As we approach the lazy days of August, I want to offer a shopping list of healthcare issues that will be the focus of any action that takes place prior to Washington’s annual August recess. There are two pieces of legislation that may see some action prior to August . . . they may even get signed into law.

The first piece of legislation is the infrastructure bill, a rare attempt at passing some type of bipartisan legislation. I can’t give you any odds on its passage, but I can tell you that it will be a prime place for some last minute backroom dealing, that could involve some of the healthcare issues listed below.

The second possible bill comes under the umbrella of budget reconciliation. This is a somewhat complicated process employed in the Senate, with the main point being that, when this process is used, it only takes a simple majority for the bill to pass and the filibuster is not in play. It is almost certain that this bill will be a partisan, Democrat only, bill. It is very possible that this bill will contain some changes to your healthcare.

There are many proposed changes to our county’s healthcare that have been considered over the years and have become more in play in the last few months. I will list these issues below, most of which I’ve discussed in earlier blogs. I won’t include all the links, but a quick search will yield the blogs that have discussed in more detail the issues you are interested in. The first group of issues are proposed changes that have some bipartisan interest and, therefore, are more likely to be included in one of these two bills.

Some bipartisan support:

• Price transparency – Unmask some of the prices and costs in the drug business process to encourage competition.
• Surprise billing – When beneficiaries use out-of-network providers they are often surprised with a huge bill. Proposed legislation would limit the amount to be charged and increase the notification process.
• Balance co-pay costs – This change would let Medicare enrollees spread out their copays in monthly installments so they wouldn’t be faced with the entire yearly cost in the first few months.
• A cap on prescription drug out-of-pocket costs – This change would put a beneficiary cap on the yearly out-of-pocket cost for the Medicare prescription benefit, Part D.

Other issues:

• Drug importation – Allow states to import drugs from foreign countries, primarily Canada.
• Drug negotiations – This would allow the government to essentially set drug prices.
• Limit drug prices – Base drug prices on those of a select group of foreign countries.
• Limit existing drug price increases – Using the Consumer Price Index (CPI)  (inflation indicator), the government will limit the amount certain drug prices could be increased.
• Expand Medicare eligibility – Possibly lower the entry age to 60.
• Expand Medicare benefits – Add dental, hearing and vision coverage.
• Change the prescription drug rebate process – Push rebate savings to the patient at the pharmacy counter.
• Telehealth – Expand payments and eligibility for telehealth services.

These are the main changes that have been proposed. There could be others that work their way into the discussion.

Finally, there is one change that I haven’t talked about in earlier blogs but has become an important, likely bipartisan, issue. This is the inclusion of diversity in all aspects of our healthcare.

The pandemic highlighted some basic flaws that have existed in our healthcare system for years but have been under reported and, in some cases, ignored. COVID-19 served to shine a light on some of these flaws that have been experienced by minorities. It showed how the lack of diversity, not only in the healthcare workforce but also in communication and in the reporting process, has had a negative impact on minorities in our country. We began to make changes, as trials for new COVID-19 vaccines and medicines were designed with a requirement for inclusion of minorities. Flawed diagnostic processes that altered the validity of the diagnosis for minorities were identified. Our country is finally awakening to the embedded lack of understanding that exists in our healthcare system. I’m pretty sure that some sort of diversity requirements, regulations and oversight will find its way into one of these bills.

It is possible that these bills will not be finalized until the fall but there is a concerted effort to have something done so that the politicians can go back to their home states and districts with something to talk/brag about. It could be an active end of July and early part of August. We’ll try to keep you up-to-speed on what’s going on.

Best, Thair

This month is UV Safety Awareness Month, which makes a lot of sense, since the summer is when the UV rays are the most damaging. Unfortunately, the only way to get most of us to really pay attention to change our behavior is to scare us into taking action. So, here’s my scare tactic.

The Assistant Secretary for Health, U.S. Department of Health and Human Services (HHS), who just happens to have worked as a skin oncologist for many years, points out that skin cancer is the most commonly diagnosed cancer in the United States, yet most cases are preventable. What???? You mean that the most commonly diagnosed cancer can be prevented without expensive medicine or operations? He also said that despite this fact, skin cancer rates continue to rise and that almost all of the conditions were caused by unnecessary ultraviolet (UV) radiation exposure, usually from excessive time in the sun or from the use of indoor tanning devices. Did you know that almost one out of three young white women between 16 and 25 engaged in some sort of indoor tanning, like tanning booths? The sobering fact is that skin cancer causes 9,000 deaths each year.

