March 1, 2019
Faster, please! Americans want something done about runaway drug costs
More Americans blame drug companies for the soaring price of medications, despite efforts by PhRMA to shift that blame to health insurers. That's just one of the takeaways from a new survey by the Kaiser Family Foundation that was released this morning. On the other hand, the public also holds PBMs partly responsible.

"While the public sees profits made by pharmaceutical companies as a major factor contributing to the price of prescription drugs (80%), a majority (63%) also say profits made by pharmacy benefit managers (PBMs), companies that manage prescription drug benefits for health plans, are a 'major factor' contributing to the price of prescription drugs," the survey states.

That something needs to be done get drug prices under control continues to gain support among a wide spectrum of people -- Democrats, Republicans, and independents. Nine out of 10 people support mandating that pharma companies show the list prices for drugs in their advertisements.

"Although Republicans tend to frown on government control over commerce, 8 in 10 Republican respondents said they support giving negotiating power to the $700 billion Medicare program in order to lower drug prices for seniors," Kaiser Health News reports.

Seventy percent say they like the idea of importing drugs from Canada and capping out-of-pocket Medicare costs. And 80% want to make it easier for generics to compete with brand-name drugs.

The poll was conducted in mid-February before this week's appearance by the heads of leading drug companies before the Senate Finance Committee, in which they continued to blame insurers and PBMs for high prices.

Will things change?

Not likely, David Henka, CEO of ActiveRADAR, a pharmacy benefit consulting company, said in a statement to HealthLeaders. "The pharma industry wants to keep the current system in place, and it's succeeding in doing so. Even after [Tuesday's] hearing, medication prices will continue to rise at a rapid, unrestricted pace. In the current congress it is very unlikely that there will be any significant movement toward reforming drug pricing."
CMS tries again to make ACA qualified health plans more interoperable
If you don't already make Katie Keith part of your reading routine, then you should, dagnammit! Keith, an attorney, writes the Following the ACA column over on the Health Affairs blog and has an uncanny ability to boil down governmental mumbo-jumbo into understandable English.

This week she deals with a 251-page proposed rule by CMS that aims to make systems that store electronic health information more interconnected. Thanks to dogged and intrepid reporting skills (we emailed her) MANAGED CARE tracked Keith down, who confirmed that she did in fact actually read all 251 pages of the rule "for better or for worse." We bow before her.

Keith starts with a quick overview of how Congress and HHS have been trying to improve interoperability among stakeholders since 2004. The proposed rule would affect insurers that offer qualified health plans (QHPs), Medicare Advantage plans, or Medicaid and CHIP managed care plans.

"Despite gains in many providers moving from paper records to electronic health records (EHRs) over the past decade, interoperability has been an ongoing source of frustration for providers and patients alike," Keith writes.

She helpfully bullet points the main thrust of the rule as so. It would (quoted text):
  • Require payers to make patient health information available electronically through a standardized, open application programming interface (API);
  • Promote data exchange between payers and participation in health information exchange networks;
  • Require payers to provide additional resources on EHR, privacy, and security;
  • Require providers to comply with new electronic notification requirements;
  • Require states to better coordinate care for Medicare-Medicaid dually eligible beneficiaries by submitting buy-in data to CMS on a daily basis; and
  • Publicly disclose when providers inappropriately restrict the flow of information to other health care providers and payers.
Down at the bottom of the column, above what would be the small print if there had been small print, is the money line. It's worth quoting Keith's entire summation.

"CMS estimates API [application programming interface] development to cost a total of 345 parent entities more than $275 million in 2020 alone, with a total price tag of $494 million from 2020 to 2024. Much of this burden would fall on commercial insurers that offer QHPs: of the total $494 million price tag, costs to commercial insurers would be an estimated $285 million, which is about 58 percent of the total cost. Medicare Advantage insurers would face costs of about $121 million followed by Medicaid and CHIP programs at about $87 million. For all three types of entities, more than half of the costs would be borne in 2020 as payers come into compliance with the proposed rule in January or July 2020."

Just one more thing on your plate.
One-two punch: Medicare-for-all idea, soaring drug prices hurt health insurer stocks 
The S&P 500 Managed Health Care Index plunged nearly 5% Wednesday as the Medicare-for-all idea builds momentum and health plan-PBM mergers may be generating unexpected fallout. UnitedHealth Group and Cigna, which own huge PBMs (Optum and Express Scripts, respectively), saw their stock drop about 4%, Bloomberg reports. The drop follows on the heels of grilling of the leaders of some of the largest pharmaceutical companies by the Senate Finance Committee this week concerning soaring drug prices.

Meanwhile, Medicare-for-all is increasingly being seen as an existential threat to the health insurance industry, inasmuch as it would do away with plans and install a single payer system. Bloomberg Intelligence policy analyst Brian Rye, says that "this doesn't have a prayer of being enacted anytime soon. But the noise factor is there, and you can bet multiple Democratic candidates will hop on board and push this in the debates starting in June."

Insurers and big pharma are fighting back, one way through their coalition, the Partnership for America's Health Care Future. The lobbying organization argues that Medicare-for-all will mean steep tax hikes and place medical decisions in the hands of politicians.

