Financial Conflicts Among Nonprofit Advocacy Groups-Who Can You Trust

The battle between the drug-industry-controlled Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid (CMS) over its’ decision to provide only clinical trial reimbursement for Biogen’s Aduhelm, has highlighted the tentacles of the drug development pipeline in nonprofit advocacy organizations. To refresh your memory, Aduhelm, an aducanumab drug was approved by the FDA under the emergency-fast-track-approval process, without the lengthy normal vetting process for new pharmaceuticals. Biogen’s motivation for this was profit, by capturing the market for a promising, but as yet unproven drug for Alzheimer’s. This is the proverbial pants-wetter for big pharma, like Viagra, the ubiquitous male libido enhancer with universal reimbursement. This articles reviews nonprofit organizations which participate in healthcare advocacy and their funders. Only nonprofit entities are reviewed because it is assumed all for-profit advocacy is conflicted, such as lobbyists paid by their clients. This table shows nonprofit advocacy groups, their funders, and their positions on the Aduhelm approval.

 Who Can You Trust-Who Pays For The Advice?

Organization	Funding Source	Recent Positions
American Geriatrics Society (American Geriatrics Society, 2022)	Professional fees from its 6,000 clinician members	Submitted a letter to CMS against the approval of Aducanumab for treatment of Alzheimer’s
Alliance For Aging Research (Butler, 2022)	100% funded by pharma; 50% of annual budget designated for marketing	ACT-AD-for accelerated approval of aducanumab or similar Alzheimer’s treatments
Alzheimer’s Association (Belluck, 2022)	$485,000 from Biogen in 2021, the developer of Aduhelm; 1.6 million from other drug companies; a small portion of gross annual budget	Wants aducanumab approval for all Alzheimer’s patients even those with mild symptoms, despite scant evidence it works
National Council on Aging (Cameron, 2022)	Nonprofit funded through grants and donors	Advocate for evidence-based treatments; adopted the position that Aduhelm should be used with caution in clinical trials, against accelerated approval
Pharmed Out (PharmedOut.org, 2022)	A Georgetown University advocacy group, funded through individuals and grants	Educates individuals on the medical concerns about Aduhelm, against accelerated approval; advocates for increase rigor and value analysis before approval of drugs
Right Care Alliance (Right Care Alliance, 2022)	Mostly funded by private donors, also Resist Foundation and Ben and Jerry’s	Sponsor of petition to withdraw approval of Aduhelm, against accelerated approval for drug

 Facts

The U.S. government is the largest funder of scientific research through these National Institutes of Health Agencies: National Institute on Aging, National Institute of Mental Health, National Institute of General Medical Sciences, and National Center for Advancing Translational Science. Other federal funding comes from the National Science Foundation, Veterans Administration, Food and Drug Administration, and the Center for Medicare and Medicaid Services.  This conclusion was drawn from a scientific literature review and meta-analysis conducted in 2018 (Cummings, 2018). Though drug companies do conduct their own less risky brand research, it is on the backs of early publicly funded mostly university-led research.

Significant concerns about the FDA working too closely with the drug developer Biogen have resulted in the following investigations; congressional committees, the Health and Human Services department’s inspector general, the Federal Trade Commission and the Securities and Exchange Commission.  Such concerns reflect the process by which this drug received accelerated approval despite scant evidence it works, manipulation of research data after it was rejected by the expert review at the FDA, and the director of the FDA’s personal relationship with the drug developer. A drug which had not even completed clinical trials and has been shown to kill patients was put on a direct path to market it as an Alzheimer's cure to the public. This resulted in clinical outcry, outright banning of the use of the drug by most major medical centers, and a public movement to draw attention to the concerns, as previously published.[1] [2] As a result, the independent government agency, the Centers for Medicare and Medicaid called for and received thousands of public comments on the concerns about this drug. Additionally, CMS only approved provisional payment for this drug for patients in clinical trials, which appears prudent. This decision infuriated big pharma because they assumed anything that could be hornswoggled through the FDA was a guarantee of payment by CMS, and thus, the giant wallet of the US government, which would be responsible for most of the cost.

