Despite A Growing Appetite, Buffet-Style Flat-Fee Clinics Shutter In Seattle

KFF Health News, June 20, 2017

After Qliance, a pioneering practice shut five clinics this month, some question whether direct primary care can succeed.

This article first appeared June 20, 2017 on Kaiser Health News.

By Michelle Andrews

In recent years, a small but growing number of practices embraced a buffet approach to primary care, offering patients unlimited services for a modest flat fee instead of billing them a la carte for every office visit and test. But after a pioneering practice shut its doors earlier this month, some question whether “direct primary care,” as it’s called, can succeed.

Many doctors and patients say they like the arrangement. Direct primary care practices typically don’t accept insurance, which frees physicians from treatment preapprovals and claims paperwork. They say that allows them more time and energy for their patients. Patients can consult with their doctor or a nurse practitioner as often they need to, typically for around $100 a month. (Some employers buy the service for their workers.) Patients need to carry a regular insurance plan for hospitalization, specialists and other services. In the long run, the result should be better patient health and lower health care costs overall.

But some health care experts are concerned that the set-up encourages the “worried well” to get more care than they need. They describe unlimited primary care as a blunt instrument that doesn’t necessarily improve the odds that patients will get evidence-based services that improve their health. Others argue it’s important to find a way to provide cost-effective primary care within the health insurance context, not outside it.

Although only a sliver of practices do direct primary care, the number is on the rise, said Shawn Martin, a senior vice president at the American Academy of Family Physicians. He puts the figure at about 3 percent.

Seattle-based Qliance, founded in 2007, was an early leader in this type of care. With startup funding from high-profile investors Jeff Bezos and Michael Dell, by 2015 the company was serving 35,000 patients at several clinics in the Seattle area, including individuals, workers at companies like Expedia and Comcast and Medicaid patients through a contract with the state’s Medicaid insurer. The company said medical claims for Qliance patients were 20 percent lower than those of other patients because Qliance members went to the emergency room less often, were hospitalized less frequently and saw fewer specialists, among other things.

By early 2017, though, Qliance was faltering. The company had lost some large employer clients, and its patient base had shrunk to 13,000. On June 15, it closed five of its clinics. Dr. Erika Bliss, the company’s CEO, said that in general the market is reluctant to pay what it takes for primary care to flourish, and in some cases payers were resistant to rewarding the company, even when Qliance exceeded targets on quality and savings. She will continue to operate one site that provides occupational health for Seattle firefighters.

“The bottom line is it’s not for free,” she said. “You can’t do this for $25 [per person] per month. If we start doing it for $50 to $100 per month then we can start doing serious primary care.”

The closure took January Gens by surprise. A Qliance patient for a couple of years, Gens, 45, had worked with her primary care doctor there to manage crippling pain from endometriosis. The $79 monthly fee was worth every penny, she thought. She had been able to reduce the dosage of some of her medications and was awaiting a referral to start physical therapy when she learned that Qliance was shutting down. Now she’s not sure what she’ll do.

“I had felt very lucky to have found Qliance, to know I had a doctor and could always be seen when needed without causing more damage to the family budget,” Gens said. “Now it’s just gone.”

(Photo courtesy of January Gens)

Patients who have chronic conditions that need ongoing management may benefit from direct primary care, said Dr. A. Mark Fendrick, an internist who directs the University of Michigan’s Center for Value-Based Insurance Design.

But for people who are generally healthy and without symptoms that need to be diagnosed, “unlimited primary care is no guarantee that the services that are provided will improve the health of those people,” he said.

As an example, Fendrick noted that the annual checkup, one of the most popular primary care services, isn’t clinically helpful for most people, according to the Choosing Wisely initiative, a program of the ABIM Foundation that identifies overused and unnecessary medical services.

An examination of research related to direct primary care practices found that they charged patients an average $77.38 per month. “Concierge” medical practices are similar to direct primary care, but their monthly fees are typically higher — averaging $182.76 — and they generally bill insurers for their services, the study found. However, the study, published in the November-December 2015 issue of the Journal of the American Board of Family Medicine, concluded that there was a paucity of data related to the quality of care provided by these practices.

Some analysts say that while they’re sympathetic to doctors’ frustration with large numbers of patients, insurance companies’ intrusion into patient care and billing hassles, the answer isn’t to turn their backs on insurance.

“I think absolutely this type of care could be done inside insurance, but it means we have to learn how to pay within the system for the things that doctors should be doing and are doing in direct primary care,” said Robert Berenson, a fellow at the Urban Institute.

As things stand now, the direct-care model can create difficulties for some patients. Take the situation where someone goes to his direct primary care provider for an earache, but antibiotics don’t work and he needs to be referred to an ear, nose and throat specialist. That patient, who likely has a high-deductible plan to provide non-primary care services, will probably be on the hook financially for the entire cost of care provided by the specialist rather than insurance paying a share.

Qliance’s Bliss scoffs at the idea that patients may get stuck paying more out-of-pocket if they have direct primary care. Most people these days have high-deductible health plans, she said. “The reality is that unless you have Medicaid, you are on the hook no matter what.”

Offering unlimited primary care inside the insurance system is no guarantee of success in any case. One such experiment, a subsidiary of UnitedHealthcare called Harken Health with clinics in the Chicago and Atlanta areas, announced it will shut down at the end of the year.

The company confirmed that it would phase out membership at the end of the year but didn’t respond to a request for further comment.

5 Things Being Weighed In Secret Health Bill Also Weigh It Down

KFF Health News, June 20, 2017

While Senate Majority Leader Mitch McConnell continues to push for a vote before the July 4 Senate recess, Washington’s favorite parlor game has become guessing what is, or will be, in the Senate bill. Spoiler: No one knows what the final Senate bill will look like — not even those writing it.

This article first appeared June 16, 2017 on Kaiser Health News.

By Julie Rovner

Anyone following the debate over the “repeal and replace” of the Affordable Care Act knows the 13 Republican senators writing the bill are meeting behind closed doors.

While Senate Majority Leader Mitch McConnell (R-Ky.) continues to push for a vote before the July 4 Senate recess, Washington’s favorite parlor game has become guessing what is, or will be, in the Senate bill.

Spoiler: No one knows what the final Senate bill will look like — not even those writing it.

“It’s an iterative process,” Senate Majority Whip John Cornyn (R-Texas) told Politico, adding that senators in the room are sending options to the Congressional Budget Office to try to figure out in general how much they would cost. Those conversations between senators and the CBO — common for lawmakers working on major, complex pieces of legislation — sometimes prompt members to press through and other times to change course.

