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The Stick or the Carrot

I’ve often written about the dangers of letting the government insert itself too deep into our healthcare. It’s not because our government is evil −it’s because the goals of government are not always aligned with those of the people it governs. It’s just another case of bad incentives. Our lawmakers don’t get elected by proclaiming that they will let our economy, through the powers of the free market, solve a problem. Their solution is generally to come up with some regulatory fix or to introduce new legislation. Unfortunately, we are partially to blame because we seem to immediately turn to the government to solve every little problem, and we continue to elect politicians who promise us easy solutions. It is for all these reasons that I try to limit the government’s involvement in our healthcare. Having said this, I do want to point out that government has its place.

Government involvement in healthcare is needed to ensure the safety of medicines and procedures and to ensure that the less fortunate have adequate care. The question I want to focus on today is, what is the best way for the government to be involved? As you might have guessed from the title of the blog, I think it comes down to the stick or the carrot.

The stick approach centers on constructing rules and regulations, created by civilian agencies, a presidential executive order, or legislation, that outline how you must operate as you dispense healthcare services. Medicare has part of both the stick and the carrot in its operation. Medicare sets standards for hospital care and doctor’s services and sets the price for these services. The program pays based on a huge number of codes that cover, at a detailed level, all the procedures and services available to doctors as they treat patients, both in and out of the hospital. Correctly coding these services in the most advantageous way for the provider has fostered a cottage industry that shows doctors and hospitals how to code procedures to extract the maximum payments. When the government finds providers who are skirting the rules or committing outright fraud it enforces consequences (the stick) and works to close the loophole. There are millions of dollars lost to fraud in Medicare. It is a cat and mouse game that takes government resources to create and update the rules and then to police them. It costs the providers money as they work to code their services correctly and to try to keep up with the changes.

A part of Medicare that highlights the value of the carrot approach is Medicare Part D, Medicare’s prescription drug program. When this program was debated, many lawmakers wanted it to be a single-payer, government-run program. The alternative was a public/private partnership where the government outlined broad requirements and incentives and then let the private insurance companies compete for our business. The public/private partnership won, and this competitive carrot approach has proven to be successful. Part D has ended up costing 40% below what was initially estimated, and the premiums have remained low even in the face of inflation and overall increases in healthcare. The choice of plans is broad – there is an average of 33 different plans available in each region. There are programs to help low-income beneficiaries pay for their premiums and cost-sharing. What other government program have you heard of that has a 90% approval rating? Could Part D be improved? Absolutely! For over a decade I’ve advocated for enacting a yearly cap on out-of-pocket expenses for Part D. There was a percentage of beneficiaries that became bankrupt by the cost of expensive medicines. Not having a cap on the costs made retirement planning a guessing game. This cap finally became law and will begin next year, guaranteeing that you won’t pay more than $2,000 a year for your medicine.

This carrot approach seems to work. Unfortunately, the same legislation that solved the out-of-pocket problem turned around and picked up the stick and instituted price fixing for selected prescription drugs, one of the worst ways that a government can insert itself into our lives. This part of the Inflation Reduction Act used methods and approaches that have been challenged in court, some of the challenges siting breaches of our rights under the constitution. Is this how we want Washington to work, making laws that can be challenged as infringing on our constitutional rights?

It seems that the trend in Washington is to venture into the grey areas of the law to bring the big stick of government to bear. Issuing large numbers of presidential executive orders has now become a common approach for the executive branch of our government. If the President’s administration can’t get the legislative branch to pass the laws it wants, it just issue executive orders. Almost by definition. this bypasses the checks and balances outlined in our constitution. This isn’t the way our government should work.

Using the stick approach brings out the worst in our government and exposes all of its worst aspects. On the other hand, partnering with private enterprise with appropriate oversight and rewards has proven to be the more efficient and appropriate way for our government to operate. The government shouldn’t be delving into the grey areas of our constitutional rights to find a big enough stick to keep private enterprise and its private citizens in line. Just the sound of that sentence makes me cringe. Our government can do better.

Best, Thair   

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To Vote or Not to Vote – Should Not Be the Question

In earlier blogs I’ve urged people to contact their lawmakers to tell them how they feel about proposed legislation or other rules that affect them. It’s no secret that lawmakers are interested in what you think because you vote.

A powerful scenario that demonstrates the power you have is when you set up an appointment with one of your lawmakers who represent you and tell them that every Saturday you meet seven friends for breakfast. As a group, you talk about what kind of job the politicians that represent you and run this country are doing– and next Saturday, when you meet again, your friends are expecting to hear about your meeting and where your lawmaker stands on these three issues that will affect you all. This scenario is powerful because the constituent that meets with the lawmaker votes, and the other seven people in the group vote, and the families and other friends of the members of this group most likely respect their opinion because of their interest in government and important issues. They vote also. You can see why a politician will pay attention to this type of meeting. Now I realize that donating to a lawmaker’s campaign is also powerful. However, only a small percentage of a lawmaker’s constituents donate, and the fact of the matter is that a donor still only has one vote.

The scenario presented above accomplishes two things, one, it informs the lawmaker how you feel, which will impact, hopefully, where they stand on important issues. The second, it gives the lawmaker the chance to win, or lose, your vote at the next election, which is the focus of this blog. Voting is the single biggest thing you can do in our representative democracy.

It seemed in earlier times that the days leading up to the election were full of debates and discussions, and even though you tried to abide by the wise council not to discuss politics with your family and friends, you somehow found yourself in the middle of a discussion with views that differed from yours. Election days were upbeat and interesting. You voted and then went home to see how the elections were progressing, celebrating when your candidate won and moaning when they lost and then you got up the next day, went to work, and soldiered on. It seems to be different now, you read about families splitting apart and even divorcing over politics. The issues seem less important than attacking an opponent on a personal level. The idea of compromise or working across the aisle to solve problems is met with disdain, with candidates of that ilk often eliminated in a party’s primaries. What scares me is that this current environment may convince some people that their vote is useless and will keep them away from the polling booth. My goal is to convince you otherwise.

