Kickas.org Forums Ankylosing Spondylitis General Discussion #1 AS Web Support Group What to do about healthcare? Can it be fixed?

Hi There,

I do have some knowledge about pricing of Rx drugs and fraud. If anybody feels like reading up, this is a very interesting case from about 10 years ago where TAP got caught red handed giving kick-backs and "marketing the spread"

http://www.phillipsandcohen.com/CM/NewsSettlements/TAP_Oct3_2001.asp

http://healthcenter.bna.com/pic2/hc.nsf/id/BNAP-548LJ8

Then Lilly

http://www.usdoj.gov/usao/pae/News/Pr/2009/jan/lillyrelease.pdf

And more recently, Pfizer

http://online.wsj.com/article/SB125190160702979723.html

http://www.miamiherald.com/business/breaking-news/story/1216716.html

A lot has been put in place since to deter these conflicts of interest, both legally (OIG) and regulatorily (FDA) and also by the industry groups like PHRMA and AMA.

http://www.mwe.com/index.cfm/fuseaction/...BDF6D8CB25E.cfm

As a regulatory person whose job it is to help companies do the right thing, this is very sad for me to see. More info coming....

Jess

OK, so here is some more information about rx drug pricing. Below is a synopsis of the rule that was put into place by the Office of the Inspector General (OIG) because companies were intentionally manipulating their product prices in different "lists" and "marketing the spread".....

OIG Integrity of Data and Government Reimbursement

The Guidance warns pharmaceutical companies against directly or indirectly manipulating sales and price data. The Guidance suggests that pharmaceutical manufacturers may be held responsible for the average wholesale prices (AWP) reported by private publishers such as the Red Book, the Blue Book or Medispan, whose listings are based on price data furnished by manufacturers. Because the U.S. Centers for Medicare and Medicaid Services (CMS) uses this published data to set federal reimbursement rates, manipulation of pricing information furnished to private publishers can inappropriately increase government health care spending. CMS also relies on pharmaceutical manufacturers to report the average manufacturer price (AMP) and Medicaid best price (MBP) for each drug for purposes of the Medicaid Drug Rebate program. The AMP is the average price at which a manufacturer sells a product, other than to federal purchasers and state drug assistance programs. The MBP is the lowest price paid by a manufacturer’s customers, excluding certain specified purchasers. CMS uses AMP and BMP data to calculate the 15.1 percent rebates that manufacturers must pay to state Medicaid programs under the Medicaid Drug Rebate Act. Moreover, many Medicaid programs and commercial insurance companies use the reported AWPs as a benchmark in setting pharmaceutical reimbursement rates.

To avoid liability under the False Claims Act and federal Anti-Kickback Statute for AWP or AMP manipulation, the Guidance indicates that reported prices should reflect actual wholesale price transactions adjusted to account for all forms of purchasing concessions. These concessions may take the form of price reductions, discounts, rebates, up-front payments, free or discounted "bundled" goods or services, grants, coupons or other items of value.

As in the draft guidance, the final Guidance expresses concern regarding active marketing of the "spread" by pharmaceutical companies. The "spread" is the difference between the wholesale price of the manufacturer and the reimbursement rate recoverable by the purchaser. "Marketing the spread" refers to the practice of encouraging product purchases based on the potential profit that customers can realize from the spread in relation to similar margins on competing brand-name or generic drugs. AWP manipulation in conjunction with marketing the spread (i.e., acting to inflate profits to drug purchasers) would appear to be particularly suspect conduct in the view of the OIG. The Guidance describes it as evidence of "unlawful intent."

The Guidance also indicates that the federal Anti-Kickback Statute is potentially implicated when manufacturers manipulate the AWP to increase customer profits from federal drug reimbursement programs. The Guidance, however, does not clarify how to accurately calculate an AWP, an issue of debate within the industry. In addition, though the Guidance states that "marketing considerations" should not "inappropriately" influence AWP reporting by manufacturers, it is not clear what "inappropriately" means in this context. Manufacturers by definition must consider marketing and profitability in the course of setting prices. On the other hand, inaccurate reporting of wholesale price sales for purposes of manipulating AWP is clearly improper in the view of the OIG. What is not entirely clear is whether the OIG views marketing the spread alone, in the absence of AWP manipulation by the manufacturer, as potentially involving the offering of illegal "remuneration" under the Anti-Kickback statute.

Quote:

---

She cannot receive Medicaid because she makes "too much money".