Although specifics, to the extent there are any, have largely stayed secret, some of the policies under consideration have slipped out, and pressure points of the debate are fairly clear. Anything can happen, but here’s what we know so far:

1. Medicaid expansion

The Republicans are determined to roll back the expansion of Medicaid under the Affordable Care Act. The question is, how to do it. The ACA called for an expansion of the Medicaid program for those with low incomes to everyone who earns less than 133 percent of poverty (around $16,000 a year for an individual), with the federal government footing much of the bill. The Supreme Court ruled in 2012 that the expansion was optional for states, but 31 have done so, providing new coverage to an estimated 14 million people.

The Republican bill passed by the House on May 4 would phase out the federal funding for those made eligible by the ACA over two years, beginning in 2020. But Republican moderates in the Senate want a much slower end to the additional federal aid. Several have suggested that they could accept a seven-year phaseout.

Keeping the federal expansion money flowing that long, however, would cut into the bill’s budget savings. That matters: In order to protect the Senate’s ability to pass the bill under budget rules that require only a simple majority rather than 60 votes, the bill’s savings must at least match those of the House version. Any extra money spent on Medicaid expansion would have to be cut elsewhere.

2. Medicaid caps

A related issue is whether and at what level to cap federal Medicaid spending. Medicaid covers more than 70 million low-income people. Medicaid covers half of all births and half of the nation’s bill for long-term care, including nursing home stays. Right now, the federal government matches whatever states spend at least 50-50, and provides more matching funds for less wealthy states.

The House bill would, for the first time, cap the amount the federal government provides to states for their Medicaid programs. The CBO estimated that the caps would put more of the financial burden for the program on states, who would respond by a combination of cutting payments to health care providers like doctors and hospitals, eliminating benefits for patients and restricting eligibility.

The Medicaid cap may or may not be included in the Senate bill, depending on whom you ask. However, sources with direct knowledge of the negotiations say the real sticking point is not whether or not to impose a cap — they want to do that. The hurdles: how to be fair to states that get less federal money and how fast the caps should rise.

Again, if the Senate proposal is more generous than the House’s version, it will be harder to meet the bill’s required budget targets.

3. Restrictions on abortion coverage

The senators are actively considering a measure that would limit funding for abortions, though it is not clear if it would be allowed to remain in the bill under the Senate’s rules. The Senate parliamentarian, who must review the bill after the senators complete it but before it comes to the floor, will decide.

The House-passed bill would ban the use of federal tax credits to purchase private coverage that includes abortion as a benefit. This is a key demand for a large portion of the Republican base. But the Senate version of the bill must abide by strict rules that limit its content to provisions that directly impact the federal budget. In the past, abortion language in budget bills has been ruled out of order.

4. Reading between the lines

A related issue is whether House language to temporarily bar Planned Parenthood from participating in the Medicaid program will be allowed in the Senate.

While the parliamentarian allowed identical language defunding Planned Parenthood to remain in a similar budget bill in 2015, it was not clear at the time that Planned Parenthood would have been the only provider affected by the language. Planned Parenthood backers say they will argue to the parliamentarian that the budget impact of the language is “merely incidental” to the policy aim and therefore should not be allowed in the Senate bill.

5. Insurance market reforms

Senators are also struggling with provisions of the House-passed bill that would allow states to waive certain insurance requirements in the Affordable Care Act, including those laying out “essential” benefits that policies must cover, and those banning insurers from charging sicker people higher premiums. That language, as well as an amendment seeking to ensure more funding to help people with preexisting conditions, was instrumental in gaining enough votes for the bill to pass the House.

Eliminating insurance regulations imposed by the ACA are a top priority for conservatives. “Conservatives would like to clear the books of Obamacare’s most costly regulations and free the states to regulate their markets how they wish,” wrote Sen. Mike Lee (R-Utah), who is one of the 13 senators negotiating the details of the bill, in an op-ed in May.

However, budget experts suggest that none of the insurance market provisions is likely to clear the parliamentarian hurdle as being primarily budget-related.

Update: This story was updated on June 19 to clarify the description of the third category in the article.

White House Task Force Echoes Pharma Proposals

KFF Health News, June 19, 2017

Senior administrative officials met Friday to discuss an executive order on the cost of pharmaceuticals, a roundtable informed by Trump’s "Drug Pricing and Innovation Working Group."

This article first appeared June 16, 2017 on Kaiser Health News.

By Emily Kopp

President Donald Trump repeatedly talks tough about reining in the pharmaceutical industry, but his administration’s efforts to lower drug prices are shrouded in secrecy.

Senior administrative officials met Friday to discuss an executive order on the cost of pharmaceuticals, a roundtable informed by Trump’s “Drug Pricing and Innovation Working Group.” Kaiser Health News examined documents that shed light on the workings of this working group.

The documents reveal behind-the-scenes discussions influenced by the pharmaceutical industry. Joe Grogan, associate director of health programs for the Office of Management and Budget (OMB), has led the group. Until March, Grogan served as a lobbyist for Gilead Sciences, the pharmaceutical company that priced its hepatitis C drugs at $1,000 per pill.

To solve the crisis of high drug prices, the group discussed strengthening the monopoly rights of pharmaceuticals overseas, ending discounts for low-income hospitals and accelerating drug approvals by the Food and Drug Administration. The White House declined to comment on the working group.

The group initially met May 4 in the Eisenhower Executive Office Building and has since met every two weeks. In addition to OMB, the working group includes officials from the White House National Economic Council, Domestic Policy Council, Health and Human Services, the FDA, the Federal Trade Commission, the Department of Commerce, the Office of the U.S. Trade Representative and the Department of Justice.

According to the documents — the latest of which is dated June 1— the working group focused on the following “principles” and “talking points”:

  1. Extending the patent life of drugs in foreign markets to “provide for protection and enforcement of intellectual property rights.” This will ensure “that American consumers do not unfairly subsidize research and development for people throughout the globe.”

Extending monopoly protections for drugs overseas has been one of the pharmaceutical industry’s top priorities since the Trans-Pacific Partnership was defeated last year.

That policy would push up global drug prices, according to Médecins Sans Frontières.

  1. Promoting competition in the U.S. drug market — both by “modernizing our regulatory and reimbursement systems” and limiting “barrier to entry, including the cost of research and development,” according to the documents.

