For years, congressional Democrats have tried to pass legislation to allow Medicare to negotiate prescription drug prices for millions of beneficiaries.
Now, they believe they have a not-so-secret weapon: President Donald Trump.
On Wednesday, U.S. Reps. Elijah Cummings (D-Md.) and Peter Welch (D-Vt.) met privately for about an hour with Trump and newly appointed Health and Human Services Secretary Tom Price to discuss ways to combat high drug prices. They were joined by Johns Hopkins Hospital President Redonda Miller.
The congressmen pitched a House bill that would expand the federal government’s ability to negotiate drug prices, and they left feeling optimistic about what Trump will do.
“He made it clear to us that he wanted to do something,” Cummings said, characterizing Trump as “aware of the problem” and “enthusiastic.” Cummings is ranking member of the House Committee on Oversight and Government Reform.
Trump tweeted the day before the meeting with Cummings and Welch that he is “working on a new system where there will be competition” in the drug industry. After the meeting, Trump relayed his desire to work “in a bipartisan fashion to ensure prescription drug prices are more affordable for all Americans.”
I am working on a new system where there will be competition in the Drug Industry. Pricing for the American people will come way down!
— Donald J. Trump (@realDonaldTrump) March 7, 2017
Allowing the federal government to negotiate drug prices is not a new idea, but Cummings and Welch painted a picture Wednesday of a political landscape that is ripe for change. They said they have a president who “gets it.”
And, Welch said, “the price is starting to kill us, we just can’t afford it.”
The lawmakers said they handed Trump and Price a bill to review and make comments. Cummings said he hopes to file the bill in two weeks.
A summary posted on the House committee website said the HHS secretary could negotiate lower prices with drug manufacturers under Medicare Part D, which provides coverage for prescription drugs bought at pharmacies.This KHN story also ran on NPR. It can be republished for free (details).
An estimated 41 million Americans are covered by Part D. The drug benefit is provided through private insurers who each have their own formulary and generally use pharmacy benefit managers for drug purchasing. The latest proposal would direct the HHS secretary to establish a formulary, which is a list of allowed drugs.
The formulary would be used to “leverage” the purchasing power of the government, according to the summary.
Douglas Holtz-Eakin, a former director of the Congressional Budget Office and president of the American Action Forum, said the idea of lowering prices through Medicare Part D negotiations is “completely unrealistic.”
Holtz-Eakin pointed out that insurers are already used to managing health care for beneficiaries and there are formularies in those plans. Adding into the law that the HHS secretary should be part of the negotiations merely adds a “bully pulpit,” he said.
“The problem with the negotiation in Part D is not a political, partisan problem, it’s that it won’t work,” said Holtz-Eakin.
Trump himself, though, has long embraced the idea of Medicare negotiating drug prices. On the campaign trail in January 2016, he told a crowd in New Hampshire that Medicare could “save $300 billion” a year by getting discounts as the biggest buyer of prescription drugs, according to the Associated Press.
“We don’t do it. Why? Because of the drug companies,” Trump said.
PhRMA, the drug industry’s powerful lobbying group, says price negotiation is already happening.
“Large, powerful purchasers negotiate discounts and rebates directly with manufacturers, saving money for both beneficiaries and taxpayers,” PhRMA’s Holly Campbell stated in an email late Wednesday.
She pointed to a Congressional Budget Office report that said HHS would not be able to negotiate lower prices than already exist.
Trump met with pharmaceutical executives in January and told them “we have to get prices down for a lot of reasons, we have no choice.”
Umer Raffat, a research analyst at Evercore ISI, said the industry felt less jittery after that meeting. They walked away understanding that Trump wants to “promote innovation” while addressing prices.
KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.
CHICAGO — At least once a day, Dr. Lee Ann Lindquist gets an urgent phone call.
“Mom fell and is in the hospital,” a concerned middle-aged son might report.
“Dad got lost with the car, and we need to stop him from driving,” a distraught middle-aged daughter may explain.
“We don’t know what to do.”
Lindquist, chief of geriatrics at Northwestern University’s Feinberg School of Medicine, wondered if people could become better prepared for such emergencies, and so she designed a research project to find out.
The result is a unique website, www.planyourlifespan.org, which helps older adults plan for predictable problems during what Lindquist calls the “last quarter of life” — roughly, from age 75 on.
“Many people plan for retirement,” the energetic physician explained in her office close to Lake Michigan. “They complete a will, assign powers of attorney, pick out a funeral home, and they think they’re done.”
What doesn’t get addressed is how older adults will continue living at home if health-related concerns compromise their independence.NAVIGATING AGING
Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.
To contact Judith with a question or comment, click here.
For more KHN coverage of aging, click here.