OK, I hope you were astounded and maybe even scared a little about reducing your exposure to UV rays. All of us are probably bright enough to understand the ways we can protect ourselves from harmful UV rays, i.e., don’t expose your skin and eyes to direct sunlight. The simple fact is we can all take action to prevent skin cancer. You can read much more about ways to protect your skin in the Call to Action to Prevent Skin Cancer on the HHS website. I would, however, like to spend just a minute talking about sunscreen, an important tool in protecting our skin.

There’s a variety of ways we can apply sunscreen, but the best sunscreen is the one we apply regularly. There are some things to remember about sunscreen, the sun protection factor (SPF) is the amount of protection the sunscreen offers. An SPF of 15 means it would take 15 times longer to burn if you didn’t use that particular sunscreen. The higher the SPF the more protection you get. . . to a point. The CDC says that anything higher than SPF 50 offers only marginally more protection. Sunscreen labeled “Broad Spectrum” offers protection for both UVA rays and UVB rays. It is also important to know that no sunscreen is “waterproof;” if you go in the water, you should periodically reapply your sunscreen.

You’ve probably been wondering about the title of the blog, “The Eyes Have It” When I learned more about UV Safety Awareness Month I realized I had always thought about protecting my skin and hadn’t thought much about the importance of protecting my eyes from harmful UV rays. Exposing your eyes to UV rays heightens the risk of developing cataracts, macular degeneration, and growths on the eye including cancer.

Here are some tips from the American Academy of Ophthalmology:

• Don’t focus on color or darkness of sunglass lenses: Select sunglasses that block UV rays. Don’t be deceived by color or cost. The ability to block UV light is not dependent on the price tag or how dark the sunglass lenses are.
• Check for 100 percent UV protection: Make sure your sunglasses block 100 percent of UVA rays and UVB rays.
• Choose wrap-around styles: Ideally, your sunglasses should wrap all the way around to your temples, so the sun’s rays can’t enter from the side.
• Wear a hat: In addition to your sunglasses, wear a broad-brimmed hat to protect your eyes.
• Don’t rely on contact lenses: Even if you wear contact lenses with UV protection, remember your sunglasses.
• Don’t be fooled by clouds: The sun’s rays can pass through haze and thin clouds. Sun damage to eyes can occur anytime during the year, not just in the summertime.
• Protect your eyes during peak sun times: Sunglasses should be worn whenever outside, and it’s especially important to wear sunglasses in the early afternoon and at higher altitudes, where UV light is more intense.
• Never look directly at the sun. Looking directly at the sun at any time, including during an eclipse, can lead to solar retinopathy, damage to the eye’s retina from solar radiation.
• Don’t forget the kids: Everyone is at risk, including children. Protect their eyes with hats and sunglasses. In addition, try to keep children out of the sun between 10 a.m. and 2 p.m., when the sun’s UV rays are the strongest.

As a golfer I haven’t paid enough attention to protecting both my skin and especially my eyes from harmful UV rays. I got sufficiently scared when I read about skin and eye diseases that are preventable and I’ve vowed to do better. I hope you have also decided to take the action necessary to protect yourself from these cancer-inducing UV rays.

Best, Thair

Medicare Part B is the part of Medicare that covers care you receive when you are not a patient in the hospital. The graphic below outlines the basic care covered under Part B. I called Part B a lifesaver because it covers the treatment for some of the most serious diseases . . . like cancer (chemotherapy), kidney failure (dialysis), and transplants (immunosuppressive drugs). While these treatments are often expensive and lengthy, they often save or lengthen our lives. Part B costs are further impacted by the fact that many treatments are provided at a doctor’s office or in a hospital’s outpatient facility.

Part B is partially funded (about 27%) by our monthly premiums, which have increased faster than inflation over the years but increased only $3.90 this year. While those in lower income brackets are protected from some increases, those in higher income brackets will pay much higher premiums. The Part B premium this year for most of us will be $148.50 a month, but some higher income beneficiaries will pay as high as $504.90 a month. The rest of the money for Part B is drawn from the government’s general revenues.

Lately, the Part B costs have increased faster than other parts of our healthcare and have come under pressure by those in Washington as a way to lower government spending on healthcare. Part of the reason for the Part B cost increases is due to the many new discoveries in medicines and treatments for some of these life-threatening diseases. There have been huge steps forward in the treatment of serious diseases; many lives have been lengthened and enriched by these new treatments. It would be a shame if the access to these life-altering treatments were restricted.