The working group also discussed two broad policy ideas that have been championed by the pharmaceutical industry, according to sources familiar with the process:

  1. Value-based pricing, when pharmaceutical companies keep the list prices of drugs unchanged but offer rebates if patients don’t improve. It’s unclear who would audit the effectiveness of the drugs, what criteria they would use to evaluate them and who would receive the rebates. Grogan invited Robert Shapiro — an adviser for Gilead and former secretary of Commerce under President Bill Clinton — to brief the working group on value-based pricing on May 18. Shapiro is the chairman and co-founder of Sonecon LLC, a Washington, D.C., firm that consulted with Gilead, Amgen and PhRMA, according to his curriculum vitae.
  1. Grogan and Shapiro also discussed issuing 10-year U.S. Treasury bonds to drug manufacturers to pay for expensive, hepatitis C drugs like Sovaldi and Harvoni under Medicare and Medicaid, to avoid rationing drugs to the sickest patients. The 2015 Senate investigation, for example, found that though Medicaid spent more than $1 billion on Sovaldi, just 2.4 percent of Medicaid patients with hepatitis C were treated.

After the working group’s first meeting on May 4, Grogan distributed detailed policy recommendations on expediting generic drug approvals, creating a new tax credit “of up to 50 percent” for investments in generic drug manufacturing, distribution and research and development. The documents also propose scaling back the 340B program, which requires drug manufacturers to provide some medicines at a discount to hospitals that treat low-income patients.

Most of these policies would not ease patient costs, and at least one would increase prices, say experts who reviewed the documents at the request of Kaiser Health News.

“This six-page document contains the kind of solutions to the cost-of-drugs problem that you would get if you gathered together all the executives of pharma and asked them ‘What sort of token gestures can we do?’ ” said Vinay Prasad, a professor of medicine at Oregon Health and Sciences University who studies the costs of cancer drugs.

The pharma-friendly recommendations appear to clash with earlier press reports indicating that OMB Director Mick Mulvaney was considering requiring drugmakers to pay rebates to Medicare patients, a measure the pharmaceutical lobby fiercely opposes.

Brand-name drug prices — which account for 72 percent of drug spending — go untouched in the handouts, said Fiona Scott Morton, a Yale economics professor and former attorney with the Justice Department’s antitrust division.

“The changes to generic markets to promote competition look helpful, but there need to be some more ideas to create more competition for branded drugs or consumers aren’t really going to notice this,” Scott Morton said.

Some of the text in the document is cribbed directly from policy papers published by the pharmaceutical industry’s powerful lobby — Pharmaceutical Research and Manufacturers Association (PhRMA).

Under the subtitle, “Encourage Use of 21st Century Tools for Drug Evaluation, Review and Approval,” one handout proposes the FDA use less rigorous clinical trial standards to speed drug approvals.

The handout cites a PhRMA paper from March 2016 that includes an identical subtitle, “Encourage Use of 21st Century Tools for Drug Evaluation, Review and Approval,” and recommends the FDA implement less rigorous clinical trial standards.

These recommendations would not lower drug prices, experts say.

Such measures “would be like a firefighter spraying gasoline on your burning garage,” Prasad said.

Another section — which recommends giving the FDA more discretion to evaluate generic copies of complex drugs — closely resembles a National Law Review article written by two lobbyists in the pharmaceutical division of Foley & Lardner, whose clients include generic drugmakers.

The handouts further recommend allowing drugmakers to supply data and off-label information to insurers and pharmacy benefit managers during the clinical trial period, before they secure FDA approval.

That’s a “terrible idea,” said Jerry Avorn, a professor at Harvard Medical School and the chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women’s Hospital. “That’s why we have the whole approval process, to determine what’s actually true,” he said.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Descent Into Secrecy: Senate Health Talks Speak To Steady Retreat From Transparency

KFF Health News, June 15, 2017

People are outraged over the lack of transparency and the loss of regular order. But both Democrats and Republicans have laid the track on which this train is rolling.

This article first appeared June 08, 2017 on Kaiser Health News.

By Julie Rovner

Congress struggling to finish a huge budget reconciliation bill. A GOP president pushing a major overhaul of federal payments for health insurance that could transform the lives of sick patients.

Sound familiar? The year was 1986. I was a rookie health reporter on Capitol Hill and watched a Medicare bill move from introduction, to hearings, to votes in subcommittees, to full committees and then to the entire House — an operation that took months and was replicated in the Senate, before the two chambers got together to iron out their differences for final passage. Everything was published in the official Congressional Record in almost excruciating detail for everyone to see — as long as they could read really tiny type.

Since then, in three decades of reporting, I’ve had a front-row seat to Congress’ slow, stuttering retreat from such step-by-step transparency, a process known as “regular order.”

It has now culminated in the Senate GOP leadership’s top-secret process to try to write a health bill that could change the formula for nearly one-fifth of the nation’s economy, with a vote they want to cast by July 4. In fact, a GOP Senate aide told the news site Axios on Monday that no details would be forthcoming until the bill is finished, adding, “We aren’t stupid.” That means bypassing the debate that traditionally went into lawmaking, in order to achieve consensus.

The extreme secrecy is a situation without precedent, at least in creating health law. Still, it’s not hard to see how we got here — and there is plenty of bipartisan blame to go around.

Since 1986, I have chronicled the passage (and repeal) of the Medicare Catastrophic Coverage Act, the fight over President Bill Clinton’s health proposal, passage of the Medicare prescription drug bill and passage of the Affordable Care Act, in addition to a dozen budget reconciliation measures that altered health care, often in fundamental ways.

Despite promises from incoming Democratic and Republican leaders over the past decade to restore a time-honored process, regular order has not returned. In fact, not only has it become increasingly rare, but the legislative process itself has become ever-more truncated, with Congress skipping steps it deemed inconvenient to partisan ends, particularly as leaders have “end run” the committees that are supposed to do the lion’s share of legislative work.

So long as there is bipartisan agreement, regular order can still prevail. A major bill completed in 2015 to reconfigure how Medicare pays doctors was the product of 15 months of work by Democrats and Republicans in the House and Senate, and passed three committees in open session by unanimous roll call votes.

But it has become progressively — and distressingly — more acceptable to set transparency aside in lawmaking over the years.

In the 1980s, Rep. Bill Natcher (D-Ky.) routinely closed the subcommittee markup of the spending bill to fund the Departments of Labor, Health and Human Services, and Education, even when there was no particular controversy to avoid. Reporters got to see the bill for the first time at the full Appropriations Committee markup.

Markups at the House Ways and Means Committee under Chairman Dan Rostenkowski (D-Ill.) also were frequently closed to the press and public, mostly for tax bills. Still, once I personally held up a health subcommittee markup for nearly a half-hour because the vote to close the session required a majority of members present. I refused to leave until a couple of committee members could be located and brought to the room to vote in person and kick me out.