Conclusion, since the government conducts most of the early scientific research, shouldn’t it, as the largest purchaser of pharmaceuticals, have a right to review drug approvals, for this is exactly what private insurance companies do with their pharmacy schedules. It is not in the best interest of tax paying Americans to waste money on specious treatments and CMS is doing all of us a favor by slowing down the approval of Biogen’s Aduhelm. The pharmaceutical industry should consider this a shot across the bow as the American public is awake and livid over the continual pillaging of our pocketbooks for their profits.

References

American Geriatrics Society. (2022, April 6). Where We Stand-Letter to CMS Commissioner on Aducanumab. Retrieved from https://www.americangeriatrics.org/: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl=https%3A%2F%2Fwww.americangeriatrics.org%2Fsites%2Fdefault%2Ffiles%2Finline-files%2FAmerican%2520Geriatrics%2520Society_Letter%2520to%2520FDA%2520Biogen%2520Drug%2520for%2520Alzheimer%

Belluck, P. (2022, April 6). Inside a Campaign to Get Medicare Coverage for a New Alzheimer’s Drug. Retrieved from https://www.nytimes.com/2022/04/06/health/aduhelm-alzheimers-medicare-patients.html?smid=url-share

Butler, J. (2022, April 5). The Alliance For Aging Research-Fronting For Pharma. PharmedOut.org. Retrieved April 6, 2022, from https://mailchi.mp/georgetown/april-2022-newsletter-update

Cameron, K. (2022, April 6). What you need to know about aduhelm. Retrieved from National Council on Aging: https://www.ncoa.org/article/what-you-need-to-know-about-aduhelm

Cummings, J. R. (2018, June 13). The price of progress: Funding and financing Alzheimer's disease drug development. doi:https://doi.org/10.1016/j.trci.2018.04.008

PharmedOut.org. (2022, April 6). Aduhelm. Retrieved from PharmedOut.edu: https://georgetown.edu/pharmedout/advocacy/aduhelm?authuser=0

Right Care Alliance. (2022, April 6). Withdraw Approval of Aduhelm Petition. Retrieved from Right Care Alliance: https://rightcarealliance.org/

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when you agree to inpatient treatments, do stipulate that for which you agree and that you decline.

 

Roberta Winter is an independent healthcare analyst who accepts no money from any sector of the U.S. healthcare system. She is the author of a guidebook to the healthcare system which was published in 2013 by Rowman and Littlefield. https://healthpolicymaven.blogspot.com/2021/09/is-fda-too-politicized-to-make-sound.html

 

 

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[1] https://healthpolicymaven.blogspot.com/2022/01/high-cost-of-single-unproven-drug.html

 

[2] https://healthpolicymaven.blogspot.com/2021/09/is-fda-too-politicized-to-make-sound.html

Should Your Hospital Get Nonprofit Status If It Doesn't Provide Enough Health Care for the Poor?

Nonprofit 501C-3 hospitals can lose their nonprofit status if they do not contribute enough of their revenue to charitable care in the communities they are supposed to serve. In 2017, a nonprofit hospital lost its tax-free status because it did not provide enough community benefit according to the Affordable Care Act Standards. The hospital, which was not named by the IRS, was deemed to have willfully flaunted the requirement that it maintain nonprofit status. (Wyland, 2017) Worse yet, this hospital was designated a disproportionate share facility, a designation which receives further federal government funding because they are located in communities with large populations of impoverished people. Disproportionate share hospitals are found in inner cities and include; Cook Hospital in Chicago, Harborview in Seattle, and Bellevue Hospital in New York City. Unfortunately, in this situation a nominal fine of $50,000 was levied to this hospital group, because that is all the statue allowed, which is coffee money for hospital corporations. Opportunism in large hospital corporations is a growing trend, but at least the Affordable Care Act finally provided some standards of proportionality for charitable care in order to actually be a nonprofit, nontax paying entity.

