February 27, 2019
The reviews are in on Senate grilling of seven pharma CEOs
The Wall Street Journal said it marked a "milestone in Washington's scrutiny of drug costs." Stat was less enthused. It characterized the hearing as "muted" and described the questioning by the senators as scattered. 

Either way, many eyes in the pharma-slash-health care world were on the Senate Finance Committee drug price hearing yesterday and the testimony of seven drug company executives. You can watch all three-plus hours of the hearing here and Stat is holding a  postgame webinar this afternoon at 1.

AbbVie CEO Richard Gonzalez spent the most time in the hot seat as senators asked him about Humira's escalating list price (it has tripled in the past decade) and patent maneuvers that are keeping approved biosimilars to Humira off the market. At one point, Sen. Ron Wyden, an Oregon Democrat, compared the AbbVie to Gollum in The Lord of the Rings. 

In various ways and at various times, Gonzalez and his fellow executives pushed back on the complaints about list prices by pointing to net prices and rebates. Pfizer CEO Albert Bourla said his company favored pegging deductibles and other out-of-pocket costs to the rebated price of a drug. There was also the now-familiar (and worn out) argument that high prices in the U.S. pay for research and development. 

The committee is expected to have PBM executives testify sometime soon.  
The latest Medicare-for-all proposal is more generous than Sanders's 
Rep. Pramila Jayapal, a Washington Democrat and co-chair of the House's Progressive Caucus, is scheduled to unveil her Medicare-for-all plan this morning. Reporters are describing it as similar to what Sen. Bernie Sanders has proposed: eliminate private insurance and Medicare and Medicaid and replace them with one single-payer system funded by taxes. 

Axios's Sam Baker says Jayapal goes further than Sanders and wants to see long-term coverage by the new system. She is also proposing global budgets for hospitals and nursing homes and fee-for-service payment for doctors. 

Whether something so sweeping will ever come to pass is doubtful; the lobbying on/against Medicare-for-all is getting fierce. 

But as many others have pointed out, Jayapal and her fellow progressives are framing the Medicare-for-all debate and forcing Democrats and their growing number of presidential candidates to decide how far they'll go down the Medicare-for-all path. 

Strange how moderate, even conservative, the ACA is looking these days. 
One in every five ACA plan claims denied
This may help explain why some Democrats are smitten by the prospect of a sweeping Medicare-for-all rather than something more incremental built on private insurance.

The Kaiser Family Foundation came out with an analysis this week of CMS data on ACA marketplace plans that showed that one in every five in-network claims were denied by insurers in 2017. Granted, that's an average; the range in denial rates by specific insurers was quite large, going from a low of 1% to a high of 40%. Appeal processes went largely unused. According to the KFF researchers, less than 0.5% of denied claims were appealed by consumers. 
Washington State group tallies up 48 low-value health care services
Unnecessary, low-value health care services are endemic to American health care. Railing against waste, in general, is so darn easy. Who is for it?

In our January-February issue, Senior Contributing Editor Michael Dalzell examines the Washington Health Alliance's efforts to drill down into the specifics. The alliance, a not-for-profit group that operates an all-payers claims database, tallied up instances (and the cost) of 48 tests and treatments that the Choosing Wisely campaign has identified as having little clinical benefit. Among the leaders in this rogue's gallery were opioids for low back pain, antibiotics for upper respiratory and ear infections, and annual EKGs for cardiac screening. That isn't terribly surprising but this effort to document low-value services is important and impressive. Read Mike's story.
Are Medicare Advantage bonuses too generous? 
The star system is supposed to reward quality. But all told, the bonuses came to $6.3 billion last year. 

Contributing Editor Joseph Burns took a look at the growing popularity of Medicare Advantage in our January-February issue. Medicare beneficiaries seem to like MA, but Joe explores how generous federal payment levels, including the star bonuses, are making the plans a profitable line of business for insurers
Peter Wehrwein
 Editor

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