Even meetings open to the press were sometimes less than revealing. In House-Senate conference meetings, members would frequently refer to what they were talking about using numbers on notes that were not shared with the audience, including reporters. So they basically spoke in code, and if you didn’t have the key you were just out of luck.

Of course, today there are fewer and fewer formal conference committees, places the two sides hammer out their differences in the public eye. Often the final versions of contentious bills are worked out behind closed doors, often without all of the members of the conference committee. In 2003, House Ways and Means Committee Chairman Bill Thomas (R-Calif.) retreated with all the Republican conferees and two of seven Democrats into his Capitol hideaway office in a group he called “the coalition of the willing.” They wrote the final bill in secret while reporters and lobbyists stood outside in the hall for weeks on end. (Sitting in the Capitol is considered civil disobedience and is strictly forbidden.) We were there so long and got to know one another so well that on my birthday someone got all the conferees in the room to sign a birthday card for me.

The final version of that bill was the one that passed the House in the dead of night – Republicans purposely scheduled the vote to begin at 1 a.m. (on the theory it would be easier to get wavering members to vote yes if only to go home to bed). The vote didn’t end until nearly 6 a.m., after President George W. Bush reportedly got the last few members to switch, via phone calls.

In 2009, creation of the Affordable Care Act was both open and closed. There were hundreds of hearings and markups that lasted days, or, in the case of the Senate Health, Education, Labor and Pensions Committee, months. But the unsuccessful effort by Senate Finance Committee Chairman Max Baucus (D-Mont.) to bring Republicans into the fold consisted of weeks of closed-door discussions, and the Senate bill that would ultimately become the foundation of the ACA was written in Senate Majority Leader Harry Reid’s office before being debated on the Senate floor for almost a month.

We got a sneak preview of how the GOP might shepherd its health bill through in 2015, when Republicans — who by then controlled Congress — orchestrated a “dress rehearsal” ACA repeal bill that was vetoed (as they knew it would be) by President Barack Obama. The bill was prewritten by leadership, approved by the relevant House committees, passed by the House and sent to the Senate. The Senate passed it with small changes (and without committee consideration). Rather than having a conference, the amended Senate bill was then simply approved by the House and sent to Obama for his veto.

That secretive process is being reiterated now. Only this time a Republican, Donald Trump, is president and the potential for change is real. People are outraged over the lack of transparency and the loss of regular order. But both Democrats and Republicans have laid the track on which this train is rolling.

Medical Responses To Opioid Addiction Vary By State, Analysis Finds

KFF Health News, June 12, 2017

Patients with private insurance who are diagnosed with opioid dependency or abuse may get different medical services depending on where they live.

This article first appeared June 12, 2017 on Kaiser Health News.

By Julie Appleby

Location, location, location. That mantra may apply even when it comes to how opioid addiction is treated.

Specifically, patients with private insurance who are diagnosed with opioid dependency or abuse may get different medical services depending on where they live, a white paper to be released in the upcoming week by a national databank indicates.

Medical responses to opioid-related diagnoses appear to differ among the five states examined by Fair Health, a nonprofit that provides cost information to the health industry and consumers. To draw that conclusion, researchers analyzed the health insurance billing codes associated with those diagnoses.

In California, for example, patients most commonly receive outpatient services, such as counseling, and also drug tests, which can include screening for narcotic use. Illinois’ top two services were 15-minute doctor-office visits and injections of naltrexone, a drug used to prevent relapse in patients who were dependent on opioids. By contrast, methadone, an opioid medication used to reduce withdrawal symptoms for patients trying to quit narcotics, was New York’s most common medical billed to an opioid-related diagnosis. All five of the most common procedures listed on bills in Texas were drug-screening tests — some of which were the same test codes as those on California’s list. But the Lone Star State also included a few that were not, including urinalysis, which checks for improper drug use.

Why those differences exist is harder to tease out, based on the data from Fair Health, which examines claims data from insurers representing more than 150 million Americans who have job-based insurance or buy it on their own. (Information identifying patients was removed.) The data do not include claims from government programs, such as Medicare or Medicaid.

The variation among the states may “reflect general attitudes, access to the health system and the services most readily available,” said Robin Gelburd, president of Fair Health.

Surprisingly, the study found that the largest percentage of medical coverage claims related to opioid abuse and dependence diagnoses nationally come from older patients — those ages 51 to 60.

This patient age group accounted for 32 percent of the services billed in rural areas and 25 percent in urban areas from 2007 to 2016. By contrast, 19- to 22-year-olds with those same diagnoses accounted for 10 percent of billed services in urban areas and just 2 percent in rural areas.

“This debunks the myth that the opioid crisis only affects young people,” said Andrew Kolodny, who directs the Opioid Policy Research collaborative at Brandeis University in Massachusetts, who did not work on the report.

Older patients can run into dependence problems when they get long-term opioid treatment for chronic pain, he said. With younger patients, he added, doctors are less likely to continue to prescribe opioids, leading some young people to turn to street drugs instead, like heroin.

Kolodny suggested that the Fair Health data may indicate that physicians are “increasingly getting the message that these opioids are not appropriate for chronic pain” and not continuing to write prescriptions indefinitely. That, in turn, he said, “could mean more older people are ending up in addiction treatment.”

As to the differences Fair Health found in the five most common services billed, Kolodny said drawing conclusions about the cause of the variation is difficult from the data provided.

Still, California’s reliance on outpatient services and drug tests among its top five procedure codes may reflect the large number of treatment centers in the state, noted Fair Health’s Gelburd, while New York insurers may rely on methadone more than other states because it has long been a common treatment in the state’s Medicaid program.

The analysis is the latest series from Fair Health, which last year released a report showing a 3,000 percent increase in the volume of insurance claims related to opioid dependence diagnoses from 2007 to 2014.

A second study put a dollar figure on the cost to insurers: From 2011 to 2015, insurers’ payments to hospitals, laboratories, treatment centers and other medical providers for patients with opioid-related diagnoses grew from $32 million to $446 million.

The new report shows the five most common, as well as the five most expensive, procedures related to opioid abuse or dependency diagnoses that insurers paid for in 2016 in five states: California, New York, Illinois, Texas and Pennsylvania, chosen because they include the country’s five most populous cities.

It’s not clear why all the top five billing codes in Texas related to laboratory tests for drugs. Perhaps treatment programs there rely heavily on screening patients for the use of legal and illicit drugs. Out-of-state drug screens processed by labs based in Texas could account for some of the billing.

