Health Advocates Attack Long Term Care Plans for Cutting Care to Patients

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The New York Times reported last week (July 20 story by Nina Bernstein) that some managed long term care insurance plans (MLTCs) operating for Medicaid patients arbitrarily reduced the number of hours of care to some of the most vulnerable and high cost aged and disabled patients.  Most of the complaints centered on a few plans.  56% of the complaints were about Senior Health Partners of Health First in the New York City area.    In fair hearings over 80% of these cuts were reversed.

Health advocates in the Medicaid Matters NY coalition of over 100 nonprofit organizations issued a report saying the reversal of these cuts indicates that some of these MLTC plans were arbitrarily reducing home care hours for clients.  The Times story profiled a woman whose weekly hours were cut from 50 to 25.   The plans have argued that managed long term care was designed to reduce expenditures on high cost users.  However, the plans are also supposed to be “managing” the client’s care and maintaining quality not just cutting hours and costs.  Many persons like the woman profiled are left struggling to find a way to manage without the help they have had.   A lawsuit is also being filed by elder law attorneys on behalf of some clients against their managed care companies.

The state has moved in recent years to require most Medicaid beneficiaries needing long term care to enroll in managed care plans or be automatically placed in one.  Advocates have expressed concerns from the beginning that this new policy was untested and that there are dangers that could result in many clients losing care in order to lower costs. The financial incentives in the program favor cost cutting:  plans are generally paid a set rate  and they can save what isn’t spent.  The state has argued that care would be better managed and beneficiaries would get more comprehensive care.  That may be true if plans do it right but it is costly to provide all the care needed and some companies that tried to provide extensive services like Senior Whole Health went out of business in some upstate areas.

The state says that 87% of those in managed long term care expressed satisfaction in surveys they have done.  That number may not show those who haven’t responded or are too ill to respond.  And, even 13% of people being dissatisfied is not acceptable if their health care has declined or been threatened with cuts.

This is an unacceptable situation that was predictable when you put the most vulnerable with the highest costs under a system that financially  rewards plans  for less care and allows for arbitrary and capricious cost cuts.  The state likes to pride itself on changing health services to an “evidence based” model that requires state money spent to prove that it has been effective in meeting its stated goals.  Perhaps there are some efficiencies that can be achieved with managed long term care but where is the care coordination and “evidence based” component of these decisions that proves that all of these plans are maintaining or improving the quality of care?

102 Year Old Woman Delegate at Democratic Convention

102 year old Jerry Emmett helped announced the vote of the Arizona delegation in the roll call vote at the Democratic convention Tuesday.  Emmett was born in 1914, six years before women even had the right to vote.  She told the media that she remembers her mother casting her first vote after women got the vote.  She was born two years after Arizona became a state and she knew the first Governor.


These centenarians are amazing.  I want to mention that I have been speaking with 103 year old Gene Shea on the phone from Florida for an article and book I have been writing. He told me about growing up with his brother, Jack, who won two gold medals at the 1932 Winter Olympics in Lake Placid.  They both went to Dartmouth and Gene helped Jack with his training.

I just finished writing Jack’s story, how he refused to skate in the 1936 Winter Olympics in Nazi Germany.  He said he couldn’t go there because of the way the Jewish population was being treated by the Nazis.  The Shea family owned a market there and had many Jewish customers who asked him not to go to Germany.  He challenged the American Olympic Committee and its leader, Avery Brundage, who rejected the movement to boycott those Olympics in Germany.  Brundage said that politics and sports shouldn’t mix, Jack Shea, who loved the Olympics, said that the discrimination against Jews was more important than than skating in the Olympics to him.

My book about Jack, Keeper of the Olympic Flame, is now published and up on and in local bookstores in Albany, Saratoga and Lake Placid.  Here’s the link on amazon

New York State Joins Justice Department Health Insurance Mega-Mergers Lawsuit

The United States Department of Justice has moved to stop the two big mergers of private health care insurance giants.  Aetna has proposed to buy Humana and Anthem wants to buy Cigna.  On Thursday, the Justice Department filed a lawsuit to stop the mergers saying they would reduce competition and cause higher price in Medicare Advantage plans as well as for the Affordable Care Act and private employers.   New York State and ten other states and DC joined the lawsuit  Doctor and hospital organizations are also supporting the lawsuit.