Now, more than in any other time, (in my humble opinion), a greater percentage of the voters in both parties have already made up their mind about who they will vote for. This is the result of the extreme polarization that exists. No manner of advertising, debates, fear of advanced age or legal troubles will change their minds. This means that it’s very possible that a small number of undecided voters will have a huge impact on who wins. I think there are many of us older people who fall into this undecided group. I’ve noticed that I have mellowed in my older years. I’m more willing to see the other side of an issue, more willing to listen rather than speak and able to bring my life experiences to bear as I evaluate an issue. I see these same traits in my older friends, and my research has confirmed the power of this older group. I think this will make our vote even more powerful.

There is another group that seems to have become disillusioned and thus somewhat disinterested in the elections. These are the voters in their 20s. They have only had three candidates they could vote for, Hillary, Trump, or Biden. These are not the candidates that sparked enthusiasm for voters of this age and, from their point of view, and in all likelihood, there won’t be a new candidate added to the list next November. If these young voters stay away on election day, it makes the senior vote even more powerful.

If you live in a state that historically votes Republican or Democrat, you may think your vote will have no impact – think again. There are state and local elections that are extremely important. It’s a fact that your state and local governments may have a more direct, quicker, and bigger impact on you than your federal lawmakers. And, once again, with the smaller number of votes needed to get elected in these state and local elections, your vote and your influence on other voters is magnified.

My goal here is to get you off your… couch and vote. Each state is a little different on how you register to vote and whether they will allow voting through the mail. Get online or ask someone to help you and make sure you’re registered. By getting registered you can participate in the primaries, which, in cities, counties and states where one party dominates the ultimate winner in November is often chosen. Once again, getting involved at this stage offers great leverage in getting your candidate elected.

Yesterday’s President’s Day gave us a chance to celebrate great Presidents in the past that had a huge impact on our country. Given the seriousness of the times we live in today, the next President may also have the chance to have a huge impact on the future of our country. I think it’s time for calmer voices to be heard, and the way they’re heard is through that quiet time inside the polling booth where you exercise the most powerful force in a democracy, the vote.

Best, Thair

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Was Senator Sanders at the Hearing to Hear – or to Be Heard?

The U.S. Senate Committee on Health, Education, Labor and Pensions (HELP) held a hearing last Wednesday on the price of prescription drugs. For the opening panel, Senator Sanders invited CEOs from three pharmaceutical manufacturers and three subject matter experts: Joaquin Duato, CEO, Johnson & Johnson; Robert Davis, CEO, Merck; Chris Boerner, CEO Bristol Myers Squibb; Peter Maybarduk, J.D., Access to Medicines Director, Public Citizen; Tahir Amin, LL.B., CEO, Initiative for Medicines, Access & Knowledge; and Darius Lakdawalla, Ph.D., Director, Research, University of Southern California Schaeffer Center.

Congressional hearings are supposed to be a way for Congress to gain information toward legislation which they do through questions posed by members of the Committee. However, this hearing was determined by many to be just a political maneuver to brow beat the drug manufacturers. Senator Sanders, the Committee chair, an Independent who caucuses with the Democrats, called this hearing and determined who would appear on the panels (something he can do due to the Democrat’s majority in the Senate). Senator Sanders’ opening remarks contained charts and graphs that framed the manufacturers as greedy capitalists who cared little about America’s patients. It certainly looked like a brow beating to me.

Senator Cassidy, a Republican, the Ranking Member (the title given to the committee leader of the minority party) voiced his opinion in his opening remarks that this was in fact a political maneuver. Senator Cassidy said he wanted to be clear that this was NOT a hearing to find legislative solutions, it followed a formula that, among other things, punished corporations for being successful under capitalism and was just a chance to call in CEOs for a public verbal “stoning”, pick out sound bites and proceed on. Senator Cassidy was rightfully concerned that they were there, not to obtain meaningful solutions, but to score political points. He went on point out that Senator Sanders did not seek his input on who would be best to testify at the hearing, an indication of its true purpose.

So, what happened at the hearing? It lasted 3 hours and 40 minutes and I watched every minute of it. Click here, and you too can be minimally entertained. The Democrats worked their best to beat up the CEO’s, who pretty much stuck to their guns that Americans get quick access to new drugs without the barriers to access of other countries and that their companies are at risk for the large cost of research and development coupled with the high risk of failure in the discovery of new drugs. The CEOs also pointed out the billions of dollars they spent on direct to patient programs that helped people who couldn’t afford their medicine. The back and forth continued in that frame, and I’m not going to attempt to detail the back and forth. There were, however, two issues that I do want to talk about.

First, Senator Sanders used the word “monopoly” in referring to the manufacturer’s business operation. These words were echoed more strongly when Peter Maybarduk testified. He indicated that the patent exclusivity granted by the Hatch-Waxman Act gave the drug manufacturers a monopoly that went against the very capitalistic principles that Senators like Romney and Paul had discussed during the hearing. He railed on about how the manufacturers used subsequent patent approvals that lengthened the exclusivity period for their drug. It didn’t seem like Mr. Maybarduk really understood how important the Hatch-Waxman Act has been for our healthcare. First, one of the most important parts of the Hatch-Waxman Act (if not THE most important part) was the regulations that encouraged and streamlined the approval of generic drugs, the biggest single contributor to lower drug prices. Before Hatch-Waxman only 35% of the brand name drugs had a generic competition, in 2012, 84% had a generic counterpart. The Act also granted a patent exclusivity period that opened the flood gates to investment in the innovation of new life enhancing and life saving drugs. This “monopoly” was the driving force behind these miracle drugs. Hatch-Waxman also encouraged the granting of follow-on patents, recognizing the fact that many new uses of a drug are discovered by continuing to do research after the drug is approved. If follow-on patents were granted, whose only purpose was to extend the exclusivity period of the manufacturer, then fix the broken patent agency, don’t throw the baby out with the bath water.