 Tracking Your Nonprofit Hospital’s Community Benefit

Boston-based Lown Institute even publishes an index that ranks community investments from hospitals and its’ latest report shows 72% of the 3.641 nonprofit hospitals  which participated actually received tax benefits in excess of their charity care and community investment. (Toleos, 2021) To determine how your local hospital ranked go to their site at https://lownhospitalsindex.org/rankings/

Lown Institute Rankings for Community Investment and Charitable Care (Lown Institute , 2022)

Standards	Hospital	Location
Most Charitable	Paradise Valley Hospital	National City, CA
2nd Most Charitable	Elmhurst Hospital Center	Elmhurst, NY
3rd Most Charitable	Queens Hospital Center	Jamaica, NY
3rd Least Charitable	University CA Medical Center	San Francisco, CA
2nd Least Charitable	New York Presbyterian Hospital	New York, NY
Least Charitable	Cleveland Clinic	Cleveland, OH

 Affordable Care Act Requirements for Nonprofit Hospitals

Under ACA mandates, hospitals must conduct a community health needs assessment (CHNA), create an action-based plan to meet objectives identified in the report, and widely disseminate the plan once it is approved. Additionally, the Internal Revenue Service has added section 501 (1) to the revenue code which has requirements for nonprofit hospital reporting and standards to demonstrate nonprofit status. (Internal Revenue Service, 2022) These requirements prohibit lobbying, political contributions, and election year issues. Further, if compensation paid to hospital executives is deemed excessive, they are taxed a 25% excise tax on each excess benefit, of which the executives are personally liable. The compensation deemed an excess must be paid back and if it is not, a 200% tax penalty is levied. A 10% tax may also be levied on the manager of the person(s) who are deemed to have received an excess benefit as well.  These penalties at least provide some teeth in the Revenue Service’s enforcement of tax code provisions which provide generous exclusions for nonprofit hospitals.

 Judge Ruled Hospital Corporation Is Non-Charitable Entity

Local communities have started to sue large hospital corporations and in Pennsylvania, a Chester County judge ruled that three local nonprofit hospitals, owned by Tower Health were not tax-exempt charities and thus subject to property taxes. This judge found these hospitals did not meet the 1997 statute for Institutions of Purely Public Charity Act. Further the court stipulated they did not provide adequate uncompensated care and declaring undercompensated care as charity care is not valid. This is a line in the sand which will reverberate throughout all nonprofit hospital groups, because they too use the undercompensated care standard tied to their “chargemaster.” This judge also decreed the chargemaster is meaningless because it has nothing to do with actual contracts or payment for services. (Johnson, 2022) As a former hospital finance department employee, I can state unequivocally that no one pays the charge master prices. Even the uninsured, who could be charged those rates can apply for charitable care or negotiate discounts. The chargemaster is in fact, a starting point in swap meet negotiation and hospitals never expect to receive reimbursements at those rates.

 Many municipalities and school districts are interested in taxing wealthy nonprofit organizations, whom may have extensive property in their communities. For example, in my state, the University of Washington is one of the largest real estate owners and landlords in pricey Seattle. Even in tiny Walla Walla, Whitman College is also one of the largest land owners in town. In the case of both of these educational institutions, they were established before Washington became a state and merely held onto their land grants.

 Communities can and should use the courts to redress exorbitant healthcare prices from hospital groups which pay no taxes and received a plethora of government financing. Perhaps when enough of the settlements cost enough money these money gouging hospital groups will start to care about the people in their communities more than their pocket books.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when agreeing to health care procedures, do stipulate that for which you consent and for which you decline. Roberta Winter is a healthcare analyst and freelance journalist who accepts no money from any sector of the healthcare industry for publication of this column.

 Works Cited

Internal Revenue Service. (2022, March 3). Non-profit Charitable Organizations Exemption Requirements. Retrieved from IRS.gov: https://www.irs.gov/charities-non-profits/charitable-organizations/exemption-requirements-501c3-organizations

Johnson, B. K. (2022, January 7). Non-Charitable Nonprofit Hospital Ordered to Start Paying Property Taxes. Retrieved from Bloomberg News.com: https://news.bloombergtax.com/tax-insights-and-community/non=charitable-nonprofit-hospital-ordered-to-start-paying-property-taxes

Lown Institute . (2022, March 3). Lown Institute Hospitals Index-2021 Rankings . Retrieved from Lown Hospitals Index.org: https://lownhospitalsindex.org/rankings/compare/?hospitals=050024,330128

Toleos, A. (2021, July 11). Most U.S. nonprofit hospitals neglect community investment obligation, analysis reveals. Retrieved March 3, 2022, from Lown Institute: https://lowninstitute.org/press-release-most-us-nonprofit-hospitals-neglect-community-investment-obligation-analysis-reveals/