“People don’t want to think about the last 10 or 15 years of their life, and how they’re going to manage,” Lindquist said.
This isn’t end-of-life planning; it’s planning for the period before the end, when health problems become more common.
Lindquist and collaborators began their research by convening focus groups of 68 seniors — mostly women with an average age of 74. Nearly $2 million in funding came from the Patient-Centered Outcomes Research Institute, created under the Affordable Care Act.
Investigators wanted to know which events might make it difficult for people to remain at home. Seniors named five: being hospitalized, falling, developing dementia, having a spouse fall ill or die, and not being able to keep up their homes.
Yet most participants hadn’t planned for these kinds of events. Investigators asked why.
Among the reasons seniors offered: I don’t know what to do, I’m uncomfortable asking for help, I’m not at immediate risk of something bad happening, my children will take care of whatever I need, and I’m worried I won’t have enough money, according to a research report published last year.
Developing the website came next. Lindquist and her team decided to focus on three issues the focus groups had raised — hospitalizations, falling and developing dementia — and to include sections on communicating with family members and managing finances.
A group of senior advisers rejected the first version: the typeface was too small; the design, too cluttered; and the content, too complex. They didn’t want to be overwhelmed with information; they wanted the material on the site to be practical and concrete.
The final version “forces people to sit down and think about their future in a very helpful and non-threatening way,” said Phyllis Mitzen, 74, who worked on the project and is president of Skyline Village in downtown Chicago, a community organization with about 100 older adult members.
An individual going through the material is asked to consider a series of questions after examining explanatory information and watching short videos of seniors illustrating the issues being discussed. For instance, which rehabilitation facility would you like to go to if you need intensive therapy after a hospitalization?
Who will take care of your pets, mow your lawn or shovel the snow from your sidewalk while you’re away? Who can collect your mail, check on bills to be paid and get medications for you when you return home?
If you begin having memory problems, who can help you manage your bills and finances? Are you willing to wear a medical alert bracelet if you start getting lost? Would you be willing to have a friend or relative check on your driving or have a formal driving evaluation?
If you require more assistance, are you open to having someone come in to help at home? Would you prefer to live with somebody — if so, whom? Would you be willing to move into a senior community?
The goal is to jump-start conversations about these issues, Lindquist said, just as seniors are encouraged to have conversations about end-of-life preferences.
Those looking for deep dives into topics highlighted on the site will have to look elsewhere. Resources listed are spare and some of the material presented — for instance, how Medicare might cover various services — is overly simplified, noted Carol Levine, director of the United Hospital Fund’s Families and Health Care Project in New York City.
Her project has prepared a much more detailed, comprehensive set of guides for family caregivers about issues such as home care, doctors’ visits, emergency room care, rehabilitation and what to expect during and after a hospitalization. Those materials are full of useful advice and can flesh out issues raised on the Northwestern website.
As for next steps, Lindquist contemplates disseminating PlanYourLifespan more widely, translating it into Spanish if funding can be secured and possibly expanding it to include more topics.
The point is to “give seniors a voice,” she said. Now, if an older woman breaks a hip and is rushed to surgery, “loved ones run around and usually make decisions without her input — she’s usually too out of it to really weigh in. That doesn’t have to happen, if only people would consider the reality of growing older and plan ahead.”
We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.
Los Angeles County arguably has more to lose than any other California county if the Affordable Care Act is repealed or dramatically scaled back.
With more than 10 million residents, it is the state’s most populous county by far ― a distinction reflected in the number of Angelenos who obtained health coverage under Obamacare.
About 1.2 million L.A. county residents have signed up for Medi-Cal, the state’s Medicaid program, under its expansion, which is a central pillar of the Affordable Care Act. They account for roughly a third of all Medicaid expansion enrollees statewide, according to county statistics.
In fiscal year 2015-2016, the county received about $900 million in federal money to serve that population, said Mitch Katz, director of the Los Angeles County Health Agency.Use Our ContentThis story can be republished for free (details).
More than 300,000 county residents also have purchased subsidized health plans through the state’s health insurance exchange, Covered California, another key element of Obamacare.
Katz is a practicing physician who ran San Francisco’s public health department before coming to Los Angeles. He believes state and local leaders must find ways to cover some or all of the L.A. County residents ― and Californians ― who might lose coverage if the health law is repealed.
He’s not alone.
Last week, the Los Angeles County Board of Supervisors adopted a motion calling on L.A. county health officials to “develop options” to maintain or extend coverage in the county and state if the law is repealed or significantly changed. It directs them to report back to the board in 60 days.
California Healthline recently spoke with Katz about his ideas. The interview was edited for length and clarity.
Q: How has Los Angeles County benefitted from the ACA?
