'How to keep people out of the emergency room'

Encouraging immigrants to visit primary care doctors creates a striking decline in costly emergency room use, according to a new study co-authored by an MIT economist.

The findings are from a New York City program that helped arrange medical appointments for undocumented immigrants with limited incomes, from May 2016 to June 2017. Those who received assistance in scheduling visits with primary care physicians experienced a 21 percent drop in emergency department use. For individuals with high-risk medical profiles who received the same help, emergency department use dropped by 42 percent.

Program participants were also far more likely to have screenings for high blood pressure and diabetes, tests that play a significant role in helping to reduce cardiovascular illness.

"This program is fairly low-touch and minimalist, yet it had a meaningful effect," says MIT economist Jonathan Gruber, co-author of a new paper detailing the study's results.

He adds: "It had the biggest impact on those who were the most ill. Lowering the barriers to care for these in-need individuals really pays off in terms of keeping them out of the emergency room."

The paper, "Reducing Frictions in Health Care Access: The ActionHealthNYC Experiment for Undocumented Immigrants," appears in the September issue of the journal American Economic Review: Insights. The co-authors are Adrienne Sabety, an assistant professor in the Department of Health Policy at Stanford University; Gruber, who is the Ford Professor of Economics and head of the Department of Economics at MIT; Jin Yung Bae, a visiting associate professor at New York University's Global School of Public Health; and Rishi Sood, executive director of health care access and policy in the New York City Department of Health and Mental Hygiene.

States and local jurisdictions in the U.S. have a variety of policy approaches regarding undocumented immigrants. A New York City government task force launched in 2014 recommended finding new ways to extend health care access for such residents. To conduct this study, the researchers worked with officials from the New York City Mayor's Office and the Department of Health and Mental Hygiene to design a pilot program drawing on the city's estimated population of 1.1 million undocumented immigrants.

The experiment had more than 2,400 participants, with 1,286 in a treatment group receiving help setting up a primary care appointment. Another 1,142 participants served as a control group, and did not receive the same help. Everyone in the program had a household income no greater than twice the federal poverty line. The program reached people by partnering with community-based groups, using mailings and social media, and buying television and print media ads.

The effect of the program was rapid. In its first three months, 57 percent of people in the treatment group visited a primary care physician, while just 16 percent of people in the control group did the same. Those in the treatment group saw a savings of just over $195 in emergency-visit costs (when not admitted), which rose to over $477 for the higher-risk patients. Federal law requires emergency departments to not turn away patients.

Overall, there was a 33.8 percentage point increase in diabetes screenings and a 45.4 percentage point increase in blood pressure screenings for those in the treatment group -- which, other research shows, leads to a 12 percent mortality reduction. The researchers used hospital data and surveys to measure these outcomes.

The program did this without extending health insurance to anyone. Most visits had a $15 co-pay; many of New York City's public health institutions scale costs to the patient's ability to pay. The aim of the program was to see what difference it would make, insurance aside, to help nudge people to see a doctor in the first place.

"I thought there was a decent chance this program wouldn't have much of an impact," Gruber says. "The fact we could find such a big effect … was surprising to me and I think it illustrates the nonfinancial barriers people are facing to get the care they need, and the role of management [in that]."

Because New York City has an extensive public health network, the researchers note in the paper, the same type of program might not be possible in some other places. And the aggregate health of participants in any such future program might be different, meaning the size of the drop in emergency care use might vary.

Separately, as the authors note in the paper, extending formal health insurance to undocumented immigrants "remains politically untenable" for the most part. On the other hand, jurisdictions might examine if other approaches increase care while, in this case, lowering emergency room traffic.

"There's this tendency with health care to think that if you give people health insurance, you're done," Gruber says. "This study is saying the right system combines insurance as financial protection with other kinds of [tools]." He adds: "There is just huge potential to use data and science to get people to where they need to be in terms of getting the most efficient care."

The institutional review boards in New York City's Department of Health and Mental Hygiene and the National Bureau of Economic Research approved the research protocol. The trial was publicly archived at clinicaltrials.gov. The pilot program was supported by the Robin Hood Foundation, the Rockefeller Foundation, and the Altman Foundation. Sabety received research funding from the National Science Foundation.

Journal Reference:

1. Adrienne Sabety, Jonathan Gruber, Jin Yung Bae, Rishi Sood. Reducing Frictions in Health Care Access: The ActionHealthNYC Experiment for Undocumented Immigrants. American Economic Review: Insights, 2023; 5 (3): 327 DOI: 10.1257/aeri.20220126

https://www.sciencedaily.com/releases/2023/09/230919154849.htm

Next Arms Package For Ukraine Includes More Internationally-Banned Cluster Bombs

 by Dave DeCamp via AntiWar.com,

President Biden's expected new weapons package being announced when Ukrainian President Volodymyr Zelensky visits Washington on Thursday is expected to have more internationally-banned munitions, Reuters reported on Wednesday.