The progressive news website Common Dreams promises more pushback against health plans, reporting that "National Nurses United (NNU) and other grassroots organizations are planning a nationwide mobilization of their own in the coming weeks in an effort to defeat [the] corporate power [of insurance companies] with a mass movement of ordinary Americans."
Latest data on the HIV battle front indicates a stalemate at the moment
The fight against HIV/AIDs has to be counted as one of medicine's great success stories. But as Managed Care reported last November, it is far from over and, in fact, a new CDC report indicates that it's stalled. After having seen drops in the number of new HIV infections for about half a decade, the number stubbornly plateaued at 39,000 new cases each year since 2013.

The report, which examines trends from 2010 to 2016, surfaces less than a month after President Trump in his State of the Union addressed vowed to effectively eliminate HIV within a decade.

Trump wants to cut new HIV infections by 90% within 10 years; 75% within five years. The CDC has outlined a plan that includes earlier diagnosis and treatment, and better efforts to protect people from getting infected in the first place. Knowledge truly is power, in this case, because 15% of the approximately 1.1 million people with HIV in the U.S. don't know that they have it.

CDC Director Robert R. Redfield, MD, last year went ever further than Trump, predicting that the AIDs epidemic could be eliminated within the next three to seven years

Redfield used the latest CDC findings as a call to arms. "Now is the time for our nation to take bold action," Redfield said in a statement. "We must move beyond the status quo to end the HIV epidemic in America."

The problem is what the CDC refers to as "HIV clusters," geographic and demographic trouble spots that buck the trends of declining HIV infections throughout the rest of the country. They include the rural South, and the African-American and Latino populations. Better focused efforts may be the answer.

"For example, urban areas like New York and Washington, D.C., have developed and enacted plans to eliminate their local HIV epidemics -- and they are seeing the results of those commitments," the CDC stated. "New HIV infections decreased about 23% in New York and about 40% in Washington, D.C., from 2010 to 2016."
CAR-T is so five minutes ago: Meet bispecific antibodies
No sooner have we hailed the coming of CAR-T therapy, than bispecific antibodies splash onto the immunotherapy scene. Stat does a good job of weighing the pros and cons of bispecifics, the major pro being that patients have a lot less chance of dying while waiting to get the therapy than they do with CAR-T.

It takes weeks to manufacture CAR-Ts, while bispecifics can be infused almost immediately. Bispecifics were invented nearly 25 years ago, but the technology -- in this case protein engineering -- needed to catch up to make them effective. That technology involves two arms of small molecules pulling together tumor cells and T cells. That should cause the "destruction of the cancer cell by the T cell, which without help might have wandered through the bloodstream forever without ever being activated into tumor-killing mode," Stat reports.

Though bispecific antibodies look as if they will be effective in rare cancers in a small fraction of patients, there are signs that they may have efficacy in a broader spectrum of cancers.

Amgen jumped in with both feet, not just with the only cancer-targeting bispecific given the OK for clinical use in the U.S. (blinatumomab, sold as Blincyto), but also with 14 more in development. Those bispecific antibodies would go after such scourges as small cell lung cancer, multiple myeloma, and glioblastoma.

The relative cheaper cost of bispecifics is also being touted. Blinatumomab goes for about $178,000 while CAR-T therapies can sell for around $450,000, because of the painstaking manufacturing process.

Still, this is no slam-dunk. "To be sure, bispecifics have a long way to go," Stat reports. "Blinatumomab, for instance, is tough to take, requiring a continuous IV infusion over several days, compared to a single one-and-done infusion of CAR-Ts."
Fighting cancer on two fronts: the disease, and against a convoluted billing system
Carol Marley, a former hospital nurse, battles pancreatic cancer and a billing system that's byzantine and error filled. Marley's a former nurse because the disease, and the treatments for it, have left her unable to work. It also keeps her on the phone for many hours a day arguing and questioning bills that too often turn out to be wrong.

This is one of those persistent problems in health care that rouses public outcry intermittently. Kaiser Health News cites disheartening stats: over 42% of the 9.5 million people diagnosed with cancer between 2000 and 2012 drained their life's assets within two years, and cancer patients are 2.65 times more likely to file for bankruptcy than those without cancer.

The angle KHN puts on Marley's struggle is her battle of the bills, which many days leave her emotionally exhausted to the point of tears. There's the $18,400 chemotherapy bill submitted without the proper information and then denied because when it finally arrived, it had missed the filing deadline. Or how about the payment denial for a $870 MRI because the provider said there had been no preauthorization?

Marley tells KHN: "It's not any one individual. It's not any one system or provider. The whole system is messed up.... There's no recourse for me except to just keep making phone calls."
Frank Diamond
 Managing Editor

Upcoming Meetings
2019 Healthcare Bundled Payments Forum
New Orleans, LA
March 11-12

2019 Telemedicine Summit for Hospitals
New Orleans, LA
March 11-12

16th Annual World Health Care Congress
Washington, DC
Apr 28-May 1

Asembia 2019 Specialty Pharmacy Summit
Las Vegas, NV
April 29-May 2

National Healthcare CXO Summit
Palm Beach, FL
May 19 - 21

Chief Nursing Officer Summit 2019
Scottsdale, AZ
Sept 16-17