The Department has studied the markets served by Aetna and Humana and said that 1.6 million people in 364 counties who are customers of Medicare Advantage would be negatively impacted through reduced competition.   Medicare Advantage has consistently been promoted as offering “choice” for older and disabled persons, yet the merger will reduce choices.  The companies dispute that and say they would be more efficient.

New York Attorney General Eric Schneiderman announced the state’s participation in the lawsuit saying,  “Affordable, quality health care is essential to the well-being of all Americans.  Most consumers are covered by insurance plans that their employers choose and negotiate with companies like Anthem and Cigna. By reducing competition, this proposed merger has the potential to significantly increase the merged firm’s power in the marketplace, to the detriment of consumers. Employers will be left with fewer choices, and ultimately consumers could be saddled with higher premium costs, reduced access to providers, and lower quality care.”

Consolidation across the health care field is happening right now as local hospitals are being bought or aligned by larger, regional facilities and doctor groups are being bought by hospitals or expanding themselves. The Justice Department has become more aggressive in the antitrust field, particularly in health care.  It has moved to stop some hospital systems from mergers and helped derail the planned merger of Pfizer and Allergan, a plan that would have allowed Pfizer to call Ireland its headquarters and avoid  some taxes in this country.

Consumer Reports Focuses on “Madness” of High Drug Prices

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The August issue of Consumer Reports magazine has a major article on high prescription drug prices, “Is There a Cure for High Drug Prices?”  The article discusses many of the factors which are leading to quickly escalating prices for some drugs and suggests some possible fixes.  It cited several reasons for high drug prices.

  1.  Drug companies can charge whatever price they want
  2. Insurance companies are also charging you more
  3. Old drugs are reformulated as costly “new” drugs
  4. Generic drug shortages can trigger massive price increases

The article cited one case in which a new drug called Treximet became available to treat migraine headache pain.   This drug is a combination of two older generic drugs.  It was then approved as a new drug from GlaxoSmithKline which later sold the drug to Pernix Therapeutics which more than doubled the price.  A three month supply went from $92 to $827 in less than a year for one woman who was profiled.  Consumer Reports suggests that that a patient could buy the two similar generics , naproxen and sumatriptan, for about $50 for a three month supply.

As prices go up insurance companies raise premiums and co-pays.  Even seniors and the disabled on Medicare have to pay 5% of the cost for some drugs in the catastrophic coverage tier after the “doughnut hole.”  That can amount to a lot of money for expensive drugs.

Consumer Reports suggests the government should take action to drive prices down by:

-setting a limit on out of pocket costs

-approve more generic versions of common drugs

-allow importation of drugs from  legitimate Canadian and European sources

-use the government’s ability to allow another manufacturer to make a cheaper generic if there is a supply shortage

The article also says that doctors only discuss drug prices with 2.6 of 10 patients even though 8 in 10 doctors are concerned about the high prices and their influencing whether a patient can afford them and comply with the doctor’s  treatment plan.

I have written before that drug companies are flirting with serious trouble from consumers, doctors and the government.  Their contributions to politicians have kept the Congress at bay but there is a rising tide against these prices which are unsustainable and sooner or later, change is coming.







Trump’s Ageist Attack on Ginsburg

As is his habit, Donald Trump unleashed a personal and ageist attack on 83-year-old Supreme Court Justice Ruth Bader Ginsburg, saying her mind was “shot” and she should resign.  Ginsburg, in an unusual and inappropriate public comment for a Supreme Court Justice – who are not supposed to express public opinions on candidates – said Trump is  a faker and she couldn’t imagine what the country would be with Trump as President.

So, Trump resorted to attacking her as an old person whose mind is gone, which of course is far from true.  It was another in his pattern of personal insults.  He could have criticized and rebutted her remarks but he chose to resort to a cheap attack on an older person, trying to stereotype her as a person over 80 who must be senile.

It is probably another case in which Trump feels he is happily not being politically correct, but it is not about political correctness.  It is about common decency.  He needs to be called on it so that other older persons are not treated like this by Trump and others who may echo him in the public sphere.