There is no doubt that the way the payments are calculated for Part B is convoluted. Payment structures to doctors who administer many of the infused drugs is complicated. There are changes that could be made to make the cost and payments more straight forward. Changes should be made at the process level rather than using a blunt force approach that will only increase the flawed incentives in the process.

Part B is the place for big discoveries that will have huge impacts on our lives. Great discoveries in biologics and other cancer fighting medicines along with breakthroughs in treatments for autoimmune disorders are on the horizon. These are the types of discoveries that deserve our focus and resources. Anything that inhibits this innovation or restricts our access to these treatments is not the direction America’s healthcare system should be headed.

There are changes afoot; this was made very evident by the President’s Executive Order signed last Friday. I’ll work hard to keep you up to date on what’s happening, and hope you’ll also stay informed and be ready to contact those in Washington and tell them how you feel about these changes.

Best, Thair

It’s the end of the summer and for me that means another birthday. In fact, my birthday is today. As I was musing about how old I’ve become I thought there had to be something productive I could do other than wish I was younger. And, as you might have guessed, I thought that maybe a birthday was a good time to do some things that will help us stay healthy and happy and might make a for a helpful blog. We all know to change the batteries in our smoke detectors when we change the clock to, or back from, Daylight Saving Time. It’s a great way to keep our houses safe. So why not use our birthday as a reminder to do some other things that not only keeps us safe and healthy but also maybe a little bit richer. You might have some more things to add to the list, I’m always open to comments with suggestions. Here’s my list . . .

Get your yearly physical – This reminder is almost as common as the smoke detector batteries, but I think it might be the most important item on the list. Many of us have been self-quarantining, which has kept us away from the doctor’s office. I just got my physical and our care givers are really good at keeping us safe. They take everyone’s temperature, we go through a check list to see if we might be a COVID-19 risk, and everyone wears a mask and makes sure we are wearing ours. They clean everything between patients. I felt safe wherever I went. Getting a yearly physical exam is the best thing we can do for our long-term health.

Review your immunization needs – Part of our yearly physical should include gathering and reviewing our immunization records and finding out what immunizations we might still need. Click here to go to my recent blog about immunizations. It has links to some great sites to help you determine what vaccines you need. If you don’t have your immunization records, request them when you visit the doctor. Many doctors’ offices have online portals that give you access to your health records. One way or another, get a copy and keep it in a safe place.

Review your Medicare Part D drug coverage – While your birthday may not coincide with the Part D annual enrollment period (October 15 to December 7), your birthday is not a bad time to get your prescription drug information together. It’s a good time to update your information with any changes you’ve had to your medications.

Actions required on important birthdays – As we get older there are some important birthdays that needs special scrutiny and possible important action. The important date for Medicare is 65, that’s when we need to sign up and register for Medicare and decide whether we want to use Medicare fee-for-service or Medicare Advantage. Even if we are still working and have private insurance there are still actions that we must take.  Go to CMS.gov to find out about your Medicare benefits. There are other important birthdates, 62, 66 and 8 months to 67 (depending on your birth year), and 70. These are birthdays when you can elect to begin receiving Social Security (SS). There are a lot of variables that go into when you should begin taking Social Security. Before your 62^nd birthday make an appointment to talk with a SS representative. In these times of the COVID-19 virus, it might be difficult to meet in person but don’t put off finding out all about this important benefit.

Inventory your medicine cabinet – Your birthday is a great time to inventory your medicine cabinet. It’s a good time to get rid of old medicine, both prescriptions and over the counter medicines. Many pharmacies will help you dispose of old medicine. Don’t flush it down the toilet or throw it in the garbage. We want to safely remove it from the environment. Now, I need to talk about a touchy but important topic. Many people suffer from drug addictions. We have all heard of the alarming increase in opioid addiction in our country. Unfortunately, a common way these drugs are obtained are by friends and relatives stealing prescription drugs from someone’s medicine cabinet. Having a medicine cabinet lock helps prevent this problem while also keeping these medicines from unsuspecting children. At the very least, monitor who has access to your prescription medicines.

Review your financial health – Being financially secure helps both our physical and mental health. You should review your finances with a trusted advisor. It’s up to you who you deem trustworthy, but it is a place to be very careful. Unfortunately, there are people out there who prey on older people and find ways to rob them of their savings. It’s always a good idea to have a third party, unconnected with your trusted advisor, independently review any actions with your savings. Due to the COVID-19 impact on the economy and investments it is especially important to review your finances. It’s also a good time to go over your non liquid assets, like property, jewelry, etc. A balance sheet to identify your net worth helps you understand your financial standing.