The other issue that stuck in my craw (I don’t know where that saying originated but it just seemed to fit here) was the oft mentioned, seemingly evil practice of stock buybacks and paying stock dividends. It seemed that Senator Sanders would have the CEOs on the panel, rather than give their stockholders dividends and enhancing their stock price through buybacks, should instead use the money to lower the cost of prescription drugs. This is an obvious attempt to create a sound bite with a statement that ignores the basic economic realities of a public owned company. If the CEO ignores their stockholders, who are the public, essentially you and me, no one will invest in them, and the money needed for investing in the next lifesaving discovery will dry up. Rather than greedy corporate thieves, as portrayed by Senator Sanders, the CEOs are rewarding investors so they will continue to risk their money on future medical innovation. The fact of the matter is, even if the CEOs would lower the list price there is no guarantee that the money would ever get back to the patient.

One more thing to add, according to MarketWatch:

“Stock-market data show that over the past one, three, five or 10 years, you were much, much better off in a simple S&P 500 index fund than you were in these stocks. Over the past decade, these three “Big Pharma” stocks have, on average, produced just three-fifths of the total returns of the S&P 500.”

It seems to me that a business that has a monopoly and can demand any price for their products ought to be a raging success. Something doesn’t add up here.

It’s my hope that you can wade through all the posturing and sound bites and recognize that more government control and price fixing is not the answer. Well thought out guidelines that reduces the perverse incentives and encourages fair competition is what will reduce the burden to those who are really at the center of our healthcare, the patient.

Best, Thair

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It’s National Heart Month – And It’s Not About Valentine’s Day

February is National Heart Month, and I’m not sure, but maybe this month was chosen because of Valentine’s Day. It would certainly be appropriate since one of the best ways you could show your love to your sweetheart is to get them in the habit of doing heart-healthy things − and also give them the gift of a healthier partner by adopting heart healthy practices for yourself. So, what do you mean when you say heart-healthy you might ask? I’m so glad you asked!

Heart-healthy means adopting a lifestyle that helps reduce the risk of heart disease. We’ve all heard the standard instructions doctors give to people that have suffered heart problems. Some of them are pretty restrictive depending on the type of heart problem they have suffered. A heart-healthy lifestyle is a preemptive set of actions that reduces the risk of suffering the heart problem in the first place. It consists of:

  • Getting Enough Sleep
  • Eating Better
  • Maintaining a Healthy Weight
  • Becoming More Active
  • Stopping Smoking

You can click here to find more details about a heart-healthy lifestyle, including all the hints/guidelines/tips/instructions/etc. Adopting this lifestyle will not only help your heart but almost every facet of your health. There are two parts of this lifestyle that I found especially interesting.

Under the Eating Better Heading, there is link to a special eating plan called the Dietary Approaches to Stop Hypertension (DASH). Having had some experience just recently with high blood pressure, which is usually classified as hypertension, this DASH approach caught my eye. I would like to control my mild blood pressure problem through changing my lifestyle and, with the guidance of my doctor, would like to attempt to lower my blood pressure without the use of prescription drugs. It takes commitment, and I’m not going to take any chances with my blood pressure. I figure it will be worth the attempt.

The other thing that jumped out was under the Be More Active heading, the fact sheet made the following statement:

“If you don’t have a lot of time in your day, try being active for 10 minutes at a time. Anything that gets your heart beating faster counts!”

I was amazed at the fact that only ten minutes could help. It dawned on me that somehow, I could extract ten minutes from watching YouTube funny animal videos to get my heart rate elevated.

The focus of the American Heart Association (it’s their 100th birthday this year) for National Heart Month is CPR (cardiopulmonary resuscitation). Sarah Fedele with the American Heart Association (AHA) says American Heart Month is about raising awareness and educating people about heart health.

“During our 100th anniversary, [we’re] about learning CPR. So, we call it our nation of lifesavers, and it’s really encouraging everyone, whether you’re a family, whether you’re a company, to really just take the time to learn hands-on CPR,” Fedele said. “Because a lot of the lives that you may save is actually someone that’s close to you, so, either a coworker or a family member.”

She says some of the common warning signs of heart disease include pressure, heaviness, or pain in the chest. But they can also include pain or numbness in the arms, nausea, extreme fatigue, or shortness of breath. The warning signs may be different in women, where they can also include random pain and general fatigue, according to Fedele.

I’ve never taken a CPR course, and it’s always been in the back of my mind that I should know how to do it. According to the AHA there are some simple ways to learn the basics of CPR. They said, “You never know when you’ll need to save a life. With Faster, Flexible and Quality CPR & First Aid Training, the American Heart Association can help make sure you are ready with a variety of courses designed to prepare you for real life situations”. They offer the simple videos: 2 Steps to Save a Life with Hands-Only CPR and a guide to learn about how to use an AED with Hands-Only CPR + AED. It could help you save a life.

The short 2 steps to Save a Life video shows the simple steps to perform the hands-only CPR, and it gave me the confidence that, at least, I could take some proactive steps in a heart emergency. I even think I could perform the hands-only CPR + AED actions. I’ve seen notices posted in many public places that AEDs are available which raises the chance that you could save a person’s life. This focus by the AHA has given me some real important information.

