Author: Ann Marie Marciarille

Policy analysts at the CDC in Atlanta have apparently been given a list of words not to use in budget documents on the grounds that they are too controversial.    The forbidden words are “vulnerable,” “entitlement,” “diversity,” “transgender,” “fetus,” “evidence-based” and “science-based.” I know, I know. This is the continuation of the kind of linguistic or is it cognitive cleansing behind the banning of the phrase "climate change"  at the U.S. Department of Agriculture as well.  

I find the inclusion of "vulnerable" on this list particularly poignant.  Vulnerable is a word with meaning beyond the budgetary context (not unlike many of the other terms on the list)  usually understood to mean something like easily hurt or open to attack, harm, or damage. We must be living in a post-vulnerability society to have no need of programs that explicitly target the vulnerable among us. And, if we use this term, I suppose  there is also the risk attendant on us acknowledging our own vulnerabilities, a necessary step, it seems to me, in learning about empathy.   The interesting thing about banning the use of the word vulnerable in the budgetary context might be its implicit acknowledgement that few choose vulnerability.  It is an uncomfortable word. It might make us want to change things. 

Are some words in broad standard  usage so politically freighted in the political or budgetary context that new words for the same phenomenon need to be invented?  Or is the very existence of the phenomenon itself what offends? It appears to be some of both.  Some terms or phrases were offered as substitutes, the alternative offered for evidence-based: Instead of “science-based” or ­“evidence-based,” the suggested phrase is “CDC bases its recommendations on science in consideration with community standards and wishes."  So, science can only be mentioned in the same breath as community standards as scientific analysis alone must be profoundly alienated from our communal lives.

 

 

 

 

 

 

The claim that all chronic care  delivery will be miraculously transformed by the Anthem-CVS merger (and inevitable "me too" mergers between other drugstore chains/PBMs and other health insurers) requires a skeptical view.

I get the claim, that re-aligning the incentives in chronic care so that PBMs/drug stores are on the same side for chronic disease management and not in a war of treatment modalities will produce better chronic disease management.  But, will it?

The way the story goes, diabetics will turn to (you guessed it!) CVS-branded minute clinics for diabetes management counseling, for example,  and so have better cheaper access to this care.  What kinds of things will be discussed in the counseling: diet? exercise? the risks of unmonitored polypharmacy? the need for group diabetes education and support, sometimes called diabetes self-management education? 

Think again.

Have the people proposing this ever even been to a CVS minute clinic? Continuity of care is not  their watchword.  Or, perhaps they are talking about the CVS minute clinic of the future, analogous to the CVS-V.A. alliances being piloted in Arizona or elsewhere, complete with electronic medical record information sharing. 

In the meantime, minute clinics work on a business model that skims the easier less complex cases from primary care.  These easier cases are the antithesis of the complex individualized analysis required for a diabetic not under tight control for example.  Now, I know this is where CVS hopes to grow its business so that it can then also supply this population with all diabetes medications and testing materials.  

But would the combined Anthem-CVS turn its CVS housed minute clinics into Diabetes diagnosis and prevention centers targeting the real challenges of individuals with diabetes in the community?  After all, wouldn't that be what it would take to create those synergies of better chronic disease management for diabetes in the post-merger world?

Well, it depends on how the business would be structured and how the services would be reimbursed. Color me skeptical in a world where one of the newest CMS posted-regulations guts or undermines some of the most promising outcome-based bundled reimbursement experiments ever proposed. 

 

 

 

 

 

 

 

I don't get it. 

Does anyone who really understands pharmaceutical pricing or compensation systems in commercial health insurance really think that health care hasn't had plenty of "blurred lines" for quite some time — try decades?  Or, does the New York Times mean that the blurriness that has long been present has finally risen to the surface? 

Like Austin Frakt, I do not lament the apparent beginning of the end for the stand-alone pharmacy benefit manager (PBM) industry but, unlike Austin Frakt, I am not optimistic that  migrating all that stand-alone PBM power into the hyper concentrated drug store and health insurance industries is necessarily going to benefit consumers. If the data on concentration in complementary industries in health care teaches us anything, concentration in ownership has not produced efficiencies  that have trickled down to the health care consuming public.  If the problems are little choice, no transparency, and conflicts of interest, how will this re-arrangement of the deck chairs change anything? 

I guess it is a good thing that we appear to be on the verge of a revival of interest in vertical mergers, if that is what is going on in the  AT&T – Time Warner challenge.  

 

When Roll Call puts out a breaking news update to announce Alex Azar's nomination at HHS but twins it with a large picture of former Secretary Don Price, are they trying to tell us something? I'm going to have to think about that for a while. 

