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Health Policy Updates: September 17 2016

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The NYTimes reports on reimbursement practices that leave many seniors and chronic ill people unable to qualify for rehabilitative and home care service, on the premise that they do not have a “rehabable” condition. This leaves many people with long-term and chronic illnesses unable to get coverage for the care they need, and either pay out of pocket or go without. Importantly, this situation continues despite recent policy changes that “improvement” is no longer an appropriate requirement; “maintenance” of current function should theoretically be sufficient to qualify.

“Medicare beneficiaries often hear such rationales for denying coverage of skilled nursing, home health care or outpatient therapy: They’re not improving. They’ve “reached a plateau.” They’re “stable and chronic,” or have achieved “maximum functional capacity.”[…] What matters, as the 2013 settlement of a class-action lawsuit specified, is maintenance. Medicare must cover skilled care and therapy when they are “necessary to maintain the patient’s current condition or prevent or slow further deterioration.”


The Economist took a swing at explaining high drug prices in the US last week. The culprit they finger? Perverse results from federal regulations meant to control the drug market.

“Rather than lower prices, rules for Medicare help raise them. Medicare rewards doctors for prescribing costly intravenous drugs—medicines that can account for up to 30% of an oncologist’s revenue. Medicare’s rules for pills, inhalers and so on are equally nonsensical. And it is illegal for Medicare to negotiate with drug companies. Private insurers do so instead, but the government binds their hands, for example by requiring them to pay for six broad categories of drugs, without exception. This suits pharmaceutical firms.”


I haven’t reported much on the opioid abuse crisis, simply because there seems to be such a clear consensus that it is a problem, and I don’t know much more about it than that. Not much has been done so far in terms of national legislation or action, but the authors of this piece argue that there is a good chance for that in the near future, because of rare bipartisan agreement on the issue.

“Results from public opinion polls in 2015 and 2016 indicate a clear path of consensus for moving forward, as Democrats and Republicans agree that treatment should come before incarceration for people caught in possession of, but not selling, small amounts of prescription painkillers obtained without a prescription or heroin; and that careful prescribing guidelines should be promoted to curb excessive opioid use without impinging on the medical needs of patients.”


The Orphan Drug system was meant to incentivize research and development of drugs for rare disease, which would not otherwise be financially profitable for drugmakers to pursue. However, this law often ends up getting taken advantage of by the drugmakers:

“Here’s the game. Find a cheap drug with lapsed patents that is approved for one indication but is widely used off-label for an orphan disease. Run the drug through clinical trials for that disease and get FDA to approve it for the new indication. Voilà! You’ve got seven years of market exclusivity under the Orphan Drug Act. Then you jack up the price. This happens a lot.”


Being poor and having cancer – not a good combination.

“Patients with Medicaid or who were uninsured were more likely to have a larger tumor at the time of diagnosis. An uninsured patient was 14 percent more likely to have a shorter survival time than someone who was privately insured, while a patient with Medicaid was 10 percent more likely to have a shorter survival time, the study found.”


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