Gelburd said the data may prompt more debate on “the most appropriate protocols with drug testing.”

In Texas and elsewhere, she said, experts may want to weigh in on whether the percentage of drug testing indicates that such screenings are “being done too frequently or not enough,” and whether medical services for addiction treatment “are focusing too heavily on screening and detection or coupling that screening with intensive therapies.”

Capitol Hill Dems, HHS Secretary Price Trade Jabs On HHS Budget

KFF Health News, June 9, 2017

Democrats accused Price of doing little to stabilize the individual insurance marketplace as insurers have announced withdrawal plans.

This article first appeared June 08, 2017 on Kaiser Health News.

By Rachel Bluth

In back-to-back appearances on Capitol Hill Wednesday, Health and Human Services Secretary Tom Price sparred with Democrats over the Trump administration’s budget cuts for his department and coming troubles in the individual health insurance market.

“President Trump’s budget does not confuse government spending with government success,” Price said, defending a spending plan that calls for substantial funding reductions to Medicaid, the Centers for Disease Control and Prevention, the National Institutes of Health and other HHS agencies.

The problem with many federal programs “is not that they are too expensive or too underfunded. The real problem is that they do not work — they fail the very people they are meant to help,” Price said in testimony before the Senate Finance Committee and the House Ways and Means Committee.

He cited Medicaid, the federal-state insurance program for low-income people, as an example of where rising costs require reforms. The administration’s budget would reduce federal Medicaid funds to states by $610 billion over a decade. Under its proposal, states would gain latitude over how to spend those funds, which Price said would lead to innovations and efficiencies.

Sen. Sherrod Brown (D-Ohio) questioned whether HHS is budgeting enough money under Medicaid to fight the opioid-abuse epidemic. Seventy percent of the $939 million that Ohio spent on opioid treatment in 2016 came from federal Medicaid dollars, he said.

“You would never propose we fight cancer with a $50 million increase to a grant program,” Brown said. “… How does this possibly work if you’re going to cut the biggest revenue stream to treat people?”

Price pushed back, pointing out that more than 52,000 Americans died of overdose deaths in 2015.

“We continue to tolerate a system that allows for overdose deaths, and I simply won’t allow it,” Price said.

Trump’s budget has come under heavy attack in Congress since its release last month and is expected to undergo much rewriting. The budget would take effect for the fiscal year starting Oct. 1.

Democratic senators and representatives on the committees repeatedly challenged Price on his testimony and the administration’s health care policies, sometimes using strong words and loud voices.

“It’s mean-spirited. It’s not good for America. We can do much better,” thundered Rep. John Lewis (D-Ga.).

With insurers facing looming deadlines to decide whether to participate in the Affordable Care Act’s online marketplaces next year, lawmakers also pressed Price on whether the Trump administration will pay insurers about $7 billion in “cost-sharing subsidies” for 2018. The White House has sent mixed signals, but many insurers’ decisions about next year’s premiums and where they will offer health plans hinge on the verdict.

Sen. Debbie Stabenow (D-Mich.) repeatedly asked Price if he would commit to making subsidy payments, but Price refused to answer beyond reiterating that the budget includes payments through 2018. Price said he could not elaborate because he is the defendant in a lawsuit regarding these subsidies — a still-pending case brought by the Republican-led House of Representatives during the Obama administration.

Democrats accused Price of doing little to stabilize the individual insurance marketplace as insurers have announced withdrawal plans. But Sen. Pat Roberts (R-Kan.) said the market was failing and it wasn’t Price’s fault.

“We are in the Obama car and it’s like being in the same car as Thelma and Louise going into the canyon,” he said. “We need to get out of the car.”

Price was also asked about a draft rule from HHS that would scale back the ACA’s mandate requiring nearly all employers to offer health insurance covering birth control. The HHS proposal would allow more types of employers to claim moral or religious exemptions to the mandate. “I think that for women who desire birth control, it should be available,” Price said.

When Sen. Maria Cantwell (D-Wash.) pressed him to answer whether birth control should be available to women through their employers, Price reiterated that it should be available to women who want it.

“This is a very big problem,” she said. ”Women cannot be discriminated against by their employers who want to cherry-pick women’s health.”

Former Pharma Rep's New Mission: To School Docs On High Drug Costs

KFF Health News, June 8, 2017

He works for Capital District Physicians’ Health Plan and when he visits physicians, he champions generic drugs.

This article first appeared June 08, 2017 on Kaiser Health News.

By Jay Hancock

As a drug salesman, Mike Courtney worked hard to make health care expensive. He wined and dined doctors, golfed with them and bought lunch for their entire staffs — all to promote pills often costing thousands of dollars a year.

Now he’s on a different mission. When Courtney calls on doctors these days, he champions generic drugs that frequently cost pennies and work just as well as the kinds of pricey brands he used to push.

Instead of big pharma, he works for Capital District Physicians’ Health Plan (CDPHP), an Albany, N.Y., insurer. Instead of maximizing pill profits, his job is to save millions of dollars by educating doctors about expensive prescriptions and the stratagems used to sell them.

“Having come from big pharma, I do really feel my soul has been cleansed,” laughs Courtney, who formerly worked for Pfizer and Johnson & Johnson. “I do feel like I’m more in touch with the physicians” and plan members, he added.

Costs for prescription drugs have been rising faster than those for any other health segment, marked by high-profile cases such as the reported 400 percent increase for Mylan’s EpiPen and 5,000 percent spike for Turing Pharmaceuticals’ Daraprim.

Health plans and others paying those costs are fighting back. Many have tried to give doctors academic research on pill effectiveness or simply removed high-cost drugs from coverage lists.

Consumer groups and medical societies have tried to spread the word about expensive drugs. Startup GoodRx lets patients compare retail prices online.

CDPHP is one of the few insurers to have taken the battle against pricey pills a step further. It is recruiting across enemy lines, hiring former pharma representatives and staffing what may be a new job category: a sales force for cost-effective medicine.

“Insurers are taking matters into their own hands,” said Lea Prevel Katsanis, a marketing professor at Canada’s Concordia University who specializes in the pharmaceutical industry. “They’re saying, ‘We can’t really rely on drug companies to talk to doctors about what’s cost-efficient.’”

If insurance companies can curb drug costs, premiums paid by employers, taxpayers and consumers need not rise as fast.

Two years ago, when one company increased the cost of a common diabetes medicine to 20 times what it had been a few years earlier, Courtney and five other former pharma and medical-device reps working for CDPHP knew what to do.