Sources told Reuters that the package will be worth $325 million and is expected to include the second tranche of widely-banned cluster bombs in the form of 155mm artillery shells. The US began providing Ukraine with cluster munitions in July despite their history of killing and maiming civilians.

The cluster munitions the US is providing Ukraine are packed with 72 submunitions, known as bomblets, that are scattered over a large area.

Cluster bombs are so hazardous to civilians because many of the submunitions do not explode on impact, and can be found years or decades later. Due to their indiscriminate nature, cluster bombs are banned by over 100 countries by the Convention on Cluster Munitions, but the US, Ukraine, and Russia are not signatories to the treaty.

A US official also told Reuters that the new weapons package will not include Army Tactical Missile Systems (ATACMS), which can be fired from the HIMARS rocket systems and have a range of up to 190 miles.

ATACMS have been long sought by Ukraine, and recent media reports said they could be soon on their way, but the White House said this week no decision has been made.

Providing ATACMS would mark a significant escalation of US support for Ukraine as they could potentially hit targets inside Russia. When asked earlier this month about Ukraine using ATACMS to target Russian territory, Secretary of State Antony Blinken said targeting decisions are up to Ukraine.

Other weapons expected to be in the new arms package include Avenger short-range air defense systems, HIMARS ammunition, TOW and AT-4 anti-tank weapons, and Javelin anti-tank missiles.

https://www.zerohedge.com/military/next-arms-package-ukraine-include-more-internationally-banned-cluster-bombs

Combatting Fraud, Waste, and Abuse in the Medicare Program

 Chris Jacobs’ September 17 opinion piece in the Wall Street Journal, “Now the Republicans Want to Raid Medicare,” vacillates between complimenting Congress for proposing to take a bite of the apple in implementing a site-neutral payment reform and accusing Republicans of “raiding Medicare.” Which is it?

Policymakers and experts from across the political spectrum, including the Brookings Institution, the Committee for a Responsible Federal Budget, and the Heritage Foundation, support site-neutral payment. Taxpayers should not be on the hook for and Medicare beneficiaries should not receive “doctor’s office care at hospital prices,” as former Louisiana Governor Bobby Jindal and the America First Policy Institute’s Charlie Katebi noted in their Wall Street Journal op-ed. With the Congressional Budget Office estimating net savings of $800 million and the bill codifying price transparency, does Jacobs not support transparent prices and seniors paying less for care?

Jacobs is wrong to accuse Republicans of raiding Medicare to pay for programs created by the Affordable Care Act. The National Health Service Corps has been around since 1970, while federal funding for community health centers dates back to 1965. Politicians of both parties have reauthorized and expanded these programs over the intervening decades, including as part of the ACA.

Perfect policy should not be the enemy of good policy. Cutting wasteful spending in a way that protects patients is a prudent policy. Paying more for the same service just because a different name is on the front door is nonsensical. Doctor’s office care at hospital prices is a bad deal, and Congress is right to correct it.

https://www.aei.org/health-care/combatting-fraud-waste-and-abuse-in-the-medicare-program/

Tackling Hospital Consolidation, a Key Driver of Health Costs

 Consolidation of large hospitals and health systems is on the political and policy radar screens of both Republicans and Democrats, offering a rare opportunity for action in a polarized Congress.

Janet Trautwein, who heads the National Assn. of Benefits and Insurance Professionals, explains how consolidation harms patients in “Healthcare Concentration Is Far From What the Doctor Ordered.”

Ninety percent of the nation’s hospital markets were considered “highly concentrated” in 2017, with many more mergers over the ensuing six years.

Consolidation can cut costs for hospitals, but the savings rarely are passed along to consumers. Hospital prices go up 6 to 20 percent when one merges with or acquires another, Trautwein writes. That leads to higher premiums but not a coincident increase in the quality of care.

The bureaucratization of medicine makes it extremely difficult and risky for physicians to remain in independent practice. Three out of four doctors now are employed by large hospital systems or health plans.

They turn over scheduling, billing, and negotiations with insurers to these conglomerates in exchange for a salary and some support staff.

Medical blogs show how this is decimating physician morale as doctors are forced to see eight or more patients an hour, with the “system” recommending expensive tests like vascular studies and abdominal ultrasounds they don’t necessarily believe are needed. 