Inventory your passwords – This might seem like a trivial item but many people’s identity and ultimately their money are stolen because a person used common passwords or made access to their passwords easy. Find a smart computer person to help you set up a secure password vault and, after it is set up, change all of your passwords. There are vaults that only require you to remember one password to get into the vault, and they have all of your other passwords.

I’m sure you can think of other things that should be done at least once a year. I suggest creating a check list. Unlike my keys or my cell phone, my birthday is one thing I don’t forget. Use that fact to help you remember some things that may be even more important than your birthday.

Be safe and register to vote, Thair

Medicare beneficiaries: listen up! The Administration is introducing a proposed rule that would arbitrarily base the prices of American medications on prices of drugs in foreign countries. Proponents of this proposal, known as the International Pricing Index (IPI), claim that this type of plan would cut costs, but the truth is, this measure could harm seniors’ access to prescription medications and stifle medical progress and the development of improved treatments here at home.

If IPI is enacted, seniors will likely see new restrictions in the number and variety of medication options available to them and their physicians. International reference pricing proposals – which would tie U.S. drug prices to foreign countries that heavily regulate medicine accessibility — could also force a one-size-fits-all approach on beneficiaries, worsening health outcomes by assuming every patient responds the same way to all medications. If seniors are not given a voice or a choice in matters regarding their own healthcare needs, it will be harder to do what their physician believes is most effective.

Seniors must act NOW! Tell the Administration just how harmful enacting IPI and other foreign reference pricing policies could be, both for beneficiaries’ health and for American medical progress. Click here to make your voice heard.

How we pay for our health care is a mystery to most of us. We get our Medicare and insurance bills and they are hard to decipher. We pay money for premiums and when we go to the doctor, the hospital and buy are medicines, but the reason things cost what they do is often a mystery. When we hear the politicians talk about changes to Medicare, they use words and descriptions that are often unfamiliar. What we do know is that when Medicare is changed it often affects us directly, either by access to care or cost. My goal with this blog is to try, and I emphasize TRY, to simplify how the different players in our health care system interact and the forces that influence how they operate. I will also seek to explain the different tools that are used and how each one of them affect your health care access and your cost. My goal is to help you become a more knowledgeable constituent, one that understands your health care today and the ramifications of possible future changes.

I realize this is a long blog, believe me it could have been many times longer. My hope is that this blog gives us a base of understanding, a reference place, that we can use when we get into a detailed discussion concerning possible regulatory and legislative changes.

There are four major players in how we receive our Medicare health care benefits:

• Patients
• Providers (doctors, hospitals, prescription drug manufacturers, etc.)
• Payers (the government, insurance companies and patients)
• Middlemen (pharmacies, pharmacy benefit managers [PBMs], etc.)

All of them have regulations, legislation, costs and
competitive forces that affect them.

Patients –
• Many of you have seen out-of-pocket costs go up while access to care has become more complicated.

Providers –
• Doctors are inundated with regulations that require ever expanding administrative costs and require them to spend more and more time on non-patient contact tasks. Malpractice insurance costs continue to rise which encourages them to protect themselves by ordering more tests, procedures and specialist appointments.
• Hospitals have huge fixed costs and are required to treat the uninsured.
• Drug manufacturers face the risk and cost of research and development that has raised the cost of developing a new drug to two billion dollars. They are faced with required discounts on drugs while paying ever increasing rebates to insurance companies and PBMs.

Payers –
• The government has seen health care prices rise while the population lives longer, drawing on a fund that is dwindling each year.
• Insurance companies must keep premiums low to compete, but costs continue to spiral up.
• Patients, especially the sicker ones, are saddled with paying a higher percentage of their health care costs.

Middlemen –
• Pharmacies are squeezed with paying after the sale rebates and providing a myriad of uncompensated services.
• PBMs are faced with a changing business model that may impact their relevance.

This is certainly a complicated business; it is a balance of the free market with a highly regulated environment. It is convoluted and, in many places, inefficient, but it is where we are today.

As the players work to improve our health care, they have tools that they use to offer choices, control costs and direct access. My goal in the explanations below is to define how these tools operate and, more importantly, how their use will impact you, either in access to care or cost.

Deductible – The patient is responsible for 100% of health care costs until this amount is reached. It is used to control unnecessary health care usage. It is a big out-of-pocket expense for patients and should be considered as health care plan choices are made.