 

No, I am not talking about Maine as a bellwether state for presidential elections. I am talking about Maine as a kind of bellwether state on using the ballot initiative process to adopt ACA Medicaid expansion. The ballot measure passed. Now, the issue is the funding for the estimated $50 million Maine will need to draw down an estimated ten times that much in Medicaid dollars. That makes all eyes turn to the Maine legislature, where the funding battle will be fought. But will they  have to fight fast because Maine has a very part time legislature?  

No. If the initiative requires spending beyond available state funds and does not provide a funding mechanism, the effective date of the initiative can be delayed until 45 days into the following legislative session. Question 2 was written to give the Department of Health and Human Services (DHHS) 90 days after its effective date to submit a plan to the federal government and 180 days to begin expanded coverage. So, maybe they get to continue to fight slow in Maine, after all.

We are told Utah and Iowa are watching this ballot measure approach.  They need to know this would  be a long slow slog. After all, even the wording of the ballot question and its official summary contained within it a microcosm of the entire debate over ACA Medicaid expansion: is it health care insurance or is it welfare?  The actual voter information in Maine eventually adopted the "coverage" compromise but, make no mistake, the fight over the characterization of the Medicaid expansion does not end in Maine.

They must have heard me talking at CVS because, yes, now there is talk of same day or next day delivery for Rx drugs. 

If you have seen the New York Times article disclosing that CVS is in talks to acquire Aetna, you have a pretty good sense of Aetna's urgency to try and insulate itself from pressure from bigger players in the health insurance world. That much seems apparent after the failure of the proposed Aetna-Humana merger. But, why would CVS want to merge with Aetna in that they already have Aetna's PBM business tied up in a long-term contract?

It is reported that a prescription drug and PBM behemoth like CVS might see acquisition of Aetna as insulation from a new entrant into the world of retail pharmaceutical drugs: Amazon.   CVS must fear quite an entry by Amazon for this to be genuine for it is CVS that is feared by almost everyone else in these spaces. But Amazon's entry might well involve the re-invention of what is now called "mail order" pharmacy — a lucrative younger sibling to brick and mortar pharmacies.

Imagine this: pharmaceutical drugs delivered to your home or your Amazon locker with the speed of Amazon Prime. Pharmaceutical drug pricing transparency that would allow you to both order online and to calculate whether it would be more cost effective to order out-of-pocket or through an insurer for a given prescription.  Perhaps, more sincere HIPAA compliance and privacy than is currently found in the CVS Drugs brick and mortar pharmacy encounter where, in an open space standing at a register with a line beginning only inches behind you, CVS now requires you to call out your correctly spelled name and your date of birth.  After all, the third ingredient for identity theft — your social security number — is apparently not difficult to guess once location and date of birth are known. Many list location of birth and date on open access Facebook pages. 

Whether all of this is just wild speculation about what Amazon might bring to prescription drugs only time will tell, but I have no doubt that a significant part of CVS's interest in Aetna is in girding its loins for an eventual CVS-Walgreens showdown. We watch consolidation in all aspects of the prescription drug industry: wholesale, PBMs, retail, mail order, specialty pharmacy, and in-store clinics that have prescribing authority while acknowledging that the retail clinic is now the primary care provider for many Americans.

The CVS-branded encounter must surely be considering outpatient surgery centers next.

Nope, a little sunshine would not help promote higher quality acute care hospitals. Not at all.  Those hospital inspection reports performed by private accrediting agencies are "not set in any context to promote public understanding" according to the American Hospital Association.

You see, knowing almost nothing about what the accreditation report by the private accrediting agency says about a facility's quality is definitely a way to enhance public knowledge about accreditation and the role of the Joint Commission in oh-so-rarely calling acute care facilities to account.

The Equifax data breach has generated a certain amount of astonishment that the credit rating bureau obtained and retained far more data than many people were aware. They're not the only data collection entity with untold resources, however.  The Medical Information Bureau is a membership organization that collects and stores health related underwriting information for health, life, disability, long-term care and other kinds of insurance.

Happy thought indeed. 

The New York Times' characterization of MRSA as the "hidden foe" of sports captures the double sense of the hiding of MRSA just about right. Yes, MRSA may be present even when symptoms of the bacteria are not present but MRSA's demonstrable evidence may also be hidden by the individual or sports team infected. After all, the Washington Post has been writing about MRSA in the NFL, for example, for over ten years.  One difference is the rise of sports league-based treatment protocols as well as prevention protocols. The real difference appears to be the acknowledgement that prevention is far more valuable than treatment by over-reliance on antibiotics, exactly the kind of problem solving that helped bring us to this impasse. 

Maybe hospitals and skilled nursing facilities can learn something about how secrecy is no disinfectant when it comes to MRSA.