The Daily Rise: Monday, May 9

The Power of Patients

We’re seeing the power of patients.

In March, the obscure Centers for Medicare and Medicaid Services announced regulatory changes that are expected to have major implications for patients’ ability access life-saving treatments. The agency never bothered to consult patients before announcing the change.

Patients mobilized, and now, the Wall Street Journal’s Stephanie Armour reports that the Centers for Medicare and Medicaid Services’ plan to slash reimbursement rates is unlikely to “survive intact.”

“They may have underestimated the strength and power of the opposition to the changes,” Tricia Neuman, a senior vice president at the Kaiser Family Foundation, told the Journal. “This seems to be an all-out war, so it’s hard to know how it will play out.”

Advocating for patients is a bipartisan issue. Republicans and Democrats on Capitol Hill are joining together in criticizing the proposed changes to Medicare Part B.

“We urge you to withdraw the proposed rule immediately as it would severely disrupt care for vulnerable beneficiaries,” Republican Senator Orrin Hatch of Utah wrote in an April 28 letter. A day earlier, Democratic Senator Ron Wyden of Oregon warned that “we have heard numerous concerns from patients, providers, and other stakeholders.”

If you haven’t commented on the proposed rule change, send in your public comment today by clicking hereStill unsure of what these changes mean for patients? Keep reading.

Reducing Access to Care

Writing at, Grace-Marie Turner, president of the Galen Institute and a co-author of “Why ObamaCare Is Wrong for America,” points out that the changes deal a major blow to doctors and community clinics that already operate on “razor thin margins.”

“Since many community oncologists and physician practices are already operating on razor thin margins, this policy could mean that they could lose money every time they prescribe newer, more innovative therapies that they believe would be better for their patients,” she writes. “Further, this financial hit may cause some doctors and clinics to sell their practices to hospitals, where costs will be higher for both Medicare and beneficiaries.”

Turner says that this “rare unanimous, bipartisan opposition from both chambers of Congress… illustrates the serious risks they believe it poses to patient care.”

Forcing Patients to Fail First

Former Democratic Congressman Dan Maffei tackles the proposed CMS changes from a different political perspective in a piece at US News & World Report, but reaches the same conclusion.

He continues to celebrate the passage of the Affordable Care Act even though he lost his seat in Congress, in part, because of his vote to pass the bill.

“Put simply, the Affordable Care Act was enacted to increase access to health care, not restrict it,” he contends. “Yet the insurance industry has found a clever way of restricting access to new effective drugs through an industry-backed group that has the appearance of independence. As we turn to improving the health care law in the future, ensuring true access to innovative medicines should be a priority.”

Maffei cautions that these CMS changes will encourage the insurance companies’ tactic of forcing patients to “fail first.”

One tactic is to require that an existing cheaper drug be prescribed rather than the new, potentially more effective drug. This process, called step therapy, has been widely criticized by patient groups and physicians alike. Or, instead of excluding the drug outright, payers often pile on onerous, bureaucratic red tape such as so-called prior authorization requirements, which make it much harder for patients to access new drugs.

How do payers justify these hurdles? One way is to strategically deploy allies in the health care nonprofit world to camouflage their decisions under the cloak of economic analysis. A key example is the Institute for Clinical and Economic Review, which recently began conducting analyses to determine whether a new drug’s benefit is worth its cost. It has found most of the drugs it has reviewed to be too expensive, giving insurance companies and pharmacy benefit managers an excuse to restrict them. Ed Silverman, who writes “The Pharmalot View” column for STAT said, the institute “is becoming a de facto arbiter for the nation’s medicine chest.”

Reducing Investment in Innovation

Kenneth E. Thorpe, a professor of health policy at Emory University and chairman of the Partnership to Fight Chronic Disease, says that these changes will hamper drug development and reduce investments in life-saving innovation.

“Chronic health conditions, which account for 86 percent of all health spending, are the real driver of rising health care costs,” he writes in a piece published at the Deseret News. “Half of all American adults suffer from at least one chronic disease. Heart disease and cancer alone account for half of all deaths.”

He adds, “Therefore, the only way to meaningfully control healthcare spending is to prevent chronic diseases from occurring — and treat and cure them when they do. Only better medicines can do that.”

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