your service area. If you are changing insurance plans, don’t assume that the plan that you are considering includes the same medications and pharmacies.

Plans can often differ in their restrictions (eg. prior approval, quantity limit & step therapy) that they place on medications as well as the significant differences in Tiers and associated  co-pay/co-insurance that they establish for each medication.

Insurance companies and their pharmacy benefit managers (PBM) establish the plans detailed policies and procedures including:their drug formulary, medication restrictions, negotiated prices paid to pharmaceutical companies and pharmacies,  preferred medications and pharmacies, and the co-pays and co-insurances that consumers will pay.

2. Use your Plan’s Preferred and Mail Order Medications along with in-network, Preferred Pharmacies, Costco & Sam’s

Consumers can experience considerable savings by using your plan’s generic and preferred brand name meds whenever possible; making use of your plan’s mail order pharmacies for maintenance drugs and using your plan’s in-network and preferred pharmacies. And don’t forget to check with Costco and Sam’s. Many people don’t realize, you don’t have to be a club member to benefit from their low drug prices.

3. Check your Eligibility for Financial Assistance Programs.

If your income is low enough, your medical expenses are high enough or you meet other special criteria, you may be eligible for low or no cost medications.

Financial assistance can come from the federal (e.g.. Medicare’s Extra Help, Medicaid, Veteran’s Administration), state (State Pharmacy Assistance Programs such as NYS’s EPIC), private (Pharmaceutical Assistance Programs) or from specific clinical research programs.

4. Make Lifestyle Changes and Reduce Your Need for Medications

While you don’t have control of your genes, there are many things you can do for your health and reduce your risk of medical problems and need for medications.

Eating a healthy diet, exercising, getting adequate sleep, managing your stress, not smoking, limit your intake of alcohol, caffeine, sugar, salt, fat and processed foods will go a long way in reducing your risk of diabetes, cardiovascular diseases, hypertension, cancer and many other debilitating conditions can substantially reduce your quality of life and increase the need for costly medications.

When it comes to your health care, ‘buyer beware”.

Remember, no one has a greater interest in your health  or your pocketbook than you.

Feel free to share your comments and general questions.We all can learn from one another. Go to http://www.healthplanadvisor.org for more articles.

Thanks

Jim Sorrentino

How Congress Has Sold-Out Serious Ill Patients and Taxpayers to Big Pharma.

Background

medicationsBig Pharma is a trillion dollar industry that has established a practice of demanding outrageous ransoms for new breakthrough therapeutics to treat life-threatening and chronic debilitating diseases. And, Congress has legalized their behavior with the passage of Patent laws, the 2003 MEDICARE MODERNIZATION ACT (MMA) and weak government regulations, oversight and enforcement.

Big Pharma’s Money and Influence over Congress

Big Pharma leads all other industries in spending billions of dollars on lobbying to gain preferential treatment with Congress’s federal laws and administrative regulations. In addition, many members of Congress, administrative officials and health care providers have been generously rewarded for their support of Big Pharma over the interests of patients and taxpayer

big-pharma

According to a recent New York Times story, pharmaceutical and devise firms paid $6.5 billion to physicians and hospitals last year. About 80% of the total payments went doctors whose prescribing decisions directly affect the profits of pharma and device firms. Payments were made to 610,000 doctors and 1,100 teaching hospitals.

Congress-For-Sale

According to the Center for Responsive Politics (CRP), the pharmaceutical and health products industry employs more than 3 lobbyist for every member of Congress; spends about $1.2 million lobbying every day Congress is in session and has created a career path for dozens of loyal Congressional and administration public employees to become well-paid private-sector pharma lobbyists.

The vast majority of Democrats and many Conservative Republicans opposed the MMA bill for different political and ideological reasons and it initially passed the House by just one vote. However, the Republican House Leadership heavily lobbied members of Congress and Big Pharma spent over $125 million to convince Congress to pass this very complex and costly drug benefit in which they were the primary beneficiaries.

cash

To help build support, Big Pharma contributed nearly $10 million to federal candidates in the 2004 election campaign with 70% going to Republicans including more than $500,000 going to the re-election of President Bush.

Republican House Majority Leader Tom DeLay and Congressman Billy Tauzin were very effective in twisting arms, threatening and offering special deals to members of Congress who voted for this legislation.

Tauzin, who steered the bill through the House, quit after its passage to accept a $2 million a year job as president of the Pharmaceutical Research and Manufacturers of America (PhRMA). More than a dozen congressional aides and administrative staff also quit their jobs to work for pharma lobbying firms.

Tom DeLay left Congress in disgrace after charges of ethics violations and Bush appointee, Thomas Scully, administrator of the Centers for Medicare and Medicaid Services also left his leadership position to become a lobbyist for drug companies.

Other notable “wayward fiscal conservative” Republican leaders that publicly supported and encouraged the passage of this costly, unfunded drug benefit included: Newt Gingrich, John Boehner, Eric Cantor, Elizabeth Doyle, Paul Ryan, Mitch McConnell, Rick Santorum and Orin Hatch. With their strong influence over members, the MMA law was finally passed in 2003 with a slim margin by the Republican Congress and signed into law by President George W. Bush, just in time for his re-election campaign.

