Planning the Patient-Centered Health Plan for America
Medicare has a drug problem
Drug Fraud Is Growing, And Costly, Problem For Medicare
NCPA Commentaries by Devon Herric. October 29, 2014
Source: Investor’s Business Daily
When Congress passed the Medicare Part D drug program, it inadvertently created a license to steal. A small minority of Medicare beneficiaries abuse prescription drugs for recreation and/or profit. In the process they also steal from taxpayers and their fellow Medicare drug plan enrollees — all of whom suffer higher premiums as a result.
Questionable drug use typically involves addictive painkillers that create a heroin-like euphoria. More than 16,000 people die each year from abusing pain relievers — double the number that die from cocaine and heroin.
For every death, there are 10 admitted to a treatment program for substance abuse and 32 emergency room visits. For each person who overdoses, 130 chronically abuse prescription drugs and 825 casually use them for nonmedical purposes.
Drug fraud costs insurers nearly $75 billion per year — about two-thirds of it from programs such as Medicare and Medicaid. That makes Uncle Sam the U.S.’ biggest illicit drug dealer.
How does this happen? The most common way Medicare drug fraud occurs is by “doctor shopping.” This involves seeing multiple doctors every month with bogus complaints about chronic pain. The drug-seekers get redundant exams and medical tests from each doctor, and ask them to prescribe powerful pain medications.
Unnecessary medical care to obtain drugs wastes far more than the cost of the drugs themselves. For every $1 worth of drugs lost due to fraud, an additional $41 is wasted for unnecessary physician visits, medical tests and ER visits to obtain the drugs.
To avoid detection, drug-seekers generally fill their prescriptions at multiple pharmacies to avoid being tracked or questioned. This tactic often fools individual doctors and pharmacies into believing their customers are not abusing prescription painkillers or reselling them.
But drug plans could easily detect drug-seeking behavior when reimbursing medical claims. The problem: federal law. Medicare drug plans aren’t allowed to restrict the benefits of enrollees thought to be abusing or reselling prescription drugs.
What could stop this? A program called Lock-In would help. It’s already been successfully used in most states for Medicaid enrollees. However, it requires a change in federal law to implement in Medicare — something that Kevin Brady, R-Texas, chairman of the House Ways and Means subcommittee on health, supports.
He recently circulated a draft bill, “The Protecting Integrity in Medicare Act of 2014,” to help Medicare drug plans fight back against prescription drug fraud and abuse.
Under a Lock-In program, enrollees exhibiting unsafe, drug-seeking behavior — such as doctor shopping and using multiple pharmacies for getting pain drugs — could be required to designate one specific doctor for pain management and one specific pharmacy to dispense pain medications.
No other physician or pharmacy could prescribe or dispense pain medications — but all other Medicare benefits would remain unaffected.
Another good idea is to expand Lock-In to include more drugs than just narcotic pain relievers if needed. Case in point: A recent government investigation found Medicare spent $32 million for AIDS drugs in 2012 for 1,600 people with questionable drug claims — more than half of which did not appear to actually have HIV.
Many of these visited multiple doctors for prescriptions and/or filled their drugs at multiple pharmacies — often obtaining excessively high doses or excessively large quantities of costly HIV drugs.
What explains this rather odd behavior? Some of these drugs were likely resold on the illicit market due to their high resale value. Another possibility is unscrupulous (possibly bogus) pharmacies stole Medicare enrollees’ identities and bilked Medicare for drugs never dispensed.
Scary thought: Sovaldi is a breakthrough Hepatitis C medication that has a 90% cure rate. The catch: it costs $1,000 per pill and requires an 84-pill course of treatment. Hepatitis C is rampant in the U.S. prison population, and among drug addicts and people with a criminal record.
How long do you think it will take the Medicare fraudsters to figure out that having a dozen different doctors prescribe Sovaldi — and then reselling it for, say, $50 per pill — could be a lucrative business model?
Medicare needs the ability to lock in troubled enrollees found to be abusing (or reselling) drugs and shut out fraudsters billing for bogus transactions. Otherwise, the rest of us will continue to pay for the abuse.
Commentary by Pete du Pont
Some thoughts on the views that have animated this column.