Wyland, M. (2017, August 18). Hospital Loses IRS Tax Exemption for Noncompliance with ACA. Retrieved from Becker's Hospital Review: https://nonprofitquarterly.org/hospital-loses-irs-tax-exemption/

 

High Cost Of Single Unproven Drug Forces Medicare To Increase Premiums by 13% for All Seniors

The Centers for Medicare and Medicaid should NOT approve Aducanumab (branded Aduhelm), because it is posing as an effective treatment for Alzheimer’s which hasn’t been proven. All of the clinicians who served on the FDA review board for this drug resigned when FDA leadership overruled their recommendation to deny approval. Further the drug is linked to heightened risk for falls and brain bleeds. Finally, the astronomical cost of the drug has forced the Centers for Medicare and Medicaid to increase its’ Part B premium by 13%, the largest rate increase it has ever had, which impacts low-income seniors disproportionately. CMS is a separate agency from the Food and Drug Administration for a reason and it has a long history of stewarding improvements in public health. The non-inclusion of Aducanumab by CMS for Medicare enrollees represents an effective method for it to soundly manage the Medicare budget and reinforce scientific methods for approval of treatments by a government agency. This conflict represents a unique opportunity for the Centers for Medicare and Medicaid to put the needs of the general public ahead of the interests of pharmaceutical companies.

 In September, I posted an article about the Biogen Aducanumab (Aduhelm) FDA approval controversy. https://healthpolicymaven.blogspot.com/2021/09/is-fda-too-politicized-to-make-sound.html The Centers for Medicare and Medicaid’s decision not to approve Aduhelm for payment reimbursement under any of its plans was a landmark rebuke of the FDA. This is the first time CMS has denied payment for a drug approved by the Food and Drug Administration. This decision speaks to the fact the FDA overruled the recommendations of the clinical experts who voted against approval of Aduncanumab for treatment of Alzheimer’s as it has not been proven to work. Currently CMS will only pay for this drug for those participating in further study via clinical trials. The FDA and CMS are separate government agencies for a reason and one should not serve as a rubber stamp for the other, yet this is the first time CMS has denied a drug for payment. This incidence does provide hope that our government agencies which are responsible for public health policies which impact us all are demonstrating leadership. Biogen, the maker of Aducanumab, branded as Aduhelm is furiously working to roll back this decision, because after all, their profits and bonuses are at stake. Yet our public advocacy efforts, led by the Right Care Alliance have been effective.. https://rightcarealliance.org/we-say-no-to-aduhelm-heres-why/ 

Here are the actions Biogen was forced to take when we made our collective voices known: 

1. Slashed the price of the unproven Aduhelm by 50% from $56,000 to $28,200

2. Aduhelm is currently only approved for payment for patients in clinical trials

3. Centers for Medicare and Medicaid have initiated a public comment period on Aduhelm through February 10th

4. Biogen’s stock has nosedived 40% because of the questions regarding the validity of the drug and the united clinical outcry against it

 Advocacy Works

The fact a group of scrappy healthcare reform advocates could incite these actions is evidence that efforts by the public can work to roll back some of the ineffective and costly treatments approved by the Food and Drug Administration. It is important to note the drug companies have been allowed to conduct their own testing to certify whether their drugs work without third party validation since 1992. No conflict of interest there- “Heh guys, I don’t like these results can you rejigger the data so it makes my drug appear more favorable?”

 Next Steps

Make your voice heard by taking these actions today:

1. Go to the Centers for Medicare and Medicaid site and post your comment here

https://www.cms.gov/medicare-coverage-database/view/national-submit-public-comment.aspx?DocID=305&commentDocType=nca&fromPage=tracking&error=Your%20comment%20has%20been%20submitted%20successfully,%20and%20your%20confirmation%20email%20se

2. Contact your senators and tell them you do favor the CMS decision not to approve Aduhelm for payment, because it has not been proven to work. This is no cure for Alzheimer’s.

 The FDA should require pharmaceutical companies to have independent third-party validation of the effectiveness and safety of their drugs before approval is given. The U.S. government needs to spend more money to oversee the drug approval process, not turn it over to profiteering drug companies. The pharmaceutical industry should not be financing 44% of the FDA’s annual budget. In 1906, when the agency was founded, the government paid 100% of its funding. Public safety and public interest for our health and our wallets are at stake.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when you consent to medical procedures, do stipulate that for which you agree and decline.

