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View Diary: Brief Notes On The Baucus White Paper About Health Reform (227 comments)

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  •  Medicare Part D versus private insurance (0+ / 0-)

    But, Medicare Part D does not have a formulary.  Instead they have guidelines within which the plans develop their fomularies.  The actual formulary is developed and implemented by the PDPs and Advantage plans themselves.

    The difference is simply that employers negotiated guidelines better than Medicare did--and that's because the Bush administration made CMS negotiate with both hands tied behind their back.

    •  You really think that explains Celebrex? (0+ / 0-)

      Insurers like predictability. From the insurer point of view, it doesn't matter whether CMS basically required that any Rx for Celebrex be filled, or basically said that it could never be filled until very stringent conditions were met. It doesn't matter, because either situation produces fairly predictable costs, and these costs are used by the actuaries to set premiums that absorb the costs. It's just in one case the cost, and thus the premium, is a bit higher. Key point: the profit margin stays the same. In fact, the health insurer loses a very small amount of money when Celebrex is never covered, because by paying out more the premium is higher and therefore the pie is larger. The profit margin slice of that pie (around 3-5%) is therefore also slightly larger measured in dollars.

      If insurers had an interest in making Celebrex hard to get reimbursed, it was for the same reason CMS did: they wanted the premiums to be lower, so that they could claim that the program was a success.

      CMS has the additional incentive that it saves them money. NOTE: it is not the insurance company that makes money by always denying Celebrex, since this is done across the board and is reflected in the premium. Rather, it is CMS and the taxpayer who saves money by denying it (I am assuming that Celebrex is almost never required as a treatment, and lower cost drugs could be substituted with equivalent effect).

      Ask yourself another question: do you think doctors in single payer nations prescribe Celebrex at anywhere near the rate US physicians do? Not a chance. Do not make the mistake of thinking that single payer means fewer cost controls or restrictions on care that is paid for by the system.

      Ein Mißverständnis ist es, und wir gehen daran zugrunde.

      by jd in nyc on Wed Nov 12, 2008 at 08:54:50 PM PST

      [ Parent ]

      •  Part D, Private insurance, Celebrex, and other (0+ / 0-)

        To answer the last question first, I think you would be surprised.  In comparison to all other OECD nations, the US ranks 19th (out of 25) in drug expenditures as a proportion of total health care expenditures.  Germany, Canada, Japan, Spain, and France, among others spend a larger percentage of their health care dime on drugs.

        So, don't make the mistake of assuming that single payer means more controls either.  Single payer has as many variations as there are nations.

        What matters is not the label, but the details in the regulatory system.  The reason why Part D may be more difficult is not because it's a public system.  It's because the Republican Congress tied CMS hands in many ways, including formularies and negotiating prices.  You write that the point whether CMS required this or just set stringent conditions does not matter.  My point is that CMS did neither of those.  The insurance companies were given the power to write the regulations through the Bush Administration.  Rather than have to negotiate, as they do in the private sector, the hands-off approach of the thankfully outgoing administration gave no room for government to engage in similar negotiations, thus resulting in a Part D plan that was developed by the insurers and pharma.

        Finally, I would completely disagree with the idea that the rules have no impact on predictibility of costs.  No insurance actuary I've ever encountered believed that.

        •  no, yes, no (0+ / 0-)

          First, I am sure you are right that the US is 19th out of 25 OECD nations in the percent of total spend devoted to drugs. What you leave out, and this is critical, is that the US spends twice as much per capita, so when you look at the drug spend per capita isn't it close to first, if not first? I don't think you tried to be misleading, but nonetheless that may have been a case of obfuscating the issue with statistics.

          I agree that single payer (and nearly single payer) systems have varying intensity of utilization controls. However, they all have intense budget controls, and directly or indirectly these have consequences in terms of treatments that physicians recommend. So does the fact that many nations don't pay their physicians on a fee for service basis. I am not complaining about that. I actually welcome it.

          Also, I certainly agree that Congress tied CMS' hands with Part D....though I also seem to recall that after 2006 Congress untied them and CMS said we won't use any new power to negotiate that you give us. Ridiculous display of ideology and captivity to corporate interests above the public interest.

          Finally, I never said that rules have no impact on the predictability of costs. I'm not sure where you got that. I described two situations (never pay for Celebrex, always pay for Celebrex when prescribed), both of which produce predictable costs. I simply stipulated that costs would be relatively predictable, though if practice patterns change that may be wrong. For example, a very successful advertising campaign could result in more people asking for Celebrex, or underhanded payments to physicians could lead them to favor that drug over others. Those situations can create surprises for actuarial models.

          Ein Mißverständnis ist es, und wir gehen daran zugrunde.

          by jd in nyc on Fri Nov 14, 2008 at 06:55:10 PM PST

          [ Parent ]

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