Source: The Wall Street Journal | May 27, 2014
Governor Pete du Pont is a Board Member of the National Center for Policy Analysis. He writes a regular column for OpinionJournal.com, the online news service of The Wall Street Journal.
Pete du Pont has served as Governor of Delaware, U.S. Congressman (R-DE), and former candidate for President of the United States (1988). Gov. du Pont formerly hosted a nationally-syndicated radio commentary and appeared on several editions of the PBS Firing Line debates with William F. Buckley, Jr.
This will be the last of my columns for this publication, so I thought it fitting to note the views that have most influenced these writings. Foremost is my appreciation of America’s character and strength and my opinion that the only earthly thing that can stop this great country is a national failure of will or a continual series of misguided political decisions.
My optimism is driven primarily by the ingenuity and resilience of America’s people. A nation of more than 300 million will have its share of lawbreakers, slackers and charlatans, but America is so much more filled with people who are wise, honest and hardworking. The capacity of Americans to sacrifice—greatly at times—for others is truly impressive.
This is why I so often stressed that individuals, families and businesses should as much as possible be the ones making decisions instead of politicians and bureaucrats, no matter how well-intentioned. Some will argue against this view, and it is certainly true that individual decisions will not always provide the optimal result. But it is just as certainly true that this approach will work better over the long term than one-size-fits-all diktats of government. From the five-year plans of the former Soviet Union to ObamaCare, the troubles that can befall a country from top-down government control and political attempts to pick winners and losers are obvious.
My optimism has also been fueled by what history shows is the amazing ability of our economy to generate jobs, innovation and better standards of living, not just for our nation but for the world. We are rightly seen as the land of opportunity, and it is no wonder people from other nations flock here.
I must admit this optimistic view has been challenged over the past decade. One of the most obvious reasons for pessimism is the sad state of the national fisc. Deficits are not in and of themselves bad, but running large deficits for multiple years is. Burdening future generations with trillions of dollars of debt is a deplorable abdication of responsibility. One key to our future will be whether government can reduce the runaway spending that comes from trying to be all things to all people. It is critical that government instead focuses on its central responsibilities, reduces its tax bite, and gets rid of onerous regulations that sap the initiative of our people and the strength of our economy.
Another cause for concern is the stifling of economic growth and opportunity under the guise of environmentalism. We cannot afford continued attacks on our energy supplies. These policies, if carried to the fruition of which the left dreams, will crush our economy and with it our standard of living and our continued ability to be a strong presence in the world.
We are still the world’s sole superpower, and like it or not, that role comes with certain responsibilities. We cannot continue to be a force for good across the globe if we continue the recent trends toward isolationism and a hesitancy to get our hands dirty. Recent efforts to shortchange our military and defense preparedness are not harbingers of success in this critical area.
We cannot let political correctness muzzle free speech. That this occurs with regularity on college campuses, where open debate should be most welcome, is a sad irony. Nor can we continue to impinge on the freedom of religion. Encouragingly, the recent Supreme Court ruling in Town of Greece v. Galloway reaffirmed the view that God has a place in the public square.
Since our strength flows primarily from our people, the character of future generations is important. Will the left succeed in making more of us dependent on government? Will the generations moving into the mainstream of politics and the economy over the next decades be like the college graduates recently in the news who seem to have majored in taking offense or claiming victim status? Or will they be more like the young men and women who have performed so amazingly in Iraq and Afghanistan, and the ones starting careers and families? The next generation does not have to be the greatest generation, but it cannot be the weakest generation.
Of course, education is critical. We must not let union bosses and other forces of the status quo stop innovations that would ensure a good education for all. We must find a way to make higher education more affordable so those needing a degree to pursue their profession are not blocked from seeking that degree or saddled with significant debt.
These are the views of, and hopes and concerns for, America on which my columns have been based. I must note my gratitude to James Taranto, my editor par excellence for these columns, and to Brad Zuber, who has provided me with research and other assistance for nearly two decades. These columns have been better because of their efforts.