References

Centers for Medicare and Medicaid. (2021, November 12). CMS Announces 2022 Medicare Part B Premiums. Retrieved from Centers for Medicare and Medicaid: https://www.cms.gov/newsroom/press-releases/cms-announces-2022-medicare-part-b-premiums

Centers for Medicare and Medicaid. (2022, January 11). CMS Proposes Medicare Coverage Policy for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease. Retrieved from Centers for Medicare and Medicaid Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-medicare-coverage-policy-monoclonal-antibodies-directed-against-amyloid-treatment

 Roberta Winter is a freelance healthcare journalist who has been publishing this column since 2007 and accepts no money from any sector of the healthcare industry. She is the author of a guidebook to the US healthcare industry, published by Rowman and Littlefield in 2013. 

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

 

 

 

Healthcare Crimes Related to Covid-19

 

Healthcare Criminals-2021 

In March of 2021, the Department of Justice announced a coordinated law enforcement Covid-19 Task Force to bring pandemic charlatans to justice and charges for nearly 2 billion have been filed, for doctors, laboratories, and pharmacies. (United States Department of Justice, 2021) The scams fall into three primary areas, telemedicine fraud, running unnecessary tests, and prescription fraud. The United States Attorney’s Office has convicted many people for pandemic related healthcare crimes from 2020 and this is a brief anthology of the more egregious convictions. (United States Department of Justice, 2021) . Though special mention goes to the ethically bankrupt Sackler family, which was not pandemic related and is therefor, not included in the table. It is important to note that ethical people still exist because internal whistleblowers were responsible for 73% of these convictions leading to the recovered funds. The U.S. government was able to claw-back over a billion dollars from corporate healthcare entities, including multinationals, and two-hundred-sixty-four million from individual grifters. (Land, 2021)

 Financial Recovery of Healthcare Fraud-2020 Convictions

Company	Crime	Restitution
Novartis	Payments (bribes) to doctors to prescribe their drugs	$ 591,000,000
Practice Fusion	Accepted payments from Purdue Pharma to increase opioid use	$ 145,000,000
Novartis	Illegally paid copays for their drugs through a foundation, with the appearance of independence; as an inducement	$ 148,000,000
Universal Health Services	False claims for mental health services	$ 117,000,000
Oklahoma Center for Orthopedic and Multi-specialty Surgery	Hospital-paid kickbacks to physicians for referrals	$   72,000,000
UTC Laboratories (RenRX)	Kickbacks for lab referrals	$   41,600,000
ResMed Corp	Paid kickbacks for medical equipment suppliers, sleep labs, and health care providers	$   37,000,000
Subtotal		$1,151,600,000
Individual Assessments	Crime	Restitution
Health Management Associates	Hospital group convicted of false billing and kickbacks	$ 260,000,000
Glen Kline, DO, Community Surgical Associates	Kickbacks from HMA (one of the nation’s largest for-profit hospital groups) for surgeries	$     4,250,000
Subtotal		$   264,000,000
Grand Total Recovered		$1,415,6000,000

 Human suffering is never complete without the opportunists and charlatans. I note that HMA, one of the nation's largest for-profit hospital groups, was previously convicted of one of the largest Medicare frauds in US history, and of course, theformer head of that company is now a Senator from Florida. And this is the healthpolicymaven signing off wishing you a healthy new year!

 This column has been in continuous publication since 2007. Roberta Winter is an independent healthcare journalist who accepts no money from any healthcare, pharmaceutical, insurance, or medical device entity. She encourages you not to sign blanket release forms when agreeing to medical procedures, do stipulate that for which you agree and which you decline.

