Q&A with Scott Gottlieb, MD
Interview by Peter Wehrwein

Scott Gottlieb, MD

Medicaid expansion often means a hollow benefit, says this resident fellow at the American Enterprise Institute. There will be some reluctance for sweeping reform, but the exchanges are in trouble and have little political support. Expect some movement there.

When it comes to customer satisfaction, prevention, and treatment, only about 10% of the 1,012 of the commercial, Medicare, and Medicaid plans obtained top quality ratings in the NCQA Health Insurance Plans Rating report. Plans participating in the ACA were not rated because the ACA rates them. Some familiar names in the top finishers in the NCQA report, including Blue Cross Blue Shield of Massachusetts, the Kaiser Foundation Health Plan, the University of Pittsburgh Medical Center, Capital District Physicians, and Tufts. Each has at least two plans that received the highet 5.0 rating.

One plan provides bus passes so people without cars can get to see their doctor nonetheless. Another offers valet cart service at community health centers so the homeless don’t have to worry about losing their possessions when they visit the doctor. It’s little details like this that could make Medicaid managed care plans boost the recently sagging fortunes of the Obamacare exchanges, the Hill reports. Nearly three-fourths of Medicaid enrollees Nearly 55 million people—about 55 million people—are now covered under managed care, a sharp increase even in the past three years.

The pharmaceutical company had been toying with the idea of splitting into two entities, one focused on patent-protected drugs, the other on older products that bring in a lot of revenue, the Wall Street Journal reports. Pfizer had spend about $600 in preparation for the split; small potatoes for a company that’s expected to rake in at least $51 billion this year.

The concussion rate for children and teens 10 to 19-years-old soared 71% from 2002 to 2015, according to a report this morning by the Blue Cross Blue Shield Association. Girls are being encouraged to participate in sports and it shows: The concussion rate for girls and young women rose 118%; it was 48% for boys and young men. And school sports usually start off in the fall, another factor that seems to show in the data.

Q&A with Paul Starr
Interview by Peter Wehrwein

Paul Starr

The Princeton sociologist and Pulitzer Prize winner says that the law left the health care system largely intact. A Clinton presidency could mean important adjustments to the law, including addressing the omission of a public option. Trump’s proposals would effectively end regulation of insurance.

Telemedicine keeps making inroads. A program at the University of Pittsburgh Medical Center connects skilled nursing facility nurses with the hospital’s geriatricians during off-hours. The goal is to reduce hospital admissions among nursing home residents, according to the Pittsburgh Tribune-Review.

It’s not often in health care that prices for anything actually go down. It’s usually big news when the rate of increases slow. But premiums for seniors in Medicare Advantage will go down 3.6%, CMS announced. The agency estimates that the average Medicare Advantage monthly premium will decrease by $1.19 in 2017, from $32.59 on average in 2016 to $31.40. This would be 13% lower than the average Medicare Advantage premium prior to passage of the ACA. Sixty-seven percent of Medicare Advantage enrollees will see no premium increase.

Many see value-based health care as a the best way to cut costs and improve outcomes, but a new study on CMS’s Bundled Payment for Care Improvement (BPCI) initiative questions whether we have enough data yet to make that assessment. Voluntary participants, including hospitals, physician groups, post-acute care providers, agree to be held accountable for episode of care payments. The initiative rewards participants if they keep costs down, but penalizes them if the costs exceed agreed upon benchmarks.

Aetna CEO Mark Bertolini just got a second letter from Senate Democrats on September 23, which asks him to detail while the health insurer has exited Obamacare exchanges. The lawmakers sent a letter on September 8, but claim that Berolini did not answer questions, Morning Consult reports. Lawmakers wonder if Aetna’s pullout is connected to a Justice Department’s challenge of a proposed Aetna-Humana merger.

Screening for prostate cancer prostate-specific antigen (PSA) tests is again put under the microscope as the Philadelphia Inquirer reports why more health care providers are having second thoughts. There are about 180,000 new cases of prostate cancer diagnosed each year. Yet, “the PSA test can’t tell which cancers are aggressive. Moreover, there is no ‘normal’ level of the antigen, which is shed by the gland.

Big Data and artificial intelligence are likely to have the greatest impacts on how health care is delivered next year, according to a Silicon Valley Bank survey of 122 founders, executives and investors in health-tech companies. Forty-six percent of respondents went with Big Data; 35% said artificial intelligence.

The good news is that the maternal mortality rates around the world fell by more than a third from 2000 to 2005. The New York Times, citing data from the Institute of Health Metrics and Evaluation, reports that the maternal mortality rate in the United States rose from 23 per 100,000 births in 2005 to 28 per 100,000 in 2013. “The findings are part of a gathering body of evidence on the dismal numbers for maternal mortality among American women and how they keep getting worse.”

Pennsylvania has been one of the states hardest hit by the opioid epidemic, with more than 3,500 people dying from the drugs last year. Michael Ashburn, MD, MPH, guest blogs today on the Philadelphia Inquirer’s health section and points out that the epidemic started with the best of intentions: relieve pain. 

Susan Ladika

Katherine Hempstead

Individual insurance policies purchased outside of state health insurance exchanges are not going to vanish any time soon. The 9 million Americans who buy such policies usually make too much money to be eligible for subsidies and can often get coverage with a broader network of providers.