There is one other thing that caught my eye as I reviewed heart information: heart murmurs. My doctor commented the last time I visited him that I had a nice little murmur. Well, I was of the belief that no murmur was a nice murmur, but he said that it is really common in older people, and there was nothing to worry about. I did some digging this week and found that one in three older people have some sort of murmur that is caused by the decreased flexibility in most parts of the circulation system. I will still stay vigilant on this front but maybe if I stay focused on living a more heart-healthy lifestyle, it will help in this area also.

Take some time this month to do your own research, consider your own situation, your family’s history, and your health to determine what your risk factors are and what you can do to lower your risk. Maybe set aside some time on Valentine’s Day to focus on your heart and the heart of your sweetheart.

Best, Thair

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Value-Based Healthcare – A Winning Formula

Many of my blogs have talked about how perverse incentives have driven parts of the healthcare process away from serving the patient and toward serving and rewarding other participants in the process. Using the adjective “perverse” might be too strong and to some reflect negatively on incentives. Incentives are a good thing when they give us better products at a lower price. It’s what makes the free market work so well. You are driven to make a better mousetrap to capture more of the mousetrap market. You are driven to be more efficient to lower your overhead costs to make your price more competitive.

Healthcare can’t operate in a pure free market because of its unique environment. We need to have insurance to protect us from financial ruin due to an illness, and we need regulations to protect us from below-standard care and hurtful medicines. It has been shown, however, that competition, within the guardrails of regulations, can bring some of the free market efficiencies into the healthcare business process. The public/private partnership of Medicare Part D is a prime example of the efficiencies of competition working within the guard rails of government regulations. The point is, in healthcare, when the regulations create incentives that encourage providers to focus on the patient’s short- and long-term health, while also controlling costs, we are on the road to a positive outcome. However, these types of good incentives in a government-regulated environment are difficult to obtain.

Medicare and, to a lesser degree, commercial insurance, has operated in a fee-for-service environment for the most part. My blog today will focus on Medicare. Fee-for-service means that Medicare pays for a specific medicine or service at an agreed upon price. While this may sound like a good approach, it offers the bad incentive of giving the opportunity to the provider to make more money by providing more medicine or more services. The focus is more on the quantity of healthcare rather than the quality. While this might tend to put doctors into a bad light, remember that they are leery of being sued for not making the right diagnosis, and they are also trying to satisfy a patient who might request/demand to have more tests or procedures performed. The patient and often the doctor are separated from cost consideration which adds to the inefficiency of fee-for-service. Since healthcare costs in Medicare are divided into separate accounting silos, i.e., hospital, doctors, and prescription drugs, if one silo lowers costs in another silo, the savings are not credited to the silo that generated the savings. For example, the savings that resulted from the introduction of a new Medicare Part D drug which reduced hospitalizations in Medicare Part A, were not attributed to Part D. Fee-for-service payment has reduced the incentive for efficiency in the different Medicare silos and continued the focus on the short term, rather than the long-term health of the patient. So, what’s the solution?

Value-based healthcare is an approach that seeks to align incentives that produce better long-term health for the patient while producing long term cost savings. Medicare has been working on testing different approaches to value-based healthcare. According to the Centers for Medicare and Medicaid Services (CMS), the goal of value-based care is to provide better care for individuals and better health for populations at a lower cost − all great goals. The trick has been for CMS to develop the right regulations that maintain the financial incentives that encourage the participation of the best providers while controlling costs.

The promise of value-based care is that it could be a win for the doctors, hospitals, insurance companies, Medicare, and the patient. One example of where many aspects of value-based care is being employed is Medicare Advantage. This program, often referred to as Medicare Part C, allows private insurance companies to assume the responsibility of providing healthcare for Medicare beneficiaries for a set fee. This arrangement, by itself, changes the focus from short term to long term. This approach makes it advantageous to coordinate care and encourage timely responses to a patient’s needs. It is to the insurance companies’ advantage to provide preventative care, free access to exercise facilities and programs to encourage healthy living, all of which result in healthier clients and reduced costs. These are the type of good incentives that result in better service and health for the patient and long-term savings.

Advances in communication, computerized record keeping and analysis, home monitoring, telemedicine and wearable devices can all add to maintaining health and provide early responses to any problems that are detected. The rise in artificial intelligence could have a huge impact on providing personalized treatments for individual patients. All of these things will add to the efficiency of value-based healthcare.

Our government needs to work quickly in updating regulations to encourage the acceptance of value-based care. Refining the incentives for coordinated care and enabling competition wherever appropriate will all add to the effectiveness of value-based care. Renewing a call for tort reform for healthcare professionals would go along way toward reducing unneeded tests. The yearly increase in Medicare Advantage participants is a testament to older American’s acceptance of this form of value-based care. We need to encourage our lawmakers to continue to push toward this winning formula for healthcare.

Best, Thair

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National Glaucoma Awareness Month – Hope for the Future

January is National Glaucoma Awareness Month and, as I said last January, glaucoma is the secret sight-stealing disease. It’s a secret because it doesn’t have symptoms in its early stages that are easily detected by the affected person. It makes being aware a particularly important part of our defense to this sight-stealing disease. On that vain, let’s review some facts about the disease.

  • Glaucoma is a group of diseases that damage the eye’s optic nerve and can result in vision loss and even blindness.
  • About three million Americans have glaucoma. It is the second leading cause of blindness worldwide.
  • The most comm form is open-angle glaucoma that is caused by the lack of drainage in the eye, causing the pressure to build up which in turn damages the optic nerve. There are often no early symptoms, which is why 50 percent of people with glaucoma don’t know they have the disease.
  • There is no cure (yet) for glaucoma, but if it’s caught early, you can preserve your vision and prevent vision loss. Taking action to preserve your vision health is key.