Finally, I want to thank all of you, the readers. I know from the comments section that not all have agreed with what I wrote each month, but I hope you enjoyed thinking about and debating the issues I raised. Please continue to read the editorial section of this great publication. It is rare to find such an abundance of writers in one place who can so interestingly write in a way that separates the truly important policy essentials from the dross of today’s political rhetoric.
It’s been a pleasure to be associated with all this over the years, and I wish everyone the very best.
Obama Kicks Seniors Yet Again
Source: TownHall.com | March 04, 2014
The Affordable Care Act (ACA) will have a negative impact on seniors’ access to care. Much of the funding for the ACA is derived by cutting $716 billion from Medicare over the next decade. One major cut includes a 25 percent fee reduction to physicians who treat Medicare enrollees. ObamaCare is also slated to cut funding for Medicare Advantage (MA) plans, which covers nearly one in every three Medicare enrollees. Compared to traditional Medicare, MA plans provide approximately $825 annually in added benefits to its mostly moderate-income enrollees.
The Obama administration is now poised to take another swipe at seniors — this time cutting their choice of Medicare Part D drug plans. The Centers for Medicare and Medicaid Services (CMS) wants to do away with the most popular Medicare drug plans: ones that offer seniors lower premiums (and lower cost sharing) in return for patronizing a preferred pharmacy network. CMS also wants to limit the number of plans an insurer can sponsor in each service region to only two, which will reduce seniors’ options for drug plans.
About 90 percent of seniors take a prescription drug in any given year. Compared to other therapies, drugs are a relative bargain. Drugs make up only about 10 percent of total medical expenditures. Nearly 39 million Medicare beneficiaries, including both seniors and the disabled, have drug coverage subsidized through the Medicare. Most of these are enrolled in coverage known as Medicare Part D.
The 6 million health insurance cancellations that occurred in the fall of 2013 will pale in comparison to the number of Medicare Part D drug plans cancelled next fall if these regulations are implemented. Nearly 14 million seniors will lose the Medicare Part D stand-alone plans they have currently if the use of preferred networks is banned.
The Medicare drug program has been quite popular. Participating seniors pay about one-fourth of the cost of their drug plan, while the government pays for about three-fourths of the cost. Overall, seniors are highly satisfied with their drug plans. Satisfaction rates average about 90 percent to 95 percent. As a result, the proportion of seniors who lacked drug coverage prior to the Medicare Modernization Act of 2003 (MMA) has fallen by 60 percent.
One reason seniors give their Medicare drug plan high marks is because they can choose among a wide range of drug plans. Nationwide, 1,169 Medicare Part D drug plans across 34 regions compete for seniors’ patronage. The number of plans varies among states, from a low of 28 in Alaska, to a high of 39 Pennsylvania and West Virginia. But that’s too many according to some within the Obama administration. Some Medicare administrators remain skeptical of the MMA — which was passed by the Bush administration with the help of congressional Democrats. The Bush administration wanted the Medicare drug program to be composed of private drug plans, whose primary mission is to vigorously compete for seniors’ patronage. Since its inception, the MMA mandated a statutory, non-interference clause. Contract negotiations between drug makers, pharmacy networks and drug plan sponsors were strictly left to the respective parties. Drug plan sponsors were responsible for negotiating prices with drug companies and drug distributors, and contracting with pharmacy network providers to secure seniors the lowest possible drug prices.
That is, until now. In January 2014, CMS proposed new regulations that would restrict the ability of drug plans to offer seniors lower drug prices in return for patronizing a preferred network. Low prices are the result of bargaining power — the ability of the drug plan managers to steer business to drug providers that agree to low prices, and deny business to a firm if their bid isn’t favorable.
The Obama administration wants to block drug plans from excluding the losing bidders — those drug provider networks that offered the highest prices during contract negotiations. The proposed regulatory change is not benign; it substantially weakens a drug plan’s power to bargain for lower prices on behalf of seniors. Without the knowledge that a “losing bid” threatens drug plan managers with losing out on all potential business from enrollees in a given Medicare drug plan, pharmacy networks will have little reason to offer low prices. The incentive is for all competitors is to bid higher, knowing a losing bid does not mean losing business — but could mean charging higher prices.