Anthem and Cigna accused each other of violating the terms of their proposed merger in letters last month, and that’s one of the issues the government brought up in filing an antitrust lawsuit over the deal, Bloomberg reports. Big bucks are involved. There’s the $48 billion deal itself. And then there’s the$1.85 billion Anthem would owe Cigna if the government blocks the merger. Sometimes, it comes down to personalities.

Insurers picked up 30% of the $78.5 tab for battling opioid abuse in 2013, the CDC reports. Included in the calculation: direct health care costs, lost productivity and costs to the criminal justice system, HealthDay reports, citing a study published in Medical Care. Nearly 2 million Americans abused opioids that year, and about 16,000 people died from drug overdoses, a dramatic rise over 2007, the most recent year data were measured.

Heather Bresch had a rough day yesterday. The CEO of Mylan NV, the maker of the much-in-the-news EpiPen allergy shot, was grilled by the House Oversight and Government Reform Committee, Bloomberg reports. Committee members played hardball, questioning Bresch’s ethics and wondering just why she’s worth $19 million a year. At the center of it all: the $600 price for a two-pack of EpiPen, yet one more example of the public’s growing dismay over the cost of new therapies.

Election 2016: Seniors
Robert Calandra
Clinton wants to expand the program, while the Republican platform calls for replacing entitlements with premium support to buy insurance. Meanwhile, seniors have few complaints because the ACA actually sweetened the deal for Medicare beneficiaries in some respects. Most notably, it gradually eliminates the “donut hole.”

Anyone who’s had to care for an older person in the twilight years knows that the rough ride often starts with the falls. This hasn’t escaped the notice of experts, either, who are starting to refer to an epidemic of falling, the Milwaukee Journal Sentinel reports.

Obamacare could use a little good news right now. Everybody’s heard about the high-profile departures of some of the biggest health insurance companies from the ACA exchanges. But Molina Healthcare, a company that made its name as a Medicaid managed care plan, is cleaning up, the Hill reports. Molina always had to rein in costs and get the best quality bang for its buck, the plan’s CEO Mario Marino, MD, explains.

Thankfully, very few children aged 5 to 11 take their own lives, but attention deficit disorder (ADD) is the reason they do, according to a study in Pediatrics. Eight-seven children in that age bracket took their own lives between 2003 and 2012. Meanwhile, during the same period, depression was the leading cause for the 606 adolescents aged 12 to 14 who did.

The CDC wants Americans to become more aware of the dangers of sepsis to the point where it’s one of the things they’ll ask doctors about when symptoms appear, the New York Times reports. Sepsis usually affects people over 65, but all ages are susceptible, even children. Between 1 million and 3 million people get it each year, and 15% to 30% of them will die.

Even though the ACA helped provide coverage for ex-prison inmates, gaps still remain, according to a study in the Journal of Internal General Medicine. “Given the high prevalence of mental illness and substance use disorders among justice-involved populations, persistently elevated rates of uninsurance and other barriers to care remain a significant public health concern,” the study states.

Election 2016: Employers
Charlotte Huff
The Cadillac tax, which has drawn fire from both Democrats and Republicans, was initially slated to go into effect in 2018 but last year Congress delayed it until 2020. But it remains an election-year point of friction, with proposals ranging from repeal to modifications.

Nothing conclusive can be drawn from data about the first year of CMS’ voluntary Bundled Payments for Care Improvement initiative, according to a report the agency issued Monday. “There have been modest reductions in Medicare episode payments for select clinical episode groups with isolated instances of quality declines and fewer instances of increased quality,” the report states.

Concerns about the over-prescribing of antibiotics have long been voiced, but the problem still persists, according to a CDC study in JAMA Internal Medicine. Bacteria grow increasingly immune to treatment. Too many hospitals, according to the study, respond by prescribing even more powerful antibiotics, drugs once considered a treatment of last resort. In what appears to be the first national, multiyear estimate of U.S.

The FDA overruled the recommendations of its own advisory committee to approve Exondys 51 (eteplirsen) to treat Duchenne muscular dystrophy, a rare and lethal form of the disease that affects about 15,000 Americans, reports Kaiser Health News (KHN). The rocky road to approval is something Managed Care has been following for awhile.

Election 2016: Hospitals
Robert Calandra
Passage of the ACA in 2010 led to some merger mania. Proponents of mergers and acquisitions say they can lower costs by creating economies of scale and smoothing the way for all kinds of clinical integration. But others say the fact that they can doesn’t mean they do.
Value-Based Care
Michael D. Dalzell
The FDA never issued regulations to clarify the boundaries of promotion of pharmacoeconomic data, something it’s been dragging its feet on for nearly 20 years. In turn, pharma companies, fearful of being penalized for off-label promotion, have erred on the side of caution, hesitating to take advantage of Section 114.
Election 2016: Physicians
Richard Mark Kirkner
Physicians are a disparate lot. At last count, there were more than 300 member organizations of the American Association of Medical Societies. These organizations tread common ground on a host of issues in play in this upcoming election cycle. They also part ways on some important issues, including their stance on the Affordable Care Act.
Election 2016: Pharma
Jan Greene
When the election ends, the time for rhetoric will be over and the new president and lawmakers will face the task of actually managing a giant, unwieldy, and complex health care system, trying to wrestle drug costs into submission before they wreck more havoc on the budgets of Medicare, Medicaid, and the American consumer.