So, the key to limiting the impact of glaucoma is early detection which means a regular visit to your optometrist. This means that when you go to get your prescription updated, make sure you also get tested for glaucoma. One of the common tests is the puff test, which is used to test the pressure of your eye. This test has you set your chin in a chin rest and wait for that uncomfortable puff of air to hit your eyeball. It wasn’t something I looked forward to. Good news, many optometrists are using a more comfortable test to determine eye pressure, and if the puff test is not for you, call around and find a doctor who is using the more comfortable test.

While it is important for everyone to get tested, there are some specific groups that are more prone to getting glaucoma, if they:

  • Are over 60 years old (like you and me)
  • Are of African, Asian, or Hispanic descent
  • Have relatives with glaucoma
  • Are very nearsighted (myopic) or far-sighted (hyperopic)
  • Use steroid medications
  • Have high eye pressure
  • Have a thin central cornea
  • Have had an eye injury

If you fall into any of these groups, it’s important that you have a regular check-up, and when you do, tell the doctor if you fit into one of these higher risk groups.

I do want to say something about the research that is going on to understand glaucoma and to eventually find a cure. While the common cause of glaucoma is increased pressure there are other ways that the optic nerve can be damaged. Research is beginning to understand more about how these optic nerves get damaged and possible ways to prevent the damage or even repair it. The Glaucoma Research Foundation has started an initiative, called Catalyst for a Cure, which brings scientists together from different areas, hoping the synergy will offer insights into possible cures. Until very recently, the only hope was to slow down or possibly stop the onset of blindness, but there was no hope for regaining the sight that was lost. Recent research has opened the possibility of restoring sight that was lost due to optic nerve damage, an approach that seemed impossible just a few years ago. Scientists are also finding that there may be a link between Alzheimer’s and glaucoma. Understanding what these links are could help better understand both diseases while also enabling earlier detection.

It amazes me that the regeneration of nerves is not science fiction anymore. While there certainly isn’t a timeline for this sight restoring miracle, this has got to give some hope to those whose sight has been affected by glaucoma. It further magnifies the importance of innovation. Organizations like the Glaucoma Research Foundation are financed through grants and donations, and I’m sure their leaders are constantly searching for more funds to push their research forward. I’ve written often about how our government’s schemes for lowering healthcare costs has often had a negative effect on innovation. While I think there are absolutely ways to bring down the cost of our healthcare, any cost saving approach should ensure that there isn’t a negative effect on research. As a country we should be spending our treasure on ways to save lives, save sight, save our hearing, save our mobility, and extend our lives. What better thing do we have to do with our money? If we want to have efficient and cost appropriate healthcare, why don’t we change to a form of benefit pricing that reflects the positive impact a procedure or medicine has on the individual and on the healthcare system? Think of the benefit and the worth of restoring someone’s sight that had been lost due to glaucoma. The money spent to treat and care for the three million people who have glaucoma could be saved if the Catalyst for a Cure was successful. We’re talking trillions of dollars saved if we cured cancer or Alzheimer’s. It seems to me that money spent on research is a long-range approach that will pay dividends far beyond these short-term money saving schemes.

I appreciate your indulgence on my tirade. Hopefully you get a sense of my frustration when I see a situation where research has the possibility to find a way we can reverse the damage caused by glaucoma. The important thing to remember is that early detection is key. It’s important to go to your optometrist and get tested for glaucoma.

Best, Thair

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CES – An Amazing Future for Healthcare

The yearly extravaganza called CES (Consumer Electronics Show) is the place where the new computer run devices and the accompanying software are revealed. It is held each year in Las Vegas Neveda. CES brought together over 4,300 exhibiters and 135,000 attendees.

I attend this conference so I can report back to you on what is new in medical devices that help older Americans and what amazing things are on the horizon. I’m not here to promote any specific company and, as such, I won’t identify any company by name. I will describe new innovations, and I’ll do my best to explain them in laymen terms, which I can report is sorely lacking at CES. While the devices themselves are extremely complicated, their impact on improving the lives of all Americans, but especially seniors, cannot be understated. Almost all are life changing and some could be lifesaving.

I do need to comment about artificial intelligence (AI). It seemed like it was a part of every device. For medical devices it seemed to be used to evaluate multiple inputs from monitoring devices and make educated assumptions. It also seemed to be good at learning about an individual, their habits, their health, etc., and reacting on a personalized level. For example, a device may  learn about the way you walk, your gait, and sense and alert you when your gait has consistently changed, something that those around you may not detect. It seemed to me that AI was the biggest new thing that will have the greatest impact on our future healthcare.

To give some order to my report, I will divide it into three different, but often overlapping, categories – devices that are Direct Medical Treatments, Enhance Our Ability to Age in Place, and Improve Our Wellbeing.

Direct Medical Treatments – Miniaturization continues to develop.   Making everything smaller and increasing the accuracy and versatility of surgical robots adds to the number of non-evasive surgeries that can be performed. Anything that shortens our hospital stays reduces our exposure to hospital infections and lowers our overall healthcare costs. There was one company that found a way to keep the camera lens clean as it made its way through our body to the place where the surgery was to be done and kept it clear as the surgery was performed. I really don’t know how doctors perform surgeries looking at a screen, but it is a common occurrence and is being improved each year.

Enhance Our Ability to Age in Place – Over my years working in the public policy space, the thing that older Americans brought up post often  was their desire to stay in their homes as they get older. I have always advocated for anything that can help this happen. Aging in place not only helps us to be healthier but also helps lower the cost of ageing by keeping seniors out of costly institutional care facilities. Almost all of the devices in this category have a way to alert doctors or caregivers if something is amiss. This might be the single best thing that allows people to age in place. I can’t begin to describe the huge number and diversity of devices that help people stay in their home as they get older, so I’ll just pick  the ones that impressed me the most.