Medicare Part D premiums have remained affordable since the MMA’s inception because per capita drug spending has been far lower than projected. In 2013 the per capita cost was nearly 40 percent less than it was projected to be back in 2006.
According to the Federal Trade Commission, regulations that ban preferred networks raise prices and harm consumers. The actuarial firm Milliman estimates this regulatory change, proposed in January, would actually cost the Medicare program nearly $1 billion per year, and would add more than $9 billion to the cost of the Medicare Part D program over the next decade. Seniors seem to appreciate drug plans that feature low-priced, preferred pharmacy networks. Enrollment in this type of plan has shot up more than 60 percent in the past year. Seniors — and taxpayers — will be losers if this option is taken from them.
How can government determine the value of an employee?
Commentary by Pamela Villarreal
Source: Investor’s Business Daily | December 04, 2013
The bottom line is that those who want to make $15 an hour flipping burgers should . . .
pursue education and skills that warrant higher pay.
This week, another fast-food walkout will take place in 100 cities.
Evidently, this one claims to be much larger than previous protests.
And no doubt the Service Employees International Union and other organized labor groups play a major role in supporting the walkout and also make up the lion’s share of the protestors.
The goal? To push for an increase in the minimum wage to $15 an hour.
But as the old adage goes, the road to hell is paved with good intentions.
The arguments made by advocates of a living wage are flawed on so many levels, and will end up hurting the people they purport to help.
One needs look no further than the evolution of large retailers. Thirty years ago, there was no such thing as a self-checkout lane.
I used to walk in to my local big-box retailer, and there was very little that was high-tech about checkout lanes.
Scanners were just starting to be used to price and sell merchandise, but the clerks had to scan each item personally, with a hand wand. In spite of the burgeoning computer technology, a warm body was still needed.
But much of the retail transformation can be attributed to increasing labor costs and decreasing technology costs.
How does this relate to this week’s walkout? It is simple. If higher wages are forced on the fast-food industry, capital eventually will replace labor in that industry as well.
Sadly, this is all under the guise of helping people, but the result will be that teenagers and low-skilled workers get the shaft.
The unemployment rate among teenagers is the highest of all age groups.
In some areas, such as Washington, D.C., it is above 50%. Teenagers there would be happy to work for $8.25 an hour.
Recently, Washington’s council almost passed an ordinance that would require the area’s newly established Wal-Mart stores and other large big-box retailers to pay a “living wage” of $12.50 an hour.
Given that 23,000 applications were submitted for the 600 jobs that were available when Wal-Mart opened its first stores in the D.C. area, it is evident that many job-seekers are willing to work for less than $15 an hour.
The fast-food industry will also seek out those people.
But once those who are willing to work are employed, any excess demand for labor will be supplied in the form of whatever is most efficient, either by enticing more workers with a higher wage or using technology instead of human capital.
It does not matter what is mandated by a city or the federal government, or what is demanded by protesters.
Businesses seek to maximize profits, and if they must replace or supplement human capital with automation they will do it.
Advocates argue that many fast-food and retail workers support families and also depend on public assistance, which costs taxpayers.
A study from the University of California, Berkeley, found that 330,000 fast-food workers are enrolled in Medicaid, the health care program for the poor, and 432,000 children of fast-food workers are enrolled in CHIP, the Children’s Health Insurance Program.
But as many states offer Medicaid benefits to households living well above the poverty level, it is disingenuous to connect Medicaid benefits directly to fast-food workers.
In fact, there are 636,000 families enrolled in Medicaid and CHIP in Massachusetts, thanks to its generous eligibility criteria, but only 34,000 households with fast-food workers.
It would hardly make sense to blame Massachusetts’ Medicaid burden on the fast-food industry.
But far be it for facts to get in the way of a good push by living-wage advocates.
Furthermore, if a minimum wage hike results in more low-wage workers becoming unemployed or unable to find a job in the first place, the cost of public assistance programs will likely increase.
The bottom line is that those who want to make $15 an hour flipping burgers should put their picket signs down and instead pursue education and skills that warrant higher pay.