Valeant Pharmaceuticals had cranked up the price of one common dosage of its Glumetza medicine for lowering blood sugar to an astonishing $81,270 a year, according to Truven Health Analytics, a data firm. Meanwhile a similar, generic version can be bought for as little as a penny a pill.

Because Glumetza was on CDPHP’s list of approved drugs, the insurer and its members had to pay for it when doctors prescribed it, resulting in millions in extra costs and stinging copayments for patients.

Dr. Eric Schnakenberg, an upstate New York family medicine doctor, was shocked when patients began complaining about what he assumed was an inexpensive prescription. Doctors are famously unaware about the cost of the care they order, a situation exploited by drug sellers and other vendors.

While physicians’ electronic prescribing programs and even pharmaceutical guides like the Physicians’ Desk Reference contain prescribing information — some are even peppered with ads — they contain no specific information about prices. Drug sales reps who visit their offices don’t highlight high prices as they drop off free samples, and drugmakers can quietly, but substantially, hike the price of a drug from one year to the next.

“As physicians, we’re blindsided by that,” Schnakenberg said. “We get patient complaints saying, ‘Hey, I can’t afford this,’ and we say: ‘It’s cheap!’”

After Courtney and his colleagues alerted doctors to what Valeant was up to, all but a handful of the 60 plan members who were taking Glumetza switched to metformin, the generic alternative. That saved about $5 million in a year.

Following an outcry over its practices, Valeant agreed last year to raise annual prices by no more than single-digit percentages, the company said through a spokesman. But such hikes could still outpace the inflation rate.

Using ‘Those Powers For Good’

Cardiologist John Bennett got the idea to hire pharma reps a few years ago, after he became CDPHP’s chief executive. He knew reps are smart, genial and motivated. Overhiring by pharma had put many back on the job market.

His sales pitch to them, he says half-jokingly, was: “You know everything they taught you in big pharma? How would you like to use those powers for good?”

Pharma companies spend billions on TV ads, doctor blandishments and expensive salespeople to keep prescriptions flowing.

Pfizer, Johnson & Johnson and other sellers responded to critics a few years ago by restricting gifts of entertainment, coffee mugs and some meals. But the industry’s ethics code still allows lavish consulting contracts for doctors and sponsorship of physician conferences as well as meals for doctors and their staffs who listen to an “informational presentation” from sales reps touting expensive pills.

“When those products go generic, nobody’s promoting them anymore,” Courtney said. Generics makers lack big marketing budgets. CDPHP’s remedy: The insurer promotes generics with its own reps.

“It’s a great idea,” said Alan Sorensen, an economist at the University of Wisconsin who has studied drug prices. “Even a small moving of the needle on their [doctors’] prescribing behavior can have a pretty big impact on costs.”

At first the team concentrated on educating doctors about cheaper alternatives to Lipitor, a widely prescribed cholesterol-lowering medicine, and Nexium, for stomach problems. That saved around $10 million the first year, much in the form of copayments that would have been owed by plan members.

Recently the plan has focused on Seroquel, a branded antipsychotic that costs far more than a similar generic. Switching to the generic saves $600 to $1,000 a month, estimates Eileen Wood, the insurer’s vice president of pharmacy and health quality.

CDPHP’s repurposed reps have helped keep the insurer’s annual drug-cost increases to single-digit percentages, whereas without them and other measures “we would certainly be well into double-digit” increases, she said.

Educating doctors about drug costs is part of a larger push for “transparency” in an industry where Princeton economist Uwe Reinhardt says consumers face the same experience as somebody shopping in Macy’s blindfolded.

Current research by the University of Wisconsin’s Sorensen finds physicians with access to data about drug prices and insurance coverage are more likely to prescribe generics.

That gives Courtney and his colleagues a fighting chance, even if, he said, “we don’t have the freewheeling, unlimited green Amex card like I did back in the day.”

If Insurance Market Crashes, Can Lawmakers Put The Pieces Back Together?

KFF Health News, June 8, 2017

The president has made his strategy clear. “The Democrats will make a deal with me on healthcare as soon as ObamaCare folds — not long,” Trump tweeted March 28.

This article first appeared June 08, 2017 on Kaiser Health News.

By Julie Rovner

In his high-stakes strategy to overhaul the federal health law, President Donald Trump is threatening to upend the individual health insurance market with several key policies. But if the market actually breaks, could anyone put it back together again?

The question is more than theoretical. The Trump administration has already acted to depress enrollment in Affordable Care Act plans, has instructed the IRS to back off enforcement of the requirement that most people have health insurance or pay a penalty and threatened to withhold billions of dollars owed to insurance companies. All of those actions make it more difficult for insurers to enroll the healthy people needed to offset the costs of the sick who make it a priority to have coverage.

The president himself has made his strategy clear in interviews and tweets. “The Democrats will make a deal with me on healthcare as soon as ObamaCare folds — not long,” Trump tweeted March 28. “Do not worry, we are in very good shape!”

But the individual insurance market is not in such good shape. A growing number of insurers are asking for double-digit premium increases or deciding to leave the market altogether. In the latest announcement, Anthem said Tuesday that it was pulling out of the Ohio marketplace next year. And while most analysts say the market probably would eventually rebound, in the short term things could get messy.

“Is the administration doing what it needs to do to stabilize the market? No, they’re doing the opposite,” said Kevin Counihan, CEO of the insurance exchange program during the Obama administration.

Trump’s biggest weapon, by far, is refusing to reimburse insurance companies for billions of dollars in payments the law requires them to make to help policyholders with incomes up to 250 percent of the federal poverty level (about $30,015 for an individual and $61,500 for a family of four) afford their deductibles and other out-of-pocket payments. These “cost-sharing subsidies” are the subject of an ongoing lawsuit, and Trump can effectively end them at any time by dropping the suit.

Meanwhile, major insurance companies like Aetna and Humana have already announced that they won’t participate in the health exchange market for 2018.

Other plans have said they would like to stay in but only if they are granted huge rate hikes, citing the uncertainty of whether the Trump administration will repay them for the cost-sharing discounts and whether it will enforce the health law’s “individual mandate” that requires most people to have coverage or pay a fine. In Pennsylvania, for example, insurers are seeking premium increases of less than 10 percent for 2018 — but warn that if the mandate to have insurance is not enforced or cost-sharing reductions not paid, those increases could balloon to 36 percent or more.