And instead of having a nurse on staff to answer patient calls, the calls may be rerouted to call centers overseas or having patients directed to urgent care centers (which the hospital systems often also own).

What to do? There is no silver bullet solution to reform how $4.3 trillion in private and public money is spent on health care every year. But it is important to begin.

Three key House committees have been working all summer to hash out details of an important health reform bill, the “Lower Cost, More Transparency Act.”

The House Energy and Commerce, Ways and Means, and Education and the Workforce committees have negotiated a package that focuses on health care price transparency, site-neutral payments, and extending funding to existing health programs that is set to expire.

Take site-neutral payments, for example. The Energy and Commerce Committee heard testimony earlier this year showing how those battling cancer are hurt by eliminating competition and limiting choices for patients.

Brian Connell of the Leukemia & Lymphoma Society testified about the importance of site neutral drug policies for cancer patients. Today, more than 45% of chemotherapy infusions for Medicare patients are done in higher-cost, hospital-owned centers, squeezing out lower-cost independent physician practices.

Patients suffer when they are forced to pay the higher copays and co-insurance associated with the higher hospital prices.

“Despite the patient going to the same office, being treated by the same staff, and receiving the same medication, the shift in underlying reimbursement—from the lower physician fee schedule to the higher hospital outpatient payment system—increases the patient’s out-of-pocket costs without any corresponding improvement to the quality of their care,” Connell testified.

“Cancer patients shouldn’t pay more simply because the nameplate on the clinic’s front door now says ‘hospital’ rather than ‘physician office.’

“Equalizing payments between these sites of service would weaken the incentive for provider consolidation, which would also produce long-term cost savings across insurance types and give patients additional options for their care,” Connell testified.

There is bi-partisan agreement in Congress and across the ideological spectrum in the think tank community on the problem.

The Third Way, for example, has a new report that explains: “Out-of-control hospital prices are part of a vicious cycle where hospital consolidation drives up prices and subverts the competition needed to keep costs in check. In turn, higher costs undermine the adequacy of Medicare payments to hospitals, which leads more hospitals to consolidate.”

And the Progressive Policy Institute also has launched a new center on Competition Policy to be headed by Dr. Diana Moss, an expert in anti-trust policy whose mission is “to advocate for strong competition enforcement and policy.”

The tri-committee bill was slated to come to the House floor for a vote on Monday night, but it was pulled at the last minute at least partly over a controversy over where the “savings” from site-neutral payments would go. The “site neutral” payment policy would have saved money to pay for several must-fund programs, such as Community Health Centers, graduate medical education, and diabetes care programs.

That was a misguided criticism. Current payment policies are a huge contributor to the consolidation in the hospital industry as they buy up private practices so they can bill more for their services. And the consolidation in turn allows monopolistic hospitals to charge more for many other services because they have bought up the competition.

The House bill begins to address the problem of hospitals billing up to four times more for the same services provided in a doctor’s office simply because it is a hospital. Hospitals, not surprisingly, object to the site-neutral payment provisions.

But that is not a reason to back down. Agreeing that hospital consolidation is a major cost driver that is impacting the entire health system is an important start.

The “Lower Cost, More Transparency Act” includes a number of other provisions, including stronger requirements for price transparency among many care and coverage providers and prescription drugs, and banning gag clauses and addressing hidden fees. The House should bring the bill back to the floor for a vote that would help patients by addressing key cost drivers in the health sector.

Grace-Marie Turner runs the Galen Institute, a non-profit research organization devoted to patient-centered ideas in health care. She can be reached at gracemarie@galen.org 

https://www.realclearhealth.com/blog/2023/09/21/tackling_hospital_consolidation_a_key_driver_of_health_costs_981139.html

Rx Price Controls Mean Hard Choices for Investors

 The Centers for Medicare & Medicaid Services just announced the first 10 drugs that will be subject to Medicare's new price controls. Under the terms of the law that gave Medicare this authority, more drugs will follow each year.

Giving government the power to dictate the price of medicines is unprecedented. Industry is already grappling with the effects this change will have on new drug development -- and it's clear that lawmakers need to enact at least one adjustment to eliminate a distortion they introduced in the development pipeline. 

The good news is that it's an easy fix.

In crafting the legislation, lawmakers saw the need to strike a balance between lower prices for the government and the preservation of incentives for the development of new medicines. If a newly approved drug is subject to price controls before its sales can generate a return, investors will stay away, bringing innovation to a halt. So, lawmakers knew that patented medicines would have to be exempt from price controls for a certain duration of time.