2016: Obama’s America
Get the real unvarnished truth about what 2016 will look like if Obama gets re-elected. You may not recognize the Home of the Free. There may not be any home of the free left on the earth if he wins. Some Freedom of Speech has been compromised. Some Freedom of Religion has vanished. This has been playing throughout our country this month. The DVD is now available. If you missed the widescreen, watch it on your PC by ordering it from Amazon and other outlets. It’s worth the price. It may save your life. It may save our country.
If you thought being one of the producers of one of the greatest anti-hate films in history, one that exposed hatred, bigotry and anti-semitism would make you immune from being labeled a hate monger, think again. “Schindlers List” left its mark on the world and did so by telling the truth about man’s inhumanity to men. Yet the slings and arrows came at me to impinge my credibility, the work of Dinesh D’Souza and to once again use hate as their passport to the dark side.
Is there anyone else out there who sometimes finds movie reviews lacking in substance and objectivity? How about a film “review” written by an online journal prior to them even viewing the film? Does that sound like the classic cart before the horse scenario? Anyone else smell something dishonest, partisan and maybe even cynical? That kind of effort can only be suspect in its mission and intent.
I speak of an online journal writing an attack piece on my latest film, ‘2016 – Obama’s America’. It labeled the film, “Feature Length Obama Hate.” Nice. And they hadn’t even seen the film.
That kind of action has to come from pure chutzpah, ideology or just plain stupidity, you can pick.
It seems the left in America can only define something they don’t understand, something that frightens them, something so truthful it hurts or something they have no real response to that leaves them grasping for any kind of answer that comes with the hope that maybe it will just go away…and if it doesn’t, do all possible to destroy it.
That won’t happen. The film is complete, it’s scheduled for release and it stands on it’s own as a well thought out visual documentary based on two books written by author Dinesh D’Souza, “The Roots of Obama’s Rage’ and the soon to be released “Obama’s America.”
A dear friend reminded me to not take the attack(s) personally and remember what a true hero of American liberalism, Nat Hentoff, wrote in his aptly titled book, “Free Speech For Me But Not For Thee: How The American Left and Right Relentlessly Censor Each Other.” Mr. Hentoff reminds all of us that the “right” and the “left” have both made blunders in their zeal to shut down the other side. But this attempt at fairness in reviewing a new film goes the extra mile in incredulity when the review comes EVEN BEFORE the film’s release.
This effort to de-legitimize the film is nothing less than “high-tech censorship,” since the first attack was trying to impugn the motives of the filmmakers and questioning how the project was funded and by whom, all in an attempt to dissuade people from watching it.
I don’t remember anyone in the mainstream press questioning Michael Moore about his motives (he wore them on his sleeve) or where the funding came from (deep pockets of those sharing his ideology). No questions asked….
The American way has always been to present ideas and new opinions, then through reason, logic, debate and even personalities, continue to expose as many points of view as possible. It makes the country a better one and stronger one for all of us.
“2016 – Obama’s America” presents a picture of an America changed through the passion of one man and his determination to turn America into ‘just another country.’ The movie should be required viewing by all Americans. Then you can do your own homework and make up your own mind.
But there are forces out there who don’t want you to view this movie and will try desperately to keep you away from the theater by impugning the character of people like me who created the work, hoping it’ll scare you away.
That’s not the American way.
I hope you’ll ignore these voices of fear and enjoy the show. And to these true forces of hate, who would seek to bully people into not seeing a movie they themselves haven’t even seen yet, let me remind them: it’s just a movie. Right?
Gerald R. Molen is the Academy award winning producer of films such as “Schindler’s List,” “Jurassic Park,” “Minority Report” and others. His film “2016: Obama’s America” will be released in theaters on August 10 and 17.
Why Medicaid Should Be Easier to Fix than Entitlement Programs
Capital Ideas By: John R. Graham, Pacific Research Institute, 6.1.2011
Congress remains gridlocked on many important issues but not every politician is afraid to challenge the unsustainable growth of Medicaid. Consider S. 1031, by U.S. Senator Tom Coburn.
This measure would increase local control over Medicaid spending and improve the incentives that have led politicians to trap ever more low-income citizens in poverty and the poor access to care that characterizes this top-heavy system.