Those who follow the market closely say the exits and requests for large premium increases are no surprise. “It’s just been one thing after another in this market,” said Kurt Giesa, an actuarial expert at the consulting firm Oliver Wyman. He said if the administration follows through on its threat not to fund the cost-sharing subsidies for the rest of the year, “that could be the straw that breaks the camel’s back.”

Giesa also pointed out that it’s not just insurance companies that would suffer if the individual insurance market is crippled. “That strategy of crashing the market has real human consequences,” he said. “There are 15-million-plus people relying on that.”

That group includes not only people who purchase insurance through the “health exchange” state marketplaces, but also those who purchase insurance on their own, usually because they earn too much to get federal assistance paying their premiums. Premium subsidies are available to those who earn less than 400 percent of the poverty level (about $48,240 for an individual and $98,400 for a family of four).

People who pay their own way are the ones getting hit hardest, said insurance industry consultant Robert Laszewski. “There is a horrific death spiral going on with the [non-subsidized] part of the market right now,” he said, because rate hikes are limited for those getting help from the government, but not for those paying the full premiums.

A major question is how hard would it be for the government to regain the trust of insurers as a reliable business partner, regardless of what changes are eventually made.

Counihan acknowledged that insurers felt they were treated unfairly even before the Trump administration took office, when Republicans in Congress prevented full payment of “risk corridor” funds that the law promised insurers who enrolled more than their expected share of sick people. Insurers are still owed millions of dollars and many have sued the federal government to try to get the money.

Counihan said the first words out of the mouths of most insurance CEOs he met with were “we don’t trust you guys.”

Giesa said the government’s misbehavior goes back even further — to the fall of 2013, when the Obama administration allowed some consumers to keep their old plans. That effectively kept healthy people out of the new markets, “after companies had set their prices,” Giesa said, resulting in some big losses for insurance companies.

Despite the woes, insurance analysts say they doubt the individual market would stay down for long.

One reason, said Laszewski, is that, unlike with big commercial insurers, for many nonprofit insurers serving the individual market as the insurer of last resort is part of their mission. Boards of Blue Cross Blue Shield plans and other nonprofits, he said, tend to be made up of representatives of “labor, the local hospitals, big employers. … They have community connections. So it’s going to take a lot to drive them off.”

Another reason insurers will likely return or work to remain in the individual market is that it’s part of the future of health care, said Counihan. With so many people now working for themselves in the “gig economy,” he said, selling insurance “is going to be more business-to-consumer than businessto-business.”

“This market could grow,” agreed Giesa. “And I don’t think [insurance companies] want to be left out completely from this market if there’s an opportunity to break even, or make a little money.”

In the end, said Counihan, regardless of what he considers the Trump administration’s “disorganized neglect, I think this market is here to stay.”

Hospitals Now Tap Lawyers To Fulfill Patients’ Legal Needs

KFF Health News, June 7, 2017

As healthcare systems continue to shift toward becoming comprehensive medical homes for patients, providers are increasingly incorporating lawyers into the teams of professionals who are on hand to help patients.

This article first appeared June 06, 2017 on Kaiser Health News.

By Michelle Andrews

Every Friday, Christine Crawford has a counseling session at a clinic at New York City’s Mount Sinai Health System as she moves ahead with plans for gender transition surgery later this year. In addition to the many medical and psychosocial issues, there are practical ones as well. So, Crawford was thrilled when a Mount Sinai representative said they would assign a lawyer to help her legally change her name to Christine.

The lawyer filed her name-change petition with the court and helped Crawford, 56, with other steps, such as notifying her former spouse and publishing the name change in the newspaper. She gave Crawford information about what she needed to do to make the change official with organizations such as the Social Security Administration and the Department of Motor Vehicles.

Perhaps best of all, when Crawford graduated with a master’s degree in social work last month, her diploma had her new name on it.

“[The lawyer] was able to expedite the petition and the court date,” Crawford said. “She was a godsend.”

As health care systems continue to shift toward becoming comprehensive medical homes for patients, health care providers are increasingly incorporating lawyers into the team of professionals who are on hand to help people at no additional charge to patients.

Roughly 300 health care systems, children’s hospitals and federally qualified health centers have set up these programs, said Ellen Lawton, co-director of the National Center for Medical-Legal Partnership at George Washington University in Washington, D.C.

The pairing makes sense in many ways. Legal issues all too often can cascade into problems with bad medical outcomes. Lawyers might file for an order of protection from a violent spouse, help appeal an insurance claim denial or get involved in child custody, guardianship or power of attorney issues.

For Care Connections at Lancaster General Health/Penn Medicine in Lancaster, Pa., housing problems are a key area that requires legal expertise. The four-year-old program provides comprehensive primary care services for people with complex health and social needs, especially patients who are frequently hospitalized, said Dr. Jeffrey Martin, managing physician for the program.

For someone with severe asthma and other chronic medical conditions, “it’s hard to use inhalers and take 16 other medications if you’re living in the back of a car or on someone’s couch,” he said.

When someone is fighting eviction, has problems with federal housing subsidies, suffers a utility shutoff or has poor housing conditions, Care Connections staff call on Catherine Schultz. She is a legal aid lawyer with MidPenn Legal Services, which has a contract to work on such cases for Lancaster General Hospital.

Christine Crawford was thrilled when a Mount Sinai representative said they would assign a lawyer to help her legally change her name. (Courtesy of Christine Crawford)

Martin described the case of one patient, a licensed practical nurse in her mid-30s who was diagnosed with multiple sclerosis. She lost her job because she could no longer work, and then her car was repossessed. She stopped taking her medications and couldn’t make it to her medical appointments.

Schultz worked to get the woman a federal housing subsidy and apply for Social Security disability benefits, then appeal the administration’s denial of benefits. They’re awaiting the results of the appeal.

In fee-for-service medicine, a hospital’s work was considered finished once patients were discharged, Lawton noted.

But health care has shifted toward value-based care that focuses on outcomes and avoiding preventable hospital readmissions. Now, “you are accountable for patients beyond the four walls of the hospital, and you have to think creatively about how to create stability for them,” Lawton said.

With that in mind, many health care systems are focusing on medical-legal partnerships that target patients who are high users of services.

“Once upon a time, the attitude of the provider was, ‘It’s not my problem that you have mold in your apartment,’” said Emma Kagel, manager of medical-legal partnerships at Denver-based Centura Health System. “‘I’m just going to keep pumping you full of steroids and give you an inhaler.’” That attitude doesn’t work with value-based care, she said.

Funding is always a problem for these programs where demand far outstrips supply. They are frequently staffed by legal aid attorneys under contract to the health care providers. Some programs use private-sector lawyers working on a pro bono basis.