GWBushMedicare2  

Bush went on to win a tight re-election against John Kerry with the smallest popular vote margin of any sitting president since Harry S. Truman in 1948. The passage of this new, complicated, unfunded Medicare drug program had the desired outcome of significantly increasing senior votes in support of Bush from 47% in 2000 to 52% in the 2004 presidential election.

Congress’s Unfunded Trillion-Dollar Medicare Drug Program

There has been long-standing public interest to reduce the high cost of health care and prescription drugs in the United States and to make these necessities available and affordable to everyone including seniors, similar to what has been done in Canada and European countries for decades.

However, partisan political conflicts and the controlling influence of millions of dollars from special interest to Congress has resulted in the status quo which profits the health care industry at the expense of patients, taxpayers and employers.

The new 2003 Medicare drug legislation did not include any cuts to existing federal spending to offset this new, costly benefit or to reduce the growing federal structural deficit for the existing Medicare Part B outpatient services and the Medicare Advantage plans that are run by private insurers.

Rather, the new Medicare Part D drug benefit, that it is run by private insurance companies, was made available largely by increasing the federal deficit.

Medicare beneficiaries contribute only 14% of the drug program cost and taxpayers pay the remaining 86%. The cost of the program is expected to grow significantly over the foreseeable future, due to uncontrollable drug prices established by drug makers and the growing senior population that uses them.

The annual cost of this drug program has grown dramatically to an estimated $76 billion in 2015. And, the 2014 Medicare Trustees report, projects the federal deficit just for the Medicare Drug program is estimated to go over $1 trillion in the year 2023.

2014-2024-debt bomb

Congress Restricts Competition, Purchasing Power and Consumer Protections

The 2003 MMA also includes a number of provisions that clearly benefit the financial interest of Big Pharma over the interests of patients, taxpayers and employers.

These include:

  • prohibiting Medicare from negotiating drug prices for over 55 million Medicare beneficiaries; eliminating price competition with extended-term drug patents;
  • making it illegal for citizens to purchase the same patented drugs, at a fraction of the price charged in the US, from Canada and other countries;
  • allowing pharma companies to increase the demand for their drugs by directly marketing them to consumers on TV and other media;
  • allowing pharma companies to withhold full disclosure of clinical data, adverse side-effects/incidents and the actual cost/benefit of drugs;
  • providing minimum government oversight and sanctions for illegal and unethical pharmaceutical and device-maker behavior.

I welcome your questions and comments.

Future blogs will describe in greater detail: the high cost of specialty drugs; how drug prices are established; the backlash from stakeholders; and some hope for future changes.

Aetna’s Pharmacy Controversy Affects 400,000 and Medicare Allows Subscribers to Disenroll

According to the 2/3/15 Kaiser Health News (KHN) report, Aetna’s errors and omissions in providing prospective and existing Medicare subscribers with accurate network Pharmacy information has affected 400,000 individuals.

The inaccurate and confusing information can affect the individual’s actual cost of their medications as well as potentially ending subscribers’ relationships with their preferred pharmacist and most convenient pharmacies. As a result, the federal Center for Medicare and Medicaid Services (CMS) is offering Aetna subscribers to either select a participating pharmacy that meets their needs or use a special enrollment period through February 28, to disenroll from Aetna and enroll in another Part D prescription drug plan.

Aetna, like a number of other insurers, has established a pharmacy benefit program that utilizes their size and national clout to drive hard deals with drug companies and pharmacies. They want to reduce their cost in exchange for offering a higher volume of business with less competition to their preferred drug companies and pharmacies.

Insurance companies through Pharmacy Benefit Managers (PBM) establish a complex structure of classifying drugs in different classes or tiers with associated co-pays or co-insurances and then add different restrictions such as requiring deductibles,prior authorization, step-therapy and quantity limit for subscribers.

Aetna’s program is a little more complex than other insurers in that they have a limited number of network pharmacies (especially local vs. national) that are grouped into either standard pharmacies and  a smaller number of preferred pharmacies. They also operate their own Aetna Rx Home Delivery pharmacy.

Aetna does offers subscribers choice for the meds and pharmacies that they use, but at a very high price. To illustrate, in the Aetna Medicare Premier PPO plan offered in Rochester, NY, if you want to use a “non-preferred brand” name medication on Aetna’s list of approved meds you will have to pay 50% of the cost for a 30 day supply vs. $45 for a “preferred brand”. Your co-pay for a 90 day supply of a “preferred generic” will be $8 (80%) more at a “standard” vs. ‘preferred” pharmacy and your co-pay for a 90 day supply of a “non-preferred generic” will be $18 (180%) more than a “preferred generic’ medication. Each insurance company through their PBM choses which drugs to include/exclude and in what tier and co-pay/co-insurance. These decisions vary among companies and are only subject to broadly written Medicare rules.

While Aetna has made a major push to expand their presence in the national Medicare Advantage market for 2015, they have not been ready for last year’s Fall Medicare open enrollment period. They heavily advertised and marketed their zero premium “Premier” plan but I have witnessed and heard numerous consumer complaints about their call centers and website regarding the accuracy of participating doctors and hospitals and being very slow in establishing provider contracts.

Hopefully Aetna will learn from this year and make changes in their plans that are responsive to seniors needs and priorities.