 References

Land, H. (2021, January 15). DOJ Recovers 1.8 billion in healthcare fraud settlements, judgements in 2020. Retrieved from Fierce Health.com: https://www.fiercehealthcare.com/tech/feds-recover-1-8b-from-false-claims-act-cases-2020

United States Department of Justice. (2021, May 26). Coordinated Task Force to Combat Healthcare Fraud Related to Covid 19. Retrieved December 31, 2021, from Department of Justice: https://www.justice.gov/opa/pr/doj-announces-coordinated-law-enforcement-action-combat-health-care-fraud-related-covid-19

United States Department of Justice. (2021, September 17). National Health Care Fraud Enforcement Action Results in Charges Involving over $1.4 Billion in Alleged Losses. Retrieved from United States Department of Justice: https://www.justice.gov/opa/pr/national-health-care-fraud-enforcement-action-results-charges-involving-over-14-billion

 

 

 

 

International Comparison of Health Care Access, Out-of-Pocket Expenses, and Drug Pricing Policies

Which Country Has the Best Health Care by former National Institutes of Health executive, Ezekiel Emmanuel, attempted to rank global health care, albeit he and his team only reviewed eleven nations. (Emmanuel, 2020) Yet his findings were interesting and this article delves into several aspects of health systems, including patient choice of health care provider and hospital, the burden of expenses paid by the patient, and pharmaceutical pricing policies. Each of these criteria are extremely important to American health care consumers and their concerns are influential in government elections.

Choice of Clinician

Americans assume that private sector healthcare plans provide a greater choice of clinician and facility, but Emmanuel shows this isn’t the case. France, Germany, the Netherlands, Norway, and Taiwan all have greater choice than the United States and they are all versions of socialized medicine. Switzerland, which is somewhat similar to the U.S. with its requirement to purchase private insurance as the funding mechanism for healthcare, offers greater provider choice than the U.S. because of its government regulations.  This table shows how these top scoring nations regulate patient choice in comparison to the U.S.

Nation	Choice of Physicians	Waiting Times
France	Individual choice, physician private practices dominate, MD's make house calls	No wait times, Availability of care depends on location
Germany	No gatekeepers, patients have free choice	Abundance of hospitals- no wait times
Netherlands	Driven by primary care providers, GP must provide specialist referral	Only 15% exceeded targeted wait times in 2014
Norway	Individuals choose provider and can switch twice each year	Significant queues and travel to specialty centers
Taiwan	Any clinician or hospital, patient chooses	Minimal queues for services
United States	Patient choice is restricted by insurance companies; surprise bills are common for non-network services	Minimal waits, but availability of care depends on location

 Out of Pocket Costs

The U.S. spends vastly more per person on health care than any other nation and individuals pay a significant portion of their health care expenses.  This table shows the healthcare burden per person (including children) and the proportionality based on median household income. Median represents the income that is truest to a representative average when outliers for highest (Elon Musk) and lowest incomes (incomes of $1,000 for example) are removed. Using the same data set for 2017 from the Commonwealth Fund.org report in 2020, I drew the per-person-out-of-pocket expenses for these countries. (The Commonwealth Fund.org, 2017) The final data comes from the latest per person income from World Population Review.com, which used World Bank data to arrive at its statistics. (World Population Review, n.d.). As you can see Americans have greater income than most Europeans, but must devote two or three times as much of their income toward paying health care expenses and this is on top of paying for insurance premiums. According to the Kaiser Family Foundation, the average medical insurance cost was $6,690 for private employer plans in 2017, which is typically paid by the employer. However, if you have spouse or children, 60% of employers surveyed required employees to pay the entire cost of their insurance assessment for family members.[1]  

Nation	Cost of Healthcare per person (2017 data)[2]	Out of pocket expenses per person cap (2017)[3]	Median Income per person (US$)[4]
France	$ 4,600	$ 463	$16,372
Germany	$ 6,200	$ 731	$16,845
Netherlands	$ 5,000	$ 572	$17,154
Norway	$ 7,400	$ 860	$22,684
Taiwan	$ 1,500	Not Available	$13,605
United States	$10,700	$1,122	$19,300

U.S. Insurance Cost to Employees

This table shows the potential pass-through costs to employees with families for employer medical plans in 2017 and 2020. There are many families who must choose between covering a spouse and children because they cannot afford to pay for the insurance for both. (Kaiser Family Foundation, 2020)

Premiums	2017	2020
Employee	$ 6690	$ 7,470
Employee and Family	$18,764	$21,342
Pass through cost to Employee	$12,074	$13,870

 Drug Pricing Policy

The United States uses more prescription drugs per person than any other nation and also pays more for their medicines. This table shows international drug pricing policies drawn from Ezekiel Emanuel’s 2020 analysis. (Emmanuel, 2020) It’s no accident residents of the U.S. are paying more for their medications; the system was designed to promote a capitalist drug system. The pharmaceutical industry maintains changing this policy will harm innovation, but major drug companies are located in nations with controlled drug pricing policies and they sell their medications to nations with restrictions on price setting.