Mount Sinai, whose program is just getting off the ground, is taking a hybrid approach. In addition to a grant from the Manhattan District Attorney’s Office to provide child and family law services, the hospital partnered with law firms and other organizations to provide transgender and end-of-life legal services on a pro bono basis.

Sena Kim-Reuter, president of the Mount Sinai Medical Legal Partnership, said she’s focused on identifying gaps in patients’ needs where she can offer assistance. “There’s no way to handle all of it,” she said.

Daylight On Diabetes Drugs: Nevada Bill Would Track Insulin Makers’ Profits

KFF Health News, June 7, 2017

Prominent patient advocacy groups, such as the American Diabetes Association, have been silent while diabetes patients championed the bill— a silence that patients and experts say stems from financial ties.

This article first appeared June 07, 2017 on Kaiser Health News.

By Emily Kopp

Patients notched a rare win over the pharmaceutical industry Monday when the Nevada Legislature revived a bill requiring insulin makers to disclose the profits they make on the life-sustaining drug. In a handful of other states, bills addressing drug prices have stalled.

Many of the 1.25 million Americans who live with Type 1 diabetes cheered the legislative effort in Nevada as an important first step in their fight against skyrocketing costs of a drug on which their lives depend. The cost of insulin medications has steadily risen over the past decade by nearly 300 percent.

Prominent patient advocacy groups, like the American Diabetes Association, have maintained stony silence while diabetes patients championed the bill and lobbied the legislature during this debate — a silence that patients and experts say stems from financial ties.

“Normally all of the patient advocacy groups rally around causes and piggyback on each other in a productive way — that’s what advocacy groups are good at — but that hasn’t been the case here,” said Thom Scher, chief operating officer of Beyond Type 1, which does not accept donations from the pharmaceutical industry. Beyond Type 1 has not issued a formal opinion on the Nevada bill.

Many of the dozens of U.S. diabetes advocacy organizations, large and small, garner significant portions of their funding from insulin manufacturers. The Nevada bill also requires such organizations operating in-state to disclose all contributions they receive from the pharmaceutical industry to discourage that sort of conflict.

In 2016, two of the “big three” insulin producers — Eli Lilly and Sanofi — contributed at least $4.7 million to such national patient advocacy groups as the American Diabetes Association, Diabetes Patient Advocacy Coalition (DPAC), JDRF International and the Diabetes Hands Foundation, according to company disclosures. The third major insulin manufacturer, Novo Nordisk, does not disclose its charitable contributions.

The advocacy groups have taken no position on the Nevada legislation. Generally speaking, their advocacy focuses on pressuring insurers to pay the price of insulin, not protesting price rises.

Local diabetes groups, hardly free from conflicts with the pharmaceutical industry, have also stayed on the sidelines.

The Nevada Diabetes Association for Children and Adults officially issued a neutral opinion.

“The Nevada Diabetes Association supports regulations on medications. The problem with SB 265 is that it is not just regulating medication but the industry,” said Executive Director Sarah Gleich.

The nonprofit does not list its fiscal sponsors on its website or most recent 990 tax form.

“We disclose what we have received, and the IRS does not require that we publicly publish from whom,” Gleich said. “No one is giving out their invitation list to the party.”

Gleich said the Nevada Diabetes Association receives table sponsorships and supplies for camp programs from the pharmaceutical industry but “nothing that would make a dent on the budget.” Auditing non-monetary donations in order to meet the bill’s transparency requirement would be burdensome, Gleich said.

Membership dues accounted for only about $6,000 of the group’s $320,000 in revenue last year, according to its latest tax form.

The American Diabetes Association — which operates a Nevada chapter — accepted at least $3.9 million from Eli Lilly and Sanofi last year.

“The American Diabetes Association believes that no individual in need of lifesaving medications such as insulin should ever go without due to prohibitive costs,” Michelle Kirkwood, its director of strategic communications and media relations, said in a statement. She would not say whether the nonprofit supports the bill.

Former American Diabetes Association president Larry Hausner wrote an op-ed in the Nevada Appeal opposing the legislation. “Caring for people with diabetes involves more than what they pay for insulin or another medication,” Hausner wrote. “As a lifelong patient advocate, I know Nevadans expect more out of their elected officials.” Hausner, now the president of a consulting and public affairs firm, serves on the board of directors of Research!America, a nonprofit promoting increased federal funding for public health research, alongside Sanofi’s president of global research & development, Elias Zerhouni.

The Diabetes Hands Foundation expressed neutrality on the bill. “This state priority in Nevada is a good step towards a larger conversation about the costs of chronic care conditions like diabetes,” said the foundation’s director of advocacy, Mandy Jones. “But it’s hard to know the particular outcome of this particular bill in the U.S. market.”

JDRF International would not comment. DPAC deferred questions to the National Diabetes Volunteer Leadership Council.

Against the backdrop of silence from these patient advocacy groups, a community of diabetes patients on Twitter elevated the bill’s profile around the hashtag #insulin4all, created by T1International, a group in the United Kingdom that does not accept pharmaceutical donations.

“People feel frustrated. At the federal level, we’re not being seen because there’s so much going on politically,” said Erin Gilmer, a Colorado advocate with Type 1 diabetes. “It might have to be a state-by-state movement.”

Sen. Yvanna Cancela, who sponsored the bill, said she believed requiring diabetes advocacy groups to reveal their sources of funding was key to understanding their positions and bringing prices down. “I believe there should be transparency across the health care system,” Cancela said.

Gov. Brian Sandoval said Monday night that he intends to sign the bill, according to a Nevada Independent reporter. If the governor takes no action, the transparency rules become law. The bill, SB539, incorporates provisions of an earlier bill approved by the legislature but vetoed by Sandoval. Sponsors stripped a controversial provision that would have required insulin manufacturers to warn patients 90 days before raising prices, which stoked concerns about drug stockpiling, the Associated Press reported Monday.

The Nevada bill “is definitely a step in the right direction,” said Elizabeth Rowley, founder and director of T1International. “Almost anything requiring more transparency is incredibly important right now, especially at a time when almost all diabetes patient advocacy groups take funding from drug and device companies.”

Laura Marston, an advocate in Washington, D.C., with Type 1 diabetes, said that there is plenty of grass-roots support for legislation on insulin prices but that advocacy organizations are not listening to the right people.

“There should be more focus on the one thing we need to survive. … Without insulin, I die a horrendous death in 12 to 24 hours,” Marston said. “No grass-roots support? There’s desperation.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

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