L.A. County’s Department of Health Services cares for about 300,000 people who have Medicaid due to the expansion. Those people are now covered while they would have once been uninsured. Prior to the Medicaid expansion, they would have come to us and we still would have cared for them. But what we have done with that money from the expansion is we have pumped it into making the system work. We now have an electronic health record that covers our entire four-hospital, 19-health-center system. And that makes everybody’s care better.
Because we now have more revenue dollars, we have increased general funds to provide coverage through My Health LA, which is the program that covers 145,000 people who are ineligible for the ACA, largely because of the fact that they are not documented. Those people now are all given a primary care home at one of the community clinics.
Q: What should California do if Obamacare is cut or repealed?
There’s no question that a state can create a plan. Before there was the ACA, there was the Massachusetts state plan, so-called RomneyCare. The ACA was largely modeled under RomneyCare.
California had two bills to create a plan before the ACA. At the end of the day, they harmonized them but it didn’t go forward. If you look back, the disagreement wasn’t, “Oh, I don’t know if we should really provide insurance.” The disagreement was on what kind of coverage are we providing and who’s paying for it.
But the state of California made a decision approximately two years ago that I very much support to cover children 0 to 19 who are undocumented. You could view it as an improvement of the ACA.
I think California has a different set of values. It’s not required. We’re doing it because we believe these children are in our country and we should keep them healthy.
We’ve made a decision as a state that we’re prepared to pay for this service even though the federal government does not.
Given that that’s true, maybe there are other things we as a state would like to do either that are not currently in the ACA or that might be taken from the ACA.
Q: What has changed that would make a California plan more likely to succeed now?
One thing that’s changed is that we’ve learned some things from the ACA. We’ve learned that when you get coverage, it actually improves health status.
Second, now we not only have Covered California, but it is widely considered to be the most successful exchange in the country. If you closed down Covered California, you would lose all the money you put in there.
Covered California does not need the ACA in order to exist. The issue is that 85 percent of the people getting coverage on Covered California are getting a subsidy. If you shrink the subsidy sufficiently, people will not be able to afford it. But you actually now have the infrastructure to provide people coverage.
The third thing that’s changed is now people are about to lose something that they hold precious. Before you were talking about creating something that people wanted. But it is more compelling when people are about to lose something that has helped them.
There might be a will at this point to create a plan to fill holes that are created by changes in the ACA.
Q: Where would you find the money to pay for it?
At this moment, all I’m saying is that we should prepare to be sure we know what the plan looks like that we want in California and start thinking about how we might support it if we need to.
The Vehicle License Fee that [former Governor Arnold] Schwarzenegger rolled back is worth [several] billion. If you put it back, is that enough? No. On the other hand, when the Vehicle License Fee was in place, we all paid it.
I would also urge people to consider why insurance is so expensive. It’s expensive because medical care is so expensive. Maybe in California, because California is different, we could better control costs.
California uses nursing homes at a higher clip than some other states. If we offered more opportunities for people to be in assisted living, which is significantly less expensive than nursing homes, we would be able to reduce costs. I think we could also do a lot better in California on limiting the use of unnecessary antibiotics.
My point is not to say any of these need to be done. If you want to try to cover people and get them the care they need, and the answer is “it’s too expensive,” you can do one of two things.
You can say, “O.K., well if you’re wealthy and employed, then you get it, and if you’re poor, you don’t get it.” Or you can say that because we uphold the values very strongly of equal access, we can look really hard at decreasing costs.
Q: In what other ways could the state provide for coverage?
The ACA has an employer mandate. The way it works is if you have at least 50 employees, you have to cover at least 95 percent of your workers. On a state level, you could go lower. You could say it applies if you have at least 20 employees. That’s a way of broadening coverage.
We could also increase taxation for those things that lead to bad health. You have tobacco taxes. We just passed a $2-per-pack increase. You could look at marijuana, alcohol and hard liquor, and sugared drinks. California has no statewide tax on sugared drinks.
Q: Who ― and what ― would this plan cover?
Ideally, I would want the coverage to be as comprehensive as possible. I understand the idea that if you don’t have enough money to cover everyone for everything, you either choose who you’re not going to cover for anything or you figure out what you can afford for everyone.
I personally subscribe to the value of trying to provide a basic level of service to everyone, if there’s not enough money to provide comprehensive services.
It’s not always easy to decide, but just because it’s not easy, I don’t think is an excuse to not do it, because the default is then that certain people get thrown off the boat.
In the days before the ACA, who got thrown off the boat? Those people who couldn’t pay for it. Now we’ve given them a hand up and we’ve said, “you know what, just because you couldn’t pay doesn’t mean you shouldn’t get health care.” If the ACA is going to toss them off the boat again, I’d like to catch them.