Nation	Policy	Drug Prices
France	Type of drug determines who can prescribe it; gatekeeper approach; some preapproval for exceptional drugs	All drugs deemed irreplaceable are paid 100%
Germany	Physicians can’t prescribe off-label drug use, except for special circumstances; no cost effectiveness requirement but RX prices are reviewed every 12 months and prices are determined after analysis of similar drugs; clinician prescribing policies are scrutinized	Everyone pays the same price for a drug; RX markups are limited for pharma
Netherlands	Preferred formularies are used to control prices; new drugs must be authorized by the Medicines Evaluation Board which accounts for efficacy of the drug and whether or not there is an equivalent already available; hospitals and pharmacists play a role in RX price control	Most drugs are free for patients
Norway	Ministry of Health and Care Services authorizes drugs for a 5-year period, prices are subject to approval after a health technology assessment; drugs are evaluated on quality-of-life impacts and scientific value; centralized procurement for hospital drugs	Blue list drugs have $58 copay for 3-month supply, subject to $275 out of pocket max/yr
Taiwan	Drugs are purchased through clinics and hospitals; Federal Drug Administration approves drugs but the National Health Insurance Administration does secondary review for prices and reimbursement policy; Drug costs are 50% of other industrialized countries	Co-pays between $7 and $32 depending on the drug
United States	No price controls- whatever the market will bear; government is prohibited from negotiating with drug companies; private sector restricts formularies to control costs	Copayments depend on the insurance plan; seniors bear significant RX costs

 In conclusion, people living in countries with some version of socialized medicine have lower out of pocket expenses than Americans and it appears, equal or much better access to care. Also, France, the Netherlands, Germany, and Switzerland all use private sector insurance along with public health programs, so there is some similarity to the U.S. method of financing health care. The difference is how they regulate price setting for drugs, approval of drugs, as well as benefit mandates for insurance plans. These countries demonstrate it is feasible to have effective healthcare programs through the use of smart regulations driven by efficacy, cost of care and method of delivery. What are Americans afraid of?

 And this the healthpolicymaven signing off encouraging you not to sign blanket medical releases when checking-in for medical procedures, do specify that for which you consent and decline.

 Roberta Winter is an independent journalist who accepts no money from any sector of the healthcare industry. Opinions expressed here are her own.  This column has been in continuous publication since 2007. In 2013, Rowman and Littlefield published her guidebook to the US healthcare system. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

References

Emmanuel, E. J. (2020). Which Country Has the World's Best Health Care? In E. J. Emmanuel, Which Country Has the World's Best Health Care? Hachette Book Group. Retrieved November 2021

Kaiser Family Foundation. (2017, September 9). Employer Health Benefits Survey-2017. Retrieved December 2, 2021, from Kaiser Family Foundation.org: https://www.kff.org/report-section/ehbs-2017-summary-of-findings/

Kaiser Family Foundation. (2020, October 8). 2020 Employer Health Benefits Survey. Retrieved December 2, 2021, from Kaiser Family Foundation.org: https://www.kff.org/report-section/ehbs-2020-summary-of-findings/

The Commonwealth Fund.org. (2017). Out-of-Pocket Health Care Spending Per Capita. commonwealthfund.org. Retrieved December 1, 2021, from https://www.commonwealthfund.org/out-pocket-health-care-spending-capita

World Population Review. (n.d.). Median Income By Country 2021. Retrieved December 1, 2021, from World Population Review.com: https://worldpopulationreview.com/country-rankings/median-income-by-country

 

 

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[1] https://www.kff.org/report-section/ehbs-2017-summary-of-findings/

[2] https://www.nyjournalofbooks.com/book-review/which-country

[3] https://www.commonwealthfund.org/out-pocket-health-care-spending-capita

[4] https://worldpopulationreview.com/country-rankings/median-income-by-country