Co-pay – An amount the patient pays each time they use a product or service. Payers use this to give the patient some cost to pay to help limit unnecessary usage. It operates a little like a deductible and adds to a patient’s out-of-pocket costs. Co-pays are often higher when seeing a specialist.

Co-insurance – Unlike a co-pay, co-insurance is not a set amount, it is a percentage of the cost of the product or service. This tool can have a big impact on a patient’s costs and its use by insurance companies has increased over the last few years. For instance, there is co-insurance in Medicare’s prescription drug benefit, Part D. If your out-of-pocket costs in 2020 exceed $6,350 dollars you are only responsible for 5% of the cost of the drug. 5% may sound small but with some of the costs of medicines today it could be a large amount. For instance, if you are taking a drug that costs $10,000 a month your out-of-pocket costs for the year would be $8,187. You would reach your $6,350 very quickly and would pay 5% of the drug’s list price after that ($500 a month). That is a lot different than paying a $3.00 co-pay once a month. By the way, the $6,350 maximum out-of-pocket in 2020 increased $1,250 dollars from 2019 rather than the approximately $100 a year increase in the years prior. This happened because of legislation that accompanied Obama care. Many senior advocacy groups fought this unwarranted increase.

Out-of-pocket maximum – Many of you are acquainted with out-of-pocket maximums, it is almost a universal benefit in private insurance. Medicare DOESN’T have an out-of-pocket maximum. Many supplemental and Medicare Advantage plans do, however, offer an out-of-pocket maximum. The Part D drug benefit also doesn’t have an out-of-pocket maximum. This is an area that many people say needs to be changed. We’ll no doubt talk more about this in later blogs.

Prescription Drugs

The following tools are used primarily in the use of prescription drugs that are covered under Medicare Part D and Part B. Part B drugs are usually injected at a doctor’s office or at the hospital.

Step Therapy – This treatment requirement is used by insurance companies to ensure that a doctor has tried the least costly medicine or procedure before prescribing a more expensive solution. This usually applies to medicines and is also called fail first, meaning the medicine must not work on the cheaper option before the more expensive option is tried. This treatment regulation is also used to negotiate with drug manufacturers to lower their price so they can be the medicine first tried in the step therapy requirement. This approach raises a barrier to timely access when the doctor, who knows a patient will not respond to the cheaper medicine must still delay the treatment that works while the patient fails on the first medicine. Another access barrier occurs when a patient changes insurance companies and must repeat the step therapy/fail first protocol before they get access to the medicine that had preciously proven to work for them. It is also important to mention that doctors sometimes receive payments for using specific, often expensive, medicines. This is one tool the insurance companies use to control costs.

Drug tiers – This tool puts different medicines in different tiers or categories, historically 3 or 4 but the number of tiers seems to be increasing. These tiers usually go from least expensive to more expensive, with increasing amounts of patient co-pay or co-insurance as the tier gets higher. It is a way to encourage a patient to use the least costly medicine. It also is used to negotiate with drug manufacturers to lower the cost to the insurance company for inclusion on a lower, i.e. higher usage, tier. Identifying which tier your medicine is in can make a huge difference in your out-of-pocket costs.

Importation – There is a disconnect between the price of drugs in America and the price of drugs in some other countries. This is one of the most complicated areas of health care. Some have proposed importing drugs from Canada. Some states have even passed legislation to allow the importation of medicines. There are safety issues and supply issues involved with this approach. Canada itself has said it couldn’t authorize, support or guarantee the safety of drug importation into the U.S. This is a tough issue that will take some big changes to rectify. This is another area we will pursue in later blogs.

International Reference Pricing – This government authored approach seeks to solve the problem described in importation of other countries paying less for medicines. It uses drug prices from some selected countries to set the maximum price for those drugs in America. This solution, which seems simple, is fraught with many questions and problems. We will delve into those questions and problems in a later blog.

Non-interference/government negotiations – This part of the initial Part D legislation left the negotiations of drug prices to the forces of the free market. While it seems like allowing the government to use its force of the millions of Medicare beneficiaries to negotiate lower prices would be beneficial, it isn’t supported by studies and projections. The main barrier is the need to restrict the formulary (the list of drugs available under Part D) to generate any leverage on drug prices. It would be a recipe for access restrictions for life saving medicines. This is another area for future discussion on this blog.

These are just a few of the tools and just scratches the surface of the complexities of our health care system. Hopefully it will give us a base for better understanding any proposed changes in the regulations and legislation that govern Medicare.