---

Hi Chris,

This is exactly the point I made in one of my earlier posts where I told the story about my good friend who is making $10 an hour as a security guard (a job that does not offer healthcare benefits, of course). While he is thrilled to have this job and to be working after a year-and-a-half period where he was employed for only about six months due to retail downsizing (he was a bookstore manager then worked at a large hardware chain for about 6 months), taking the job absolutely meant he would be making too "much" money to qualify for any state or country social services programs, including any kind of subsidized healthcare plans they might offer, or for any federal programs, including Medicaid. His fiancee is my ex-wife, a Canadian citizen, and they have a 2-year-old child together (a miracle baby--she had been told by several doctors she could never have children, so please, no comments from anyone reading this about the irresponsibility they showed by having a child when their economic situation was in shambles). For a time they were able to afford renting a house here in the States and lived as a family, but once he lost the hardware job, he was unemployed for about 8 months and they lost their rental home.

With both unemployed (more on this in a moment), they could have qualified for some programs here in the United States. Well, my friend and their son could have--my ex cannot ever qualify for Medicaid or state health insurance programs unless she becomes a U.S. citizen; a green card is not enough to qualify for these programs. If they had needed help when she was pregnant, she would have been able to receive assistance with neonatal nutrition, etc., and I'm sure they could have found a charity hospital where they could have had the baby for free. Luckily, they did have some money still during almost the entire pregnancy, and plus, I was still carrying her on my insurance (and paying for it), as we were only separated then, not divorced (a situation I've explained here at KA many times and don't care to go into again unless totally necessary). With my excellent insurance, her pregnancy was totally covered; immediately after the birth, we started the divorce process and were legally divorced several months later. At that time, she had no ability to get ANY insurance in the U.S. due to her lack of citizenship and her inability to work--a key point I left out. She has very serious chronic health problems of her own: incredibly serious and nearly debilitating Type 1 adult onset diabetes (the really, really bad type of diabetes that mostly begins when you're a child; it is very rare to come down with this as an adult) and the worst case of degenerative disc disease her spinal doctor had ever seen. More on her working in a moment.

Anyhow, with no money, no job on the horizon, and no health insurance, they had to make a very tough decision. For the past 8-10 months (maybe longer, I'm horrible with dates and memory!), my friend has lived here in the States with his parents so he can keep his job, while she and their son have returned to Canada to live with her parents. Luckily, her parents live only an hour or so from the U.S. border, either through Port Huron/Sarnia or the ferry at Algonac. While I know many folks have it even worse and can't fall back on their parents like this and thus end up homeless, that does NOT mean this has been a good solution. Their separation has torn them apart and left their engagement in doubt, as they are constantly struggling to have enough money to take care of their son and their own basic needs. It's hard having a long-distance relationship in the best of circumstances, and nearly impossible when such harsh economic realities loom over them 24/7 and affect every aspect of their lives. Even though she knows he is working 8-12 hours a day at least five days a week on second shift, she sometimes can't help herself and becomes resentful of him because she must provide single-parent care (ie, constant care, a state many in KA experience daily, I know, as I know we have our fair share of single parents here) for at least those 5 days; as their son grows older and heavier, it becomes harder and harder for her to take care of him, play with him, etc. She has her mother and father there helping out a great deal, but unfortunately, her family has some big issues of its own that is putting an enormous amount of stress on my ex over and above her own stressful situation. It is just a terrible, terrible situation, trust me. And it was all brought into being because my friend was "downsized" and there are so few retail job openings for someone with managerial experience and a great work record that he has been forced to take whatever he could to survive.

Which brings us full circle back to the original point: By doing the right thing and busting his a** at a $10/hour job--at which he has already been shot at once, BTW--he moves his family well above the poverty line at which people can receive access to healthcare and other social services programs. Honestly, it would be better for the three of them if he quit his job and, at least temporarily, lived off the various government housing and healthcare programs, among others. They could probably all live together here in the States in subsidized housing, something that would no doubt reduce the terrible tension in their relationship. However, like many here and throughout every country in the world, he is a proud, able-bodied man in his 30s who wants to work and who prides himself on his strong work ethic; the idea of living on welfare is simply anathema to him and something he cannot bring himself to do as long as he can find A job of almost any kind that at least pays enough to provide the basic essentials for his family.

But wait! I know some of you must be saying, "Hey, you mentioned your ex is Canadian and is once again living in Canada--doesn't she now requalify for the wonderful Canadian system we hear so much about?" Well, yes and no. Because her son was born to a Canadian and a U.S. citizen (in the States), he has dual citizenship and can receive coverage in Canada. She thought that all she had to do to reinstate her OHIP coverage in Ontario was visit the proper provincial government offices and re-establish her residency in Canada, and in a way that was true. She had filled out all the paper work and was ready to turn it in, but when she did, the government employee told her, "OK, all I need now is your green card--to receive your Canadian benefits once again, you have to relinquish your green card." WTH? The only reason the employee even knew she had a green card was because it had come up in casual conversation as she did the paperwork--she had no way of knowing that information was dangerous! Of course she did not turn in her papers that day, as she had to think about this enormous decision. It didn't take her long to realize that once all things were taken into account, she simply could NOT lose her green card. For starters, once the economy is better and her guy gets a better job (it WILL happen, I pray every night for that), they fully intend to live in the States again. FYI, she is doing nothing illegal by keeping the green card she earned by marrying me, either. We were married for more than 12 years, which is long enough for her to even remain in the States living on her own after the divorce, even if she had never met her current fiance and never had a child. (What I'm saying here is that by giving birth to a child in the U.S.--a child that is automatically a U.S. citizen for being born on U.S. soil--and ultimately marrying another U.S. citizen, she would have had those new ways to "re-qualify" for her green card very soon after our divorce. However, immigration law is such that she did not need ANY of that stuff to happen to stay here at least until the current 10- or 12-year period on her green card wore out. At least I think that is the time period, although there is a chance she is actually at the point where she was here and married to me long enough to qualify for a lifetime green card--either way, she it was totally ok for her to stay over here if wanted. I just wanted to be very clear on a point that maybe wasn't apparent from my original statement.)

Above and beyond wanting to live here again in the future, there is the simple fact that having the card makes it much easier for her to go back and forth between the U.S. and Canada so she can spend some time with her ex and son over here (although most weekends, he goes over there). It's easier to cross the border, and she doesn't have to worry about being pulled at the border to face tough questions about how long she was in the U.S., did she have any receipts to prove how long she was there, etc. Bottom line, the green card is far too valuable for her to give up, too high a price to pay for even something as important as the healthcare coverage she needs desperately. Thus, thanks to this horrible economy, she faces this unbelievably difficult decision--go for the short-term gain of giving up the card so she can receive the low or no-cost healthcare that she desperately needs, or do the smarter long-term thing and keep the card so that it will be easy for the three of them to live together as a family again once things do settle down. Quite a price to pay for keeping the card, no? Luckily, by living in Canada, she has at least received assistance from the Canadian division of the company that makes her insulin pump, as they provide her with a decent quarterly stipend with which she can pay for her insulin and her test strips and pump equipment (which must be changed regularly and is quite expensive--I know because I was paying for that equipment in the months since we've been divorced because I told her I would ALWAYS provide as much help as I could for her, her fiancee [because he is my good friend now too--it's odd, I know! ]--and their son when it came to medicine or other health needs, which I still do).

Oh, I also said earlier I would revisit her unemployment status due to her health issues. Despite being in enormous pain every day due to her DDD, and despite her sometimes wildly unpredictable adult-onset Type 1 diabetes that has landed her in the hospital several times even though she monitors her sugar religiously, she did apply for and land a job working at a Tim Horton's in her hometown. She never would have even received an application to fill out if not for the fact that her mother used to work at that Tim Horton's and was friendly with the shop's owners. She managed to keep the job for about four months--never calling in sick once--until a few months ago when she was hit by a very mysterious, and very serious, infection that nearly killed her twice. This infection wreaked havoc on her entire immune system and caused nearly crippling pain throughout much of her body, but even worse was the fact that just about every infection can cause a diabetics sugar to suddenly go completely haywire and either skyrocket into the 600s (seriously) or plummet to 40 or lower; sometimes, the high and low would happen on the same day! The first time this hit, she asked her mother to take her to the hospital, but her mom told her she was positive that it was only the flu or a bad cold and there was no reason for her to go to the hospital. Finally, almost 24 hours later, she convinced her mother that something very serious was wrong and she did go to the ER. There, she had confirmed what she already knew, which is that she was deep into ketoacidosis. Ketoacidosis occurs when the body does not have enough insulin and it begins breaking down fat to get the energy it needs. If there is no fat left, the body turns to muscles, etc. and begins breaking those down. Once the body begins breaking down fat, large numbers of ketones are produce, which can quickly cause a diabetic coma and even death. When my ex reaches the ER that night, her doctor quickly diagnosed the problem and took steps to stabilize her. Once that was accomplished, she told my ex that if she had waited just two more hours to come to the hospital, it was almost certain she would have been dead--it was THAT serious.