  • Health monitoring – This was clearly the area that had the largest number of approaches. Devices could determine through watching you on a camera, everything from heart rate to blood pressure to oxygen saturation. Pads you sleep on can determine your sleep efficiency. I know that many of our smart watches do that now, but everything is getting more accurate and precise. There is a device that you wear on your head as you sleep that monitors your brainwaves and uses the results to play sounds that help you sleep better.
  • Problem detection – Using cameras and other sensors, like radar, allow monitoring systems to detect if bad things have happened, such as a person not taking their medications, falling, or  remaining in bed.
  • Personal Mobility – If you can’t move around by yourself, you probably can’t stay in your house if you live alone. There were many things that helped seniors be more mobile. There was a kind of exoskeleton you put on your legs that had small motors that can sense when you step and help you walk, especially when climbing stairs. There was a simple device that fastened to your walker or cane that projected a line out in front that gave you a target to step to. It also had a beeping mechanism that gave you a target pace. These inputs are especially useful for people who have ALS, have experienced a stroke, or have otherwise had their ability to walk impacted. The device helps develop alternate pathways for signals to reach someone’s legs. I think this would have really helped my good friend who died of Lewy body dementia. He sometimes just stood but couldn’t get his legs to take the first step.

Improve Our Wellbeing – Many of the things that make our life easier can also improve our health and let us stay in our house longer. I got to experience an absolute pain free laser device that pricked my finger for a blood sugar test that diabetes patients endure every day. This approach could be a big help for people who are afraid of needles. There were cuffless blood pressure devices and instant urine analysis. Then there were the robots.

There were robots that could cook, make drinks, clean our house and our swimming  pools and robots that could help us be happy. The one that I liked the best was the dog robot. It just seemed to sense the people around the demonstration area and would react to them. Here is a short video that gives you a sense of how it worked. One of the exhibiters related to me how this robot would calm Alzheimer’s patients who were normally agitated and even abusive. I sense that many monitoring devices would find their way into a robot that became the “watchdog” for an older person.

My vote for the device that improved wellbeing the most was hearing aids. My choice might have been influenced by the fact that I’m in the market for hearing aids. My old age and my time in a B-52 have conspired to make my hearing less than optimal, so I was extremely interested in the many hearing aids available due to the relaxed regulations on over-the-counter purchases. There were many opportunities to take hearing tests right on the exhibition floor, although they were somewhat hampered by the noisy environment. There were over the ear, behind the ear and in the ear devices. Almost all had the ability to use Bluetooth to work with an app on your phone as well as talk on your phone and listen to music. Here’s my description of the hearing aid that I think will be the best when it is finalized in a few months. It fits in your ear with different size collars depending on the size of the ear channel. It was programmable through an app that allows you to personalize the settings depending on your hearing and your environment. The thing that I thought differentiated this device from others was its ability to perform a hearing test and then download that test to your hearing aids, which then tuned them into your individual hearing test requirements. This gives you a base to start with as you fine-tune the hearing aids. I think being able to hear is something that helps every part of your quest toward staying healthy.

I’ve already gone past my normal length for my blogs, and I’ve still only covered a fraction of what I saw. In closing, there are a couple of things that did cause me some pause. When you have a robot filming you 24/7, even for logical health reasons, it gathers a large amount of private information exposing it to the threat of getting hacked. Information is power for good and for bad. The government is wrestling with AI and what protections should be put in place. AI has the ability to change our lives faster and in bigger ways than anything else in history. How do we limit the bad aspects of AI without squelching the innovation that will improve everyone’s life? It is a big question that has yet to be answered. All in all, for what I could see, our healthcare future looks great.

Best, Thair

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It’s Not Rocket Science, or Is it?

It seems to me that the older I get the more things I don’t understand. This is not a new phenomenon; I think every generation since the beginning of time has felt this way, but it seems that things change so fast that it’s tough to understand how these new things will affect my life.

For instance, what the heck are cryptocurrencies? Is it really money that you can mine from a computer and put it in a wallet that only exists in the cloud or inside your computer and then the value changes depending on the whim of some mystical complicated marketplace? I’m still mad that the country went off the gold standard, and now you want me to have faith in something that I can never hold in my hand? Am I missing a big investment opportunity?

These are things that I don’t understand completely, but they have the power to have a big effect on my world. In both cases our lawmakers are themselves trying to understand them and are wrestling with what they should do. Do they need to regulate how cryptocurrency is handled? Since we are governed by a representative democracy, we count on those who represent us to understand these complicated processes and do what’s best for us.

I’ve often discussed in my blogs how complicated healthcare has become. There’s providers, insurance companies, manufacturers and others that all have to work together to discover and administer these complicated but life changing and life-saving treatments. What’s the best way to encourage innovation while maintaining broad access to each new discovery?

This was the question in the minds of two Senators, Bob Dole and Birch Bayh, in the late 1970s. The United States was lagging behind the rest of the world in medical innovation and these two men thought of a way to help bring ideas and discoveries to the marketplace. While our government awarded grants to universities and scientists, their resultant discoveries were not being developed into final products. It’s not surprising since it costs about 100 times more than the basic research to bring a discovery to the marketplace. These two senators, a Democrat, and a Republican, introduced the Bayh-Dole Act which would allow universities, small businesses, and non-profits to retain the patents on their discoveries and work with private entities to develop, manufacture and distribute the resulting medicine or product. The bill passed with huge bipartisan support and was signed into law in December of 1980.