After literally years of promises, House Republicans finally have a bill they say will “repeal and replace” the Affordable Care Act.
Some conservative Republicans have derided the new proposal — the American Health Care Act — calling it “Obamacare light.” It keeps intact some of the more popular features of the ACA, such as allowing adult children to stay on their parents’ health plans to age 26 and, at least in theory, ensuring that people with preexisting conditions will still have access to insurance.
In some cases the elements of the law that remain are due to political popularity. In others, it’s because the special budget rules Congress is using — so Republicans can avoid a Senate filibuster — do not allow them to repeal the entire law.
But there are some major changes in how people would choose and pay for health care and insurance. Here are some of the biggest:
Tax Credits To Help Buy Insurance
Both the GOP bill and the ACA provide tax credits to help some people pay their premiums if they don’t get insurance through work or government programs. And in both, the credits are refundable (meaning people who owe no taxes still get the money) and advanceable (so people don’t have to wait until they file their taxes to get them). But the GOP’s tax credits would work very differently from those already in place.Use Our ContentThis KHN story can be republished for free (details).
Under current law, the amount of the credit is tied to a person’s income (the less you earn the more you get) and the cost of insurance where you live.
The GOP tax credits would be tied largely to age, with older people getting twice as much ($4,000 per year) as younger people ($2,000). But the Republican plan would also let insurers charge those older adults five times as much as younger adults, so even a credit twice as big might not make up the difference in the new, higher premiums.
The GOP credits also do not vary by location, so they would be worth more in places where health care and health insurance is less expensive.
The GOP credits do phase out gradually, starting with incomes above $75,000 for an individual and $150,000 for families.
The biggest changes the Republican bill would make are to the Medicaid program. Starting in 2020, it would roll back federal funding for the ACA’s expansion that allowed states — if they so chose — to provide Medicaid coverage to all low-income individuals under 138 percent of the poverty level, rather than just the specific categories of poor people (children, pregnant women, elderly, disabled) who were previously eligible. Thirty-one states opted to pursue this ACA provision. People who are covered under the expansion would continue to be funded by the federal government after that, but states would no longer be allowed to enroll anyone under those expanded criteria. And an enrollee who loses eligibility for the expansion program could not re-enroll.
But the bill would go further as well, making changes to the underlying Medicaid program that House Energy and Commerce Committee Chairman Greg Walden (R-Ore.) described as “the biggest entitlement reform in the last 20 years.”
Currently, Medicaid costs are shared between states and the federal government, but the funding is open-ended, so the federal government pays its percentage of whatever states spend. Under the proposed bill, the amount of federal funding would be capped on a per-person basis, so funding would go up as more people qualify. But that per-capita amount might not grow as fast as Medicaid costs, which could leave states on the hook for an ever-increasing share of the costs of the program.
“Capping federal contributions to the Medicaid program will likely force states with already tight budgets to limit eligibility and cut benefits to at-risk Americans,” said the American Public Health Association in a statement.
Help For Wealthier People
If you earn a lot of money, or even just enough to put aside something extra for health expenses, the GOP bill will provide a lot to like.
First, it would repeal almost all of the taxes that were increased by the ACA to pay for the expansion of health coverage. Those include higher Medicare taxes for high-income earners, a tax on investment income, and various taxes on health care providers, including insurance companies, makers of medical devices and even tanning salons.
The bill would also provide new tax advantages for those who can afford to save — including allowing more money to be deposited into health savings accounts, and lower penalties for those who use those accounts to pay for non-medical needs.
In addition, the plan would lower the threshold for deducting medical expenses on income taxes and allow people with job-based tax-preferred “flexible spending accounts” to put away more money pre-tax. It would also restore over-the-counter drugs as eligible for reimbursement from those accounts.
Mandates To Buy Or Provide Coverage
The GOP plan doesn’t actually repeal either the requirement for individuals to have coverage or for employers to provide it. That’s because it can’t under budget rules. Instead, the bill would reduce the penalties in both cases to zero, rendering the requirements moot.
The individual requirement was used by the health law to force healthy people into buying coverage to help improve insurers’ risk pools since they could no longer bar customers with preexisting conditions. Instead of the requirement that most people obtain health insurance or pay a penalty, the Republican plan would provide a penalty for those who do not maintain “continuous coverage.” Those with a break in insurance coverage of more than 63 days could still purchase insurance without regard to preexisting health conditions, but they would be required to pay premiums that are 30 percent higher for 12 months.
The employer “mandate,” which requires firms with 50 or more workers to offer coverage or pay a fine, has actually had relatively little impact on insurance coverage, analysts have concluded, and probably is not necessary to prevent employers from dropping coverage. In both the ACA and the GOP bill, however, workers whose employers offer coverage could not decline that coverage and get a tax credit instead.
How To Pay For It
With all the taxes and fees stripped from the ACA, how will Republicans pay for their tax credits? The answer is not clear yet.
“We are still discussing details, but we are committed to repealing Obamacare and replacing it with fiscally responsible policies that restore the free market and protect taxpayers,” said the Republican fact sheet that accompanied the release of the bill.
Also still missing is an estimate from the Congressional Budget Office that will detail not only how much the proposal will cost, but also how many people would gain or lose health insurance. Republicans insist that estimate will be available before the full House votes on the bill.
Firsts can be life-changing — think about your first kiss, your first time behind the wheel of a car. But what about the first time you got a prescription for a narcotic?
James Hatzell, from Collingswood, N.J., is now a technology officer for a college addiction treatment program. He didn’t realize it at the time, but that spring day of his junior year of high school — seven years ago — was a pivotal moment in his life.
“We’re in our 2001 Honda Odyssey minivan, driving to the dentist,” Hatzell recalled. “And we get there, and I’m just pumped. I was very excited to get my wisdom teeth out.”
The prospect of pain didn’t thrill the teen, but he’d heard from friends that when the dentist took out his teeth, he’d get his very own bottle of pain pills.
Those pain pills, Hatzell now says, eventually derailed his life.
Dentists have long been frequent prescribers of immediate-release opioids like Vicodin and Percocet for the pain from tooth extractions. That’s a lot of pills and teeth; annually more than 3.5 million people, mainly young adults, have their wisdom teeth removed.This story is part of a partnership that includes WHYY, NPR and Kaiser Health News. It can be republished for free. (details)
For many patients, these drugs never pose a problem. But deaths of some 165,000 people in the U.S. in the past 15 years involved an overdose of heroin or opioids, and many other people are struggling with addiction. Health officials say the nation’s major epidemic of drug use has been fueled by the misuse of prescription painkillers.
So dentistry is at a crossroads. Many in the field are now reassessing their prescribing habits, with state dental boards and associations issuing new guidelines for patients and practitioners. As of this year, Pennsylvania requires new dentists and those renewing their clinical license to get training in the best practices of prescribing opioids.
Hatzell says he was always a little afraid of narcotics in high school, until that day he had dental surgery. He’d tried Vicodin recreationally before that, he says, but with caution. Friends would find an extra pill in a medicine cabinet at home; they’d crush it, mix it with pot and share it.
But getting his own prescription from a health professional felt different, Hatzell recalled. It seemed legitimate — like maybe it wasn’t as dangerous as he’d feared.
On the way home from the dentist’s office that day, Hatzell was still high from the drugs he was given during the procedure and could not wait to pop his first pill.
His mom noticed.
“We got home, and my mom took the pills and was like, ‘You can’t have these,’ ” he said.
But he knew where she’d hid the bottle. When she wasn’t watching, he sneaked into her room, emptied out the pills and replaced them with Advil.
“I definitely was every parent’s worst nightmare,” Hatzell said, laughing.
He can joke about that day now, he said, but what opioids did to him and his family wasn’t funny. A few years later, he was arrested for dealing drugs in college.
A 2011 study in the Journal of the American Dental Association estimates that dentists are responsible for 12 percent of prescriptions for fast-acting opioid pain relievers — just below general practitioners and internal medicine doctors as top prescribers of common opioids. Roughly 23 percent of opioids in the U.S. are used non-medically, according to the study.
Dr. Joel Funari, a dentist who specializes in oral and maxillofacial surgery in Devon, Pa., said that when he started out as a dentist more than three decades ago it was common to prescribe a bottle of 30 or more narcotic pills after procedures such as a wisdom tooth extraction. He now calls that excessive prescribing.
“Dentists don’t like to see patients in pain,” Funari explained. “We tend to be compassionate people, and I think we were falling into a trap we were creating ourselves.”
In 2014, Funari joined a group tasked by the Pennsylvania Department of Health to develop prescribing guidelines for dentists. In reviewing the science, he and his colleagues realized there’s a better way to address standard dental pain.
“Non-steroidal anti-inflammatory drugs — the Motrins, the Advils, the Aleves — when used in a certain way, are very effective,” Funari said. “More effective than the narcotics.”
NSAIDs reduce inflammation, which is a main source of the pain, he said. And because wisdom tooth removal is so common, it has actually been an ideal procedure to study the benefits from this alternative in treating pain.
The 2014 guidelines that Funari and his colleagues came up with are the state’s first to tackle how to best use a combination of opioids and other drugs to manage pain in dental patients. National discussions have been expanding, too.