However, in a misguided move, lawmakers arbitrarily offered a lengthier exemption for large-molecule, "biologic" medicines. Specifically, the law affords biologics -- which are created using complex, living organisms -- a 13-year exemption from price controls. It subjects traditional, small-molecule drugs, which are created through the combination of chemical compounds, to price controls after just nine years. 

This distinction dramatically changes the investment calculus for life-science venture capital. 

Drugs that make it to the marketplace typically need years of sales growth before generating a positive return. The upfront cost of developing a medicine is enormous, of course, and even after a drug receives FDA approval, it typically takes the clinical community time to become familiar with its potential application. That’s in addition to ramping up manufacturing and negotiating with insurers to ensure coverage. It's not surprising, then, that around 50% of a drug's cumulative sales occur in years 10 to 13 of availability.

While lawmakers were right to worry that stripping biologics of revenue in those years would wipe out future development prospects, they didn't adequately consider the full effect of a shorter revenue window for small-molecule drugs. For the latter, sales in years 10 to 13 are no less important to recouping upfront investment and paying for all the failures along the way. 

This difference -- what investors are now calling the "small-molecule penalty" -- is motivating biotech investors to favor biologics over small-molecule therapies, even though the medical potential for the latter is brighter than ever.

Small molecule drugs currently make up 75% of all FDA-approved medications, including some modern blockbusters. Several of the first medicines subject to government price controls are small-molecule drugs that have had significant impacts on disease -- including one that helps lower blood-sugar levels for patients with type 2 diabetes and another that inhibits B-cell proliferation to slow the spread of blood cancers. 

It's fair to ask whether their developers would have proceeded with these medicines if they had known that their products would be among the first subject to price controls.

Drug developers can’t simply turn their small-molecule candidates into biologics to take advantage of the new law. The differing chemical properties lead to different therapeutic opportunities. 

For some conditions, the diminutive size and low-molecular weight of small-molecule drugs offers a huge advantage, as they can penetrate cells and reach therapeutic targets more readily. These properties have researchers optimistic about new treatments for brain cancer, Alzheimer's, obesity, osteoporosis, genetic disorders, and even aging itself. (Biologics, by contrast, are particularly good at treating autoimmune conditions like rheumatoid arthritis, multiple sclerosis, and Crohn's disease.)

The shorter revenue window for small-molecule drugs threatens to curtail development into these exciting prospective therapies. Indeed, some biotech firms began to close the door even before CMS made its announcement. In July, Vir Biotechnology shut down its entire small-molecule pipeline, which included plans for a potential cure for multi-respiratory hepatitis B.

Lawmakers shouldn't have put a financial thumb on the scale of the medical and scientific question of which avenues of treatment to develop. They can fix their error by amending the price-control timelines to give both small molecules and biologics a 13-year window to earn a return. That way, investors and developers alike can focus on bringing the best drugs forward, regardless of size. 

John Stanford is executive director of Incubate, a Washington-based coalition of life-science venture capitalists.

https://www.realclearhealth.com/blog/2023/09/21/rx_price_controls_mean_hard_choices_for_investors_981142.html

Zelenskyy to meet with nation's top financiers, diplomats in NYC

 Ukrainian President Volodymyr Zelenskyy on Wednesday is scheduled to meet in New York City with a who's who of the nation's top finance people, business leaders, diplomats and even a chef to discuss how private sector money can be used to help rebuild his war-torn country, FOX Business has learned.

The meeting was put together by JPMorgan, the big bank serving as Zelenskyy’s financial adviser to attract private capital for a new investment fund to rebuild Ukraine’s infrastructure destroyed in its war with Russia, according to people with knowledge of the matter. 

Earlier in the afternoon, Zelenskyy met privately with BlackRock CEO Larry Fink, the sources say. BlackRock is the world’s largest asset manager and has also been advising Zelenskyy on how to attract U.S. private sector money for the rebuilding effort.

The list of invitees, according to sources, includes William Ackman, the head of hedge fund Pershing Square Capital; Ken Griffin of the Citadel investment empire; Jonathan Gray, president and chief operating officer of private equity powerhouse Blackstone; Philipp Hildebrand, a vice chairman at BlackRock; Michael Bloomberg, former New York City mayor and founder of Bloomberg LP; and Eric Schmidt, the former CEO of Google and now head of the Schmidt Futures, a philanthropic organization.

◀︎▶︎

Image 1 of 6

Bill Ackman, CEO and portfolio manager at Pershing Square Capital Management, speaks during the SALT conference in Las Vegas in 2017.  | Reuters

Other invitees include Robert Kraft, owner of the New England Patriots; Dan Lubetzky, founder and executive chairman of snack maker Kind LLC; Henry Kissinger, the renowned diplomