June 8, 2018
Feinberg says he will stay in Danville

CNBC is reporting this morning that David Feinberg has decided to keep his job as CEO of Geisinger rather than take charge of the inchoate Amazon-Berkshire Hathaway-JP Morgan health care venture.
Just yesterday, Berkshire Hathaway CEO Warren Buffet and JP Morgan CEO Jamie Dimon said they had settled on a pick (presumably Feinberg) for the venture's leader and that the person would be named in the next two weeks. 
Now it is back to the resumes it seems. 
Feinberg, who had been advising the venture, had apparently emerged as the winner in a winnowing process that seems like the kind of reality show that they'd dream up at  Health Affairs or the Commonwealth Fund. The top ten candidates were asked to submit white papers on how to fix the health care system, according to CNBC. From that group, Dimon interviewed three candidates, referred two to Buffet, who referred one to Amazon CEO Jeff Bezos.
"I appreciate being part of the conversation, which I believe reflects the accomplishments of the entire Geisinger team" Feinberg said through a spokesperson, according to CNBC's report. 
Whoever the pick ends up being--and whatever the joint venture ends up doing --it will be hard to live up to the frothy expectations. Some of the fizz may already be gone.  "...Amazon's health care ambitions look a whole lot less earth shattering and unlikely to diminish health care profitability for years to come," a  Investor's Business Daily story said this week.
American Academy of Neurology Annual Meeting Briefing

Precision medicine, big data, Alzheimer's Disease, migraine, and RNA therapeutics.
Learnings from the April 2018 meeting.

Edited by Jill Condello, PhD,
ICON Access, Commercialisation & Communications.

Click to download
Cancer immunotherapy, flying high, comes down to earth

Maybe this is a week of course corrections.  
New York Times story this week put a spotlight on an NCI-funded phase 2 trial of Opdivo (nivolumab) for people with adult T-cell leukemia-lymphoma. As researchers recounted in a letter to the  New England Journal of Medicine last month, the cancer got worse, not better, in the first three patients of this trial. The study was shut down. 

Opdivo is a checkpoint inhibitor, and the letter in NEJM mentions evidence that one of those checkpoints, PD-1, is a tumor suppressor in T-cell lymphoma in mouse models. 
Or, as the researchers put it: "The consistent and rapid amplification of cancer in all three patients after a single dose of nivolumab in our trial provides support for the probable role of PD-1 functioning as a tumor suppressor in humans." 
It seems that inhibiting a tumor suppressor as a cancer treatment might not always be such a good idea. 
Meanwhile, this week Michael Joyce at HealthNewsReview.org deconstructed the breathless media coverage of a case of an apparently successful immunotherapy treatment of breast cancer. Steve Rosenberg's research has been hyped before, and Joyce argues that it is happening again. 
Merck among the ASCO winners  

There is so much health care and medical news these days that anything that happened in the past (the past as in just last week) gets buried in the avalanche of more recent events. And so doesn't the ASCO annual meeting last week seems like ancient history?
But if you want to catch up quickly on what happened in Chicago, the always readable Matthew Herper at  Forbes has a short list of winners and losers. Merck and Keytruda top his winners list, Nektar Therapeutics and Bristol-Myers Squibb are tallied in his losers column, and Bluebird Bio gets an incomplete.  
The 'broken promises' of ACOs...

A top official at the OMB said at a meeting this week that ACOs are among the " broken promises and failed estimates" of the ACA. 
Joseph Grogan, an associate director of OMB, cited a report from Avalere in late May that says ACOs cost CMS about $384 million from 2013 to 2016, reported  Modern Healthcare's Virgil Dickson. 
But perhaps patience with ACOs will be rewarded. That same Avalere report also says that after three years of costing money, the Medicare Shared Saving Program ACOs produced net savings of $152 million during their fourth performance year. 
...and the promise of a major change to Medicare Advantage

The CHRONIC Care Act hasn't gotten much attention. But read an expository piece about it in this week's  New England Journal of Medicine and you'll think that it should. 
Amber Willink at Johns Hopkins and Eva DuGoff at the University of Maryland explain that the legislation could open the door to Medicare Advantage plans offering services and supports like meals, transportation, and home repair and modifications (grab bars in bathrooms, for example). Under the current law, the plans must stick to benefits that were more directly related to health care. CHRONIC also allows plans to tailor benefits to subgroups of patients and so, perhaps, take a more targeted approach to some people with chronic health problems.  
Here is the glass half full: Allow Medicare Advantage plans greater flexibility to include nonmedical services without asking them to cover all nonmedical services (nursing home care, for example) and beneficiaries may stay healthier and live independently longer--without a huge increase in Medicare spending. 
Willink and DuGoff are not Pollyannaish. Risk selection could (will?) be an issue and the plans may react in ways (e.g., not offer the services so they don't attract sicker, possibly more costly members) that will undercut the purpose of broadening and integrating services.
Regardless, it seems wise to keep an eye on the CHRONIC Care Act and how it may reshape Medicare Advantage. 
Jonathan Bush is out at Athenahealth

These are not the best of times at Athenahealth, the Watertown, Mass., company that talks about the wonderful things its "network-enabled," data-driven services can do for the kludgy aspects of American health care. 
Politico described the company as being stuck in the "financial doldrums" and referenced its flat stock price. And this week its co-founder and CEO, Jonathan Bush, was forced out amid allegations of sexual harassment and reports based on court records that he had hit his ex-wife. 
(Bush is one of  those Bushes: the nephew of former President George H.W. Bush and the cousin of former President George W. Bush.)
Elliott Management, the activist hedge fund run by Paul Singer, wants to take over Athenahealth. Various media reports have mentioned Elliot's not-so-gentle tactics for ousting the leadership of companies it wants to buy. And so perhaps the appearance of this dark cloud that Bush is leaving under. 
Singer and Elliott Management may have some competition. Cerner is interested in acquiring the company, according to the  Wall Street Journal. Others who might be sniffing around include tech heavyweights like Microsoft, Oracle, even Apple.
My, what a difference a tax credit can make

Using filings with state regulators, the Kaiser Family Foundation has started to track what the premiums will be for ACA exchange health plans in 2019. So far, information for only a handful of states is available. Not surprisingly, some major increases are in the offing. In Maryland, for example, the premium for the lowest cost bronze plan will go up by a whopping 41% (from $314 in 2018 to $443 next year). We'll be hearing a lot about skyrocketing premiums, the failed ACA, and so on. 
But it's an entirely different story once the ACA tax credits are included. For a hypothetical 40-year-old nonsmoker who makes $30,000 a year, the premium will decrease by 54% (from $59 in 2018 to $27 in 2019) after tax credits are applied, according to Kaiser's calculations.  
Could 'progressive' health benefits catch on?

Speaking of Kaiser, Drew Altman has a piece this week via Axios about progressive health benefits. Progressive health benefits would, to some extent, link premiums (or perhaps other out-of-pocket costs) to employee wage or salary levels. Altman says Americans who get insured through work aren't getting any relief from health care costs so "don't be surprised if more employers give lower wage workers some help by linking premiums or other out-of-pocket costs to wage levels." 
Actually, it would be very surprising if that does happen. Many workers feel lucky to have any kind of employer-based health care coverage. It's hard to imagine them pushing for lower costs than their bosses. 
The unintended consequence of the end of CSR funding

If you are looking for an explanation for the complicated business of ACA cost-sharing reductions (CSR), you need go no further than Louise Norris's piece this week at Healthinsurance.org, a consumer website that is, nevertheless, fearless about getting into the weedy details. 
Norris reports that because insurers expected the loss of CSR funding (President Trump cut it off in October 2017), they bumped up their 2018 premiums. Because they increased premiums, the ACA premium subsidies also increased. "The overall result," she writes, "is that the federal government is really still funding CSR, via larger premium subsidies rather than direct reimbursement." 
Democrats ready to go on the offensive in health care

The primaries on Tuesday didn't seem to send a particularly strong political signal. But Sam Baker at Axios says Democrats are gearing up to campaign this fall on health care issues, especially increasing costs, and most especially increasing drug prices. 
As for Republicans, this will be the first midterm in a decade that Obamacare will not be the issue that unites and energizes them, Alex Conant, a GOP strategist and former aide to Marco Rubio, told Baker. "If Republicans are going into the midterms having done nothing on drug prices, it will be a tremendous vulnerability," Conant said.
This is terrible. So what are we going to do about it?

The CDC's  MMWR doesn't tend to be bearer of glad tidings, but this week's report that suicide rates are up by nearly 30% since 1999 was a gut punch, especially with after the news this morning of Anthony Bourdain's suicide and Kate Spade's earlier in the week. 
About half (48.5%) of suicides are committed with a firearm, according to this report. And about half (54%) of "suicide decedents" didn't have any known [emphasized added] mental health problems.  
Others have studied suicide as part of the epidemic of despair that is increasing the number of premature deaths among white Americans.
The CDC authors steer clear of discussing firearm safety and gun control when it should be part of the conversation. They mention efforts to prevent the onset of "mental health conditions" and support of people with known conditions "to decrease their risk for poor outcomes." 

Peter Wehrwein
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