The bill jumpstarted a tremendous increase in innovation and the development of critical medicines and products in America. The Economist Technology Quarterly opined that the Bayh-Dole act was “[p]ossibly the most inspired piece of legislation to be enacted in America over the past half-century… (it) unlocked all the inventions and discoveries that had been made in laboratories throughout the United States with the help of taxpayers’ money. More than anything, this single policy measure helped

to reverse America’s precipitous slide into industrial irrelevance.” It is exceedingly rare that the normally stodgy Economist Technology Quarterly gives such glowing praise to any government legislation.

So, for 43 years the Bayh-Dole Act worked… until politicians decided they could twist the language of the Act to help enact price controls on drugs. They proposed to do this through a provision in the Act called march-in rights. This provision allowed the government to march-in and reassign the patent if the commercial entity chose to not aggressively move toward the commercialization of the product or they chose to sit on the patent to block a competitor’s access to the discovery. As clarified later by the original authors, Bayh and Dole, this language was never meant to be used to set prices. Any attempts to use march-in rights as a reason to control prices have been rebuffed, in 1994, 2002 and 2004, yet, President Biden, who, as a senator, voted in favor of the Bayh-Dole Act, is now supporting a renewed effort to use march-in rights to control drug prices. From my perspective, this move by the present administration goes against a myriad of acceptable and constitutional rules.

First, what right, and I mean constitutional right, does the administration have to insert its own interpretation into a law for its own purpose? Where are the checks and balances in this approach? If I can interpret law to match my own whims, then there is no need for a Congress or Judiciary. As with many of the actions taken by this, and past, administrations, this approach will most certainly be challenged in court.

Second, why does our government seek to mess with successful government programs? This is eerily similar to what happened with Medicare Part D, a program that has worked and been popular for 17 years, but our government suddenly decided to fundamentally change it to the detriment of innovation. The government seeks to change the function of the Bayh-Dole Act, that has worked efficiently for 43 years, once again to the detriment of innovation.

Third, I can’t help but point out that drug manufacturers net revenue has fallen in each of the last 5 years and, when adjusted for inflation, fell 8.7% in 2022. I don’t know of any other healthcare cost that has decreased, yet attacking drug companies remains politically popular, especially in election years.

Why, when it’s so hard to understand what actions to take in response to the new and complicated changes in our healthcare system, does our government revert to changing proven and popular healthcare laws. Many of the life changing and life-saving medicines were developed because our government embraced the public/private partnership of the Bayh-Dole Act. There are ways for seniors to engage on this issue. Tell those that represent you in Washington that you want to continue the innovation made possible by the Bayh/Dole Act, tell them you and your family deserve the hope represented by the new medicines that are just now appearing on the horizon.

Best, Thair

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The Ghost of Healthcare Past and Future

This has been a banner year for changes to our healthcare. We began the year by trying to return to our pre COVID status, and it hasn’t been easy. The reduced funding and the return to the established Medicaid rules have proven to be difficult. Removing people from Medicaid eligibility impacts people, and it was exacerbated by the administrative problems each state had to overcome. This is an example of how difficult it is to withdraw a government benefit, even one that was instigated as a temporary emergency reaction to a pandemic.

This year implementation of the Inflation Reduction Act (IRA) that was passed in 2022 also began. The 2023 impacts on beneficiaries were:

  • A $35 cap on the monthly cost of insulin
  • Free vaccinations
  • An increase in Medicare’s services for behavioral health

While not affecting patient costs directly in 2023, the IRA has the power to demand that companies rebate to Medicare the amount of all drug price increases that exceed the rate of general inflation. I wonder what impact this will have on patient costs. Will the drug companies raise their initial price of a drug when it is first introduced? Will Medicare use the rebate to lower premiums? Will drug companies quit working on risky innovative cures because they won’t be reimbursed year over year? I always look out for the unintended consequences of changes to our healthcare system.

There have been a few silver linings to the pandemic, costly in lives and money but still a silver lining. The pandemic forced us to discover the best way to use telehealth, with the development of efficient procedures and equitable payment criteria authorized under the pandemic emergency procedures. Some of these emergency allowances were made permanent, including procedures concerning behavioral health and the ability for rural emergency hospitals to be the originator of a telehealth process. Other telehealth services were continued on a temporary basis, such as:

  • Being able to have telehealth services in your home
  • Not requiring an in-office visit within 6 months of a telehealth behavioral session
  • Allowing all Medicare eligible patients access to telehealth services
  • No geographical restrictions on telehealth originators

Another improvement to Medicare in 2023 was the elimination of the two-to-three-month delay for those who sign up for Medicare and also allowing people who have lost their eligibility for Medicaid to sign up during a special enrollment period.

Between the pandemic and the IRA, we have seen some immediate and long-term changes to Medicare. Some good, and some not so good.

As we gaze forward into 2024, the chances for more changes to our healthcare are extremely high. It’s a presidential election year and President Biden has already set the tone for more government oversight of our healthcare. When former President Trump voiced his plan to repeal and replace the Obama signature healthcare plan, the Affordable Care Act, President Biden accelerated his foray into changes to how healthcare is delivered in America. He will work to expand the number of drugs eligible for price controls under the IRA while expanding the price controls to the commercial (click here to read my blog predicting this would happen). He would like to make the enhanced federal premium subsidies that are scheduled to end after 2025 permanent. The Biden administration would like to see those states that haven’t embraced Medicaid expansion to get on the band wagon. While these proposed changes are certainly not insignificant, they are not the worst change that the President would like to make.