Anyhow, she spent several days in the ICU following that infection and keroacidosis and had to take huge doses of antibiotics at home once she was discharged (luckily they were available in generic and very cheap). Eventually she appeared to fight off the infection, which doctors never were able to pin down and assign a name or cause--frankly, they were baffled by the symptoms she displayed and just how this infection was acting in her body. When she felt better, she returned to work as soon as she felt strong enough. It should be noted that this was after her family doctor, who she saw as part of her hospital after-care, told her that he would never approve of her returning to work and would never write her a note for that purpose--in his mind, her diabetes was simply far to serious and unpredictable, especially combined with the possibility that this unknown infection could return at any time, since nobody had ANY idea what it was or how she got it. I can add that she has a long history of constantly coming down with UTIs, sinus infections, ear infections, and other "common" infections. (Basically, her health greatly deteriorated just a few years into our marriage, which is when this woman who had been physically extremely health her whole life suddenly saw her immune system seemingly go to he** in a hand-basket. She saw a rheumatologist and many other specialists connected to immune system disorders in one way or another, and not one of them ever came up with any kind of diagnosis (well, she did learn about her DDD then, which at least provided her with a real explanation for her horrible back pain, not to mention total vindication for all the doctors who told her that x-rays showed her back was fine and all her family members who thought she was acting and whining). When the Type 1 diabetes finally manifested itself several years after her immune system started acting up, her doctors were content to say that all her earlier problems had been her body working its way toward this full-blown diabetes, and for a while, she believed they might have been 100 percent right. It was only after she continued to get regular infections and then suffered this incredibly dangerous body-wide mystery infection that she realized that she still had no real idea why her immune system went nuts in the first place and that the diabetes was just another result of some bigger problem that was still undetected (and remains so today).

Just as she and I both feared, the infection that put her near death returned only a few weeks after she went back to Tim Horton's. (Please NOTE: This is NOT in any way an indictment of Tim Horton's, nor am I stating or implying that it was her work in that store that caused her infection and near-death experience; in fact, the store owners and everyone else at her store treated her with absolute respect and great concern for her well-being, not to mention they never threatened to fire or reassign her. Heck, after the first incident, the owners moved her to their second store where a position was available that would be less physically demanding and give her a better schedule to take care of and be with her son.) This time, she was ready for it and knew exactly what symptoms to watch for; the minute the first one hit, she was off to the hospital (no problem convincing mom this time!) and onto IV antibiotics. Her quick action meant she only spent one night/day in the ICU that time and only a few days in the hospital in total, plus she recovered at home much more quickly and did not require a few weeks to rebuild her energy levels. Still, as a result of this second incident happening almost immediately after she returned to work, she knew that she would have to give up that job and do what her family doctor had suggested. Not only had he told her he would not approve her return to Tim Horton's, he also told her that she really should not attempt to work at all, as it was simply too hard on her body at this point in her life.

Thus, she cannot work any more even if a job was available. She would love to apply for disability in Canada, but applying for that would undoubtedly mean giving up the ol' green card again, and we already covered that ground. She is trying to find some freelance work she can do from home, which would involve work from the publishing company we both used to work for, and at least one lead there looks promising. Hopefully, she can find some work of this type and thus bring in some money.

Sorry this covered so much--I originally just intended to make a very quick point about how I agree with Chris regarding the whole "oops, you make too MUCH money to qualify for, well, anything!" post because I had already told the story of my friend who is experiencing the exact same catch-22. However, as I made that point, I realized that there were many other things that had happened recently that might be of interest to others, so I dived into those things as well. The result is this unintentionally loonnngggg post. Hope it has some info that benefits at least one person here!

Brad

Morning Dow!

Healthcare reform has been a platform for officials of every level for as long as I can remember.

I do understand that "we" won't have an opportunity to vote on this, and the workings of our political system. And I am not calling out any one party or group. Democrat or Republican we have all had a bite at the apples and we have all had our success and failure.

As I stated I amnot against a government run heallthcare, as long as it can be run fairly across all boundaries and in the black without huge taxes upon people that are already taxed to the hilt. What bothers me with the route this bill(s) is taking is that they, our elected officials, are trying to rush something through to show that they made a change regardless of the cost in dollars, and more importantly quality of care. SLOW DOWN!! Lay a solid proven ground work to build on. If it doesn't happen during Obama's tenure it can carry on to the next administration. We are talking about peoples healthcare, their lives, not killing snakes. There are countries that have already made the mistakes, and are finally making it better, ie Canada and England. Look at their systems, quit playing the Almighty USA and ask our neighbors for some input so that we don't fall into the same holes that they did getting their system up and running.

We have the Medicare system already in place. Far be it from perfect or financially sound. Can it be restructured to fit the needs of all people, or is there a need to re invent the wheel?

Quote:

---

Curious to know, Chris, more about which one (or all) of my thoughts you disagree on?

---

I was merely disagreeing in general from standing in my republican shoes, that I am to be feared, that I am against reform from the democratic party, or that I have waved my health insurance policy over someone less fortunate.

As for mistrust or lack of trust in the government to pull this off? I don't know. I guess it depends on whether you watch CNN or Fox.. Do I have mistrust or lack of trust, Sure I do. Just as we all do, or else we wouldn't be having this discussion or have a vote to change the powers that be in Washington or any level. Do I want to see healthcare reform fail? Heck No! It directly effects me and my future accessibility to healthcare.

This is and has been a political hot potato for years. And yes we have to be somewhat political in discussing it. After all we are talking about politicians!!

A little good back and forth doesn't hurt. I just wish that Washington could get along as well as ASKickers..