Dr. Paul Moore, a dentist and pharmacologist at the University of Pittsburgh’s School of Dental Medicine, studies the relative usefulness of ibuprofen and other NSAIDs in acute pain management, and worked on a recent update of the American Dental Association’s prescribing guidelines for opioids. It was the national group’s first update on the topic in a decade, Moore says.
The effort to get dentists and dental students to be wiser prescribers recently became personal for Moore. Among the more than 3,000 overdose deaths in Pennsylvania last year, one young man was Moore’s nephew. The growing abuse of opioids by adolescents particularly concerns him.
“I’m very sensitive to the issue,” he said.
Prescribing more pills than are needed to mitigate pain, Moore said, leaves extra pills or an unused prescription that can be sold or abused.
Dr. Elliot Hersh, a professor of pharmacology and oral surgery at the University of Pennsylvania School of Dental Medicine and a research collaborator of Moore’s, said he regularly brings in a retired narcotics officer to address his class of dental students.
“I’ve been teaching my students that you have to be really, really careful with these drugs,” he said. “That if you write too many of these prescriptions, for either good or bad intentions, either the state dental board and/or the DEA [Drug Enforcement Agency] is going to come down on you.”
Hersh said one of the biggest hurdles in improving prescribing habits is countering — among his students, practicing dentists and patients — long-held misunderstandings about the pain-relieving power of less addictive drugs.
NSAIDs work at least as well as opioids, he said; they just haven’t received as much hype, because they’re available over the counter.
“A lot of the lay public believes if they’re available over the counter, they’re weak and they don’t work,” Hersh said.
Hatzell is 23 and has been in recovery for his opioid addiction for three years. He says one of the most terrifying thoughts he faces as he navigates his recovery is that he might need surgery one day and again need pain medication.
These days, whenever he goes to a dentist or doctor, he makes it a point to say right up front that he cannot take opioids.
An electronic program launched in 2012 by Los Angeles County’s health care system has reduced wait times for specialty care and eliminated the need for some safety-net patients to see specialists at all, according to a new study in the journal Health Affairs.
The program, eConsult, allows primary care doctors to get specialists’ advice for their patients and expedite referrals for those who need in-person appointments. About a quarter of the requests included in the study were resolved without patients needing to see an advanced-care doctor, though there was variation among the specialties.
“It completely changed how specialty care was delivered in a safety net system,” said Michael Barnett, an assistant professor of health policy and management at Harvard T.H. Chan School of Public Health and lead author of the study.
The Los Angeles County Department of Health Services provides care for about 670,000 patients each year in a system that includes four hospitals, 19 health centers and dozens of community providers. The system serves a low-income population — mostly uninsured or covered by Medi-Cal — who traditionally have had difficulty getting access to specialty care.
The eConsult system handles over 17,000 requests each month. About 4,500 providers from more than 400 clinics use the system, according to the county. In 2016, the program served about 130,000 patients.Use Our ContentThis story can be republished for free (details).
One of the major benefits of the eConsult system is that it centralizes requests for care from specialists such as cardiologists, neurologists or gynecologists, Barnett said.
Primary care doctors using eConsult have access to a secure, web-based portal to make requests for assistance from specialists. A specialist “reviewer” responds and helps the primary care physician decide how best to manage the patient’s condition.
That may mean giving advice, suggesting a specific treatment or recommending the patient see a specialist. If a patient needs a visit right away, the system allows for an expedited appointment.
In many cases, primary care doctors can resolve clinical issues with their patients simply by having a conversation, Barnett said. “Many referrals are for issues that could be resolved pretty easily if a primary care doctor could get a specialist’s attention,” he said.
That means those patients wouldn’t need to take another day off work, figure out transportation across town and wait to see a specialist, said Paul Giboney, director of specialty care for the Los Angeles County Department of Health Services. Instead, the care could be delivered in the offices of their primary care doctors.
About 30 percent of patients who needed a face-to-face visit with a specialist in 2015 were able to get one within 30 days, up from 24 percent in 2014.
Difficulty getting appointments with specialists is a challenge for low-income patients across the United States. Without timely access, patients may get sicker and turn to the emergency room for care.
That was happening on a large scale in L.A. County before the implementation of the eConsult program. Some patients had to wait more than nine months for an appointment with a urologist or a gastroenterologist, for example, the study said.
The eConsult program started as an experiment to reduce the backlog, but Giboney said the county’s public health care system is now using it “day in and day out.”
Despite the size and complexity of the Los Angeles County health care system, the eConsult program works efficiently, suggesting that “specialty access is not an intractable problem,” the study said.
Giboney said the results show that electronic conversations between primary care doctors and specialists can improve the way business is done.
“Within a day, the specialist is already engaged and adding something to the patient’s care,” he said. “We are a public system that is delivering a speed of specialty care that is really unmatched.”