The idea of a single payer healthcare system, i.e., government-controlled healthcare, is not new by any stretch of the imagination. It has been talked about for decades, most recently during Biden’s 2020 presidential campaign, but it has been effectively squashed…until now. It is ominous for a sitting President to resurrect this discussion. To make the proposal more palatable, he has proposed that we just make the government-controlled healthcare an option to compete with commercial healthcare, another trick detailed in the blog referenced above. It doesn’t take a rocket scientist, or an economist, to see how this would go. The government healthcare option would be subsidized by government workers, paid for by tax dollars, and the whole program operated at a deficit in government terms, a loss in business terms. This artificial competition would soon force all the commercial providers out of business, at which point the government could set prices, ration services, and raise taxes to support the program. While I may be an alarmist, this all seems a logical progression to the point where the government is controlling every facet of our healthcare. An indication of the immediacy of this progression is a hearing scheduled for next month.

All the Democrats on the Senate Committee on Health, Education, Labor, and Pensions (HELP) have scheduled a hearing with some CEOs of major drug manufacturing companies on January 25, 2024, to discuss the high price of prescription drugs. Senator Bernie Sanders is the chairman of the committee and is orchestrating this partisan hearing. It seems that healthcare changes are on the top of the heap in this election year. I would be disingenuous if I didn’t point out that Senator Sanders is the leading champion of government-controlled healthcare. I’ll keep you advised as to the outcome of the January hearing.

Well, that’s where we’ve been and maybe where we’re going. I guess I haven’t painted a very positive picture of our future healthcare. To keep this blog in the spirit of the season (and to make sense of the blog’s title) maybe what I’ve described, like the ghost of Christmas past, are the problems in our healthcare past and then described the dire scenes of a healthcare future that could happen. The good news is that the ultimate message of A Christmas Carol is that the future doesn’t have to be that way, we can still have an impact on what will happen in 2024. We can make our feelings known by those that represent us in Washington. The need for us to speak out will be extremely important in 2024.

I hope you and yours have a great holiday with your families, see you in 2024. Best, Thair

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Ideas on Becoming a More Powerful Voter

One of the greatest attributes of the Constitution is its reliance on checks and balances that spread the power to run our country among the three branches. Each of these branches, in one way or another, involves the citizen vote. We vote for the President, we vote for our Senators and our House Representative, and the President and Members of Congress appoint or nominate and vote on members of the Judicial branch. Our vote impacts all three branches. It would seem that this powerful tool, the ability to vote, would be a basic freedom that was assured to all citizens and that the selection of the candidates who are available for us to vote on would be an open and inclusive process. But historically that hasn’t been the case, and it remains an evolving process today.

At our country’s birth, the right to vote was given only to a small subset of the population: white, male landowners. Over the years different states sought to expand the right to vote while others tried to limit it by gender, race, income, literacy, and age. The federal government, either through amendments to the Constitution or by rulings of the courts tried to stop these screening methods and has been mostly successful. Today, voting is a powerful way to voice our opinion. We are constantly seeing and hearing public service announcements urging us to vote. I know that some people may think that their vote doesn’t mean anything. If you live in a state that is solid red or blue, you might think it is a waste of time, especially if you belong to the minority party. Hopefully, some of the following ideas will open your eyes to some ways that you can make your voice and your vote even more impactful no matter where you live.

The way candidates are chosen is a state-by-state decision, and the methods vary widely. The primaries can be closed, partially closed, partially open, open to unaffiliated voters, open or top-two. Primaries become the de facto election in States and Congressional Districts that are historically solid Democrat or Republican. The gerrymandering of Congressional Districts has added to the number of races that are decided in the primaries.

These non-competitive general election races make it more important that you don’t just vote but work to ensure that you have the best chance of making your vote count. When I review the candidates that are on the ballot, whether they be local, state, or federal races, I choose the one that I think will best represent my stance on the issues that affect me most. I want someone that thinks like me or at least is the closest to thinking like me. Now, if I’m a Democrat in a solid Republican State or District there’s a good chance that the candidate that wins the election will not reflect my stance on most issues. I’ll talk about some things we can do in that situation later. Right now, I want to discuss what happens when I’m a member of the same party that is in solid control of my State or District. The primaries become the battle ground where the winner is chosen.

It’s my experience that getting involved in the primaries is different depending on the state you live in. Your first step is to make sure you are a registered voter, and your registration is correct, in spelling, address and party affiliation. In some states only voters who have registered with a specific party can participate in that party’s primaries, in other states the participation is open. You might have read about voters of one party participating in the opposing party’s primary in competitive situations to try to get a weaker candidate into the general election. Your participation in a solid majority State is to choose the candidate that more closely reflects your thinking. Recently for Republican voters this usually means MAGA (Trump followers) candidates or the more moderate Republican candidates. The Democrats usual choices are also between the more liberal and moderate Democrats. There are ways to get involved beyond voting, including attending meetings or running to get selected as a delegate. These are ways for you to expand the power of your vote. It takes some work but can mean getting the candidate you like on the ballot of the party that will win in the general election.

Now, what happens if you are part of the minority party in your State or District. Often, you can still participate in the primaries and have an influence on getting the candidate on the ballot that is, from your point of view, the lessor of the two or more evils. Even if you can’t participate in the primaries, you can still stay in contact with your lawmakers and tell them where you stand. No matter what party you are affiliated with, you are still a constituent, and they have a responsibility to pay attention to you. Depending on which committees and subcommittees your lawmakers belong to, they can be influenced to make tweaks to bills that reflect your stance. They know that active constituents, no matter what party they belong to, can influence who is chosen in the primaries.

Voting is a way to get the people that think like you elected, but your vote is made a hundred times more powerful when the lawmaker that best reflects the way you think makes it on the ballot. Quite a few years ago, I lost the chance to vote for the man I thought would make the best Senator in Utah because he never made it through the primaries. I don’t want that to happen again.

I hope this gives you some ideas on how to get involved. Whatever the case, don’t forget to vote. At the very least it gives you the right to complain about what your government is or is not doing.

Best, Thair