Medicaid is often described as an “entitlement,” but that is wrongheaded. Medicaid is welfare, targeted at low-income Americans. And Medicaid should be easier to fix, politically, than two other troublesome programs.
The politicians who invented Social Security and Medicare asserted that these programs would be funded by payroll taxes in order to foster the illusion of entitlement. We pay for the benefits in our working years, and the benefits arrive after we’ve retired. It’s all nonsense of course.
The taxes we pay do not go into accounts that belong to us. Rather, they pay current retirees and fund other government programs. Nevertheless, it is exceedingly difficult to convince people of the truth that we have not paid for our Social Security or Medicare. But Medicaid spending, to which nobody is “entitled,” is now greater than Medicare spending.
This has occurred because Medicaid’s funding formula incentivizes the political class to overspend. For every dollar a state politician spends on Medicaid, the federal government pitches in at least one dollar – or even more, as a result of the misnamed “stimulus” of 2009 – via the Federal Medical Assistance Percentage (FMAP). The federal government actually rewards states for making more residents dependent on Medicaid.
S.1031 would transform the federal government’s funding for Medicaid, but it would transform it into a “capped allotment.” This was the model of the successful welfare reform of 1996, which reformed Aid to Families with Dependent Children (AFDC) into Temporary Assistance to Needy Families (TANF).
The number of average monthly recipients dropped from more than 12 million in 1996 to fewer than 4 million in 2008 – and low-income Americans faced better incentives to seek productive work. We have recently experienced a successful example of a reform in this direction.
Rhode Island received a waiver on the last day of the Bush administration that capped its total (state and federal) Medicaid spending at $12.075 billion through 2013. At the current rate, it looks like the actual spending will be about $9.3 billion – with no evidence of reduced access to care. And Rhode Island’s waiver preserved the flawed FMAP.
Coburn’s S.1031 introduces even better incentives, from which all states and taxpayers will benefit. It gives states more control over their program dollars to get rid of waste, fraud, and abuse. It encourages states to make Medicaid providers accountable to the neediest patients in their communities, instead of remote federal bureaucracies. Finally, it will protect taxpayers from politicians’ worst impulses to spend unaccountably.
It is generally recognized that TANF, which passed with bipartisan support, produced positive outcomes. It is long past time to introduce similar reforms to Medicaid. The current stalemate on the debt limit should not prevent Congress from taking up S.1031 at the earliest convenience.
On Tax Day, Friday, April 15, 2011, Atlas Shrugged Opens
The time has arrived!
Friday, April 15, the Atlas Shrugged movie will open on more than 300 screens around the country. Find the theater closest to you (and demand it in your city, if it’s not already there) by going here:
All of us who love Ayn Rand’s novels should bring our friends to see the movie on the opening weekend. This is hugely important; it shows theater owners how much demand there is for this independently produced and distributed movie based on Ayn Rand’s revolutionary novel.
Equally important, though, is to go back the following weekend—with even more friends. This helps demonstrate the movie’s momentum in no uncertain terms, and will draw even more theaters on board.
If you haven’t already seen the trailer and the excellent preview clips (‘Henry Rearden Comes Home’ and ‘Dagny Taggart Confronts the Union’) from the movie, you can watch those here:
Enjoy the show. Meantime, to help capitalize on this new wave of publicity for Ayn Rand’s writings, we’re hard at work building new functionality for the Atlasphere, including better search functionality, enhanced (and free) social networking options, and some innovative ways of sharing our enjoyment of Ayn Rand’s ideas. We’ll have more updates for you on this front shortly.
You may also wish to read Don Luskin’s review in the WSJ on “Atlas Shrugged.”
The author of “Atlas Shrugged” was an individualist, not a conservative, and she knew big business was as much a threat to capitalism as government bureaucrats.
By DONALD L. LUSKIN
Tomorrow’s release of the movie version of “Atlas Shrugged” is focusing attention on Ayn Rand’s 1957 opus and the free-market ideas it espouses. Book sales for “Atlas” have always been brisk—and all the more so in the past few years, as actual events have mirrored Rand’s nightmare vision of economic collapse amid massive government expansion. Conservatives are now hailing Rand as a tea party Nostradamus, hence the timing of the movie’s premiere on tax day. . .