Since eConsult was rolled out in L.A. County, Giboney said he has talked to providers from Colorado, Illinois and Connecticut about starting similar programs.
Despite the efficiency of the system, Barnett said, there is still room for improvement on the wait times. The average amount of time it took for a patient to see a specialist in 2015 was still 52 days, though it had dropped about 17 percent from 63 days in 2014.
Patients who needed ear, nose and throat doctors and those who had kidney problems, cancer or blood diseases saw the most dramatic reductions in waiting time. The wait to see an ear, nose and throat specialist, for example, dropped from 72 to 44 days.
Wait times increased in only one of the dozen specialties examined: Patients had to wait on average 75 days in 2015 to see a podiatrist, up from 65 the previous year.
Barnett said the next step is to study the impact of the program on quality of care.
Giboney said he isn’t satisfied with the wait times either, despite the reduction, but he noted that sometimes doctors want patients to wait a few weeks to see if a treatment is working before going to see a specialist.
“It is not always about reducing the wait time,” Giboney said. “It’s about delivering the right specialty care at the right time.”
KHN’s coverage in California is funded in part by Blue Shield of California Foundation.
Doctors From Banned Countries Provide 14 Million Medical Appointments A Year In U.S., Analysis Finds
Los republicanos de la Cámara de Representantes revelaron su muy esperado plan de reemplazo de la Ley de Cuidado de Salud Asequible (ACA) el lunes 6 de marzo, reduciendo la expansión del Medicaid y desechando el requisito de que las personas compren cobertura o paguen una multa. Pero optaron por seguir proporcionando créditos tributarios para alentar a los consumidores a comprar cobertura, aunque el programa sería muy diferente al que está vigente.
La legislación mantendría las disposiciones de la ley de salud permitiendo que los hijos permanezcan en el plan de seguro de salud de sus padres hasta los 26 años y prohibiendo a las aseguradoras cobrar más a las personas con condiciones médicas preexistentes, siempre y cuando no dejen que su seguro caduque. Si esto ocurre, bajo la ley republicana las aseguradoras pueden cobrar un recargo del 30% por inscripción tardía por encima de la prima base.
En una declaración, el líder de la Cámara de Representantes, Paul Ryan (republicano de Wisconsin), dijo que la propuesta “reduciría los costos, estimularía la competencia y daría a cada estadounidense acceso a un seguro de salud asequible y de calidad”. Agregó que “protege a los adultos jóvenes, a los pacientes con condiciones preexistentes, y proporciona una transición estable para que nadie quede fuera”.Use Nuestro ContenidoEste contenido puede usarse de manera gratuita (detalles).
El plan del GOP, como se predijo, elimina la mayoría de los impuestos y tarifas de la ley, y no impondría el llamado mandato del empleador, que requiere que ciertos empleadores proporcionen un nivel establecido de cobertura de salud a los trabajadores, a riesgo de tener que pagar una multa si no lo hacen.
Los demócratas rápidamente condenaron el plan. “Esta noche, los republicanos revelaron un proyecto de ley (Make America Sick Again), que les da a los multimillonarios un nuevo recorte fiscal masivo mientras se trasladan costos y enormes cargas a las familias trabajadoras de todo el país”, dijo Nancy Pelosi. “Los republicanos obligarán a decenas de millones de familias a pagar más por una cobertura peor, y empujarán a millones de estadounidenses fuera de los seguros de salud por completo”.
La legislación ha sido el foco de intensas negociaciones entre las diferentes facciones del partido republicano y la administración Trump desde enero. El ACA se aprobó en 2010 sin un solo voto republicano, y el partido lo ha denunciado fuertemente desde entonces, con la Cámara votando más de 60 veces para revocar el Obamacare. Pero más de 20 millones de personas han ganado cobertura bajo la ley, y el presidente Donald Trump y algunos republicanos del Congreso han dicho que no quieren que nadie pierda su seguro.
Cuando los republicanos tomaron el control del Congreso y de la Casa Blanca este año, no lograron un acuerdo sobre el camino a seguir para reemplazar la ley, con algunos legisladores de los estados que han ampliado el Medicaid preocupados por el efecto de la revocación, y con el ala conservadora del partido pidiendo que se eliminara toda la ley.
El senador Rand Paul (republicano de Kentucky), y uno de los que está a favor de una derogación completa, twitteó: “Todavía no hemos visto una versión oficial del proyecto de ley de la Cámara para reemplazar el Obamacare, ¡pero por informes de los medios de comunicación esto parece un Obamacare Lite!”.
Complicando el esfuerzo está el hecho de que los republicanos tienen sólo 52 escaños en el Senado, por lo que no pueden reunir los 60 necesarios para superar un contraataque demócrata. Esto significa que deben usar una estrategia legislativa complicada llamada “reconciliación presupuestaria” que les permite revocar sólo partes del ACA que afectan el gasto federal.
A partir de 2020, el plan republicano ofrecería créditos impositivos para ayudar a las personas a pagar el seguro de salud, en base al ingreso familiar y la edad, con un límite de $14,000 por familia. Cada miembro de la familia acumularía créditos, desde $2,000 para un individuo menor de 30 a $4,000 para personas de 60 años o más. Los créditos empezarían a disminuir después de que los individuos alcanzaran un ingreso de $75,000, o de $150,000 para las parejas que presentan sus impuestos de manera conjunta.
A los consumidores también se les permitiría invertir más dinero en cuentas de ahorro de salud (HSA, por sus siglas en inglés) libres de impuestos y elevaría el límite de $2,500 en las cuentas de ahorro flexibles a partir de 2018.
La legislación permitiría a las aseguradoras cobrar a los consumidores mayores hasta cinco veces más por la cobertura que a los jóvenes. La ley de salud actualmente permite una proporción de 3 a 1.
Los centros de salud comunitarios recibirían $422 millones en financiamiento adicional en 2017 bajo la nueva legislación, lo que también condiciona la congelación de un año de financiamiento para Planned Parenthood y prohíbe el uso de créditos tributarios para comprar un seguro médico que cubra el aborto.
El Comité de Energía y Comercio y el de Ways and Means tienen programado ponerle el sello final al proyecto este miércoles 8 de marzo. Los comités todavía no tienen ningún análisis de la Oficina del Presupuesto del Congreso sobre cuánto costaría la legislación o a cuántas personas cubriría.
Los líderes del partido han dicho que quieren entregar el proyecto al presidente Trump en abril.
En una declaración, los demócratas de alto rango en ambas cámaras dijeron que la medida cobrará a los consumidores “más dinero por menos atención. Esto aumentaría drásticamente los costos de atención de la salud para las personas mayores. Y la derogación racionaría el cuidado de más de 70 millones de estadounidenses, incluyendo adultos mayores en hogares, embarazadas y niños que viven con discapacidades, al cortar y limitar arbitrariamente Medicaid”, dijo el representante Frank Pallone de Nueva Jersey y el representante Richard Real de Massachusetts.
El nuevo plan plantea cambios dramáticos al Medicaid, el programa de seguro de salud estatal-federal que cubre a 70 millones de estadounidenses de bajos ingresos. El programa comenzó en 1965 como un derecho, lo que significa que el financiamiento federal y estatal están asegurados sin importar el costo y la inscripción. Pero el proyecto de ley republicano limitaría los fondos federales para el Medicaid por primera vez.
El gobierno federal recauda entre la mitad y el 70% de los costos del Medicaid. El porcentaje varía en función de la riqueza relativa del estado.
Bajo el plan republicano, el financiamiento federal se basaría en lo que el gobierno gastó en el año fiscal que terminó el 30 de septiembre. Esas cantidades se ajustarían anualmente, en base a la inscripción del estado y la inflación médica.
Actualmente, los pagos federales a los estados también tienen en cuenta cuán generosos son los beneficios del estado y qué tasa utiliza para pagar a los proveedores. Eso significa que estados como Nueva York y Vermont obtienen fondos más altos que estados como Nevada y New Hampshire, y esas diferencias estarían bloqueadas para los próximos años.
Los republicanos han presionado para limitar el financiamiento federal a los estados a cambio de darles más control sobre el funcionamiento del programa.
La legislación también afecta la expansión del Medicaid promovida por el ACA, por la cual el gobierno federal proporcionó una mayor financiación a los estados para ampliar la elegibilidad. El proyecto de ley también pondría fin a esa financiación adicional para cualquiera que se inscriba bajo las directrices de expansión a partir de 2020. Sin embargo, permitiría a los estados mantener el financiamiento adicional que proporcionó el Obamacare a las personas que ya están en el programa de expansión y que permanezcan inscriptas.
Cerca de 11 millones de estadounidenses se han sumado al Medicaid desde 2014.
Cambiar el programa de expansión es un delicado equilibrio para los republicanos. Cuatro senadores republicanos de los estados que eligieron ampliar el Medicaid dijeron que se opondrían a cualquier legislación que derogara la expansión.
“Nos preocupa que cualquier cambio mal implementado o mal programado en la actual estructura de financiamiento en Medicaid podría resultar en una reducción en el acceso a servicios de atención de salud que salvan vidas”, dijeron los senadores Rob Portman, de Ohio; Shelley Moore Capito, de West Virginia; Cory Gardner de Colorado, y Lisa Murkowski de Alaska en una carta al líder de la mayoría republicana Mitch McConnell.