Democratic Platform Pledges Expansion Social Security But Rejects Lifting Earnings Cap and New COLA

Democrats on the party’s platform committee have agreed to expand Social Security but the committee controlled by Hillary Clinton backers rejected two amendments proposed by supporters of Senator Bernie Sanders.  One of those amendments would have helped pay for the expansion by lifting the earnings cap subject to Social Security taxes, a position long supported by progressives.  That cap is currently at $118,500.  Earners making more than that pay no Social Security taxes on incomes above that level, though they still have to pay the Medicare tax where the cap is already lifted.  The other  rejected amendment would have revised the formula for calculating the annual cost of living adjustment (COLA) to better reflect the cost of living for older Americans’ health care costs.  The COLA has yielded no increase in benefits this year and in other recent years has been either zero or minimal.

During the campaign, expanded benefits were discussed by both Clinton and Sanders t0 primarily to benefit lower income retirees.  The benefits formula would be altered so that lower income retirees would get more money.  The platform apparently does not detail how the program would be expanded  though and how that would be paid for, either with more revenues or re-adjusting the formula to lower benefits for higher income retirees.

Despite the defeat of the two amendments, the commitment to expand Social Security is a remarkable reversal from the defensive position that has dominated Democratic politics in the last two decades as Republicans have tried to privatize the program or discuss raising the eligibility age to 70.”  This is smart politics, and if the Republicans are smart, they’ll have it in their platform, too,” said Eric Kingson, a Social Security expert who ran a strong but unsuccessful primary bid for Congress in central New York and was endorsed by Sanders.

The Republicans are finishing their platform this week before their convention begins next Monday.  There have been no details in the media about how they are handling Social Security.  Donald Trump said during the campaign that he did not support cutting Social Security.  However, some media reports recently suggested he may have been more supportive of cuts when he met with House Speaker Paul Ryan.  Ryan has proposed major changes in Social Security and Medicare for future retirees.  He has proposed providing Medicare vouchers to purchase private insurance instead of the current guaranteed coverage with benefits and the program run by the government with private Medicare Advantage plans as an option for beneficiaries.

High Drug Prices Bring Flurry of State Action

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As I have mentioned before, the pharmaceutical industry is tempting fate with its exorbitant prices.  As the prices of old drugs are raised as well as sky high prices on new drugs, insurers and government leaders are starting to move to hold prices down or force the companies to justify prices.  Pharmaceutical lobbyists have had so much influence they have prevented the government from negotiating prices in the Medicare program.    So, there is little expectation of action coming from Congressional legislation on that issue. The Senate Aging Committee led by Senator Susan Collins, (R- Maine) has held a number of hearings on drug prices and could come forward with some bills. The Obama Administration has tried to institute some rules on Medicare drug prices but those have being resisted.

The New York Times reported on Tuesday that , state legislators and citizen activists across the country are pushing campaigns to hold down prices through legislation as well as a major referendum on the ballot in California this fall.  That initiative would restrict prices to no more than what the government pays for veterans though the Veterans Administration, prices which are lower than Medicaid and Medicare.    The drug companies and their allied patient advocacy groups are mounting a major campaign to defeat the referendum.

Pharmaceutical companies have been able to rely on support from patient advocacy groups who argue they need the new, higher priced drugs for survival.  The Times reported what is common knowledge, that the drug companies provide major funding to the patient and disease groups.   However, the AARP (which does not receive pharmaceutical funding) is supporting the California referendum.

Meanwhile in other states including New York, legislation has been introduced to require transparency and notification on drug price increases.  Some state legislation requires notification if drug prices rise by more than ten percent.

Here in New York State, Senators Kemp Hannon, Ruben Diaz  and Liz Krueger have introduced legislation.  The Diaz and Krueger bills would require greater disclosure and transparency regarding costs.  None of these bills were acted on by the Senate Health committee this year.

Hannon’s bill , S7022, would prevent price gouging.  The bill requires prior authorization for Medicaid if cost increases exceed 100% in a twelve month period.  The text adds a statement about protecting the public interest:

The bill states that price gouging or "excessive price increases to 
prescription drugs that lack justification based on market forces"
 is a "public health risk" in the state and that 
"the legislature declares that the public interest requires that 
conduct be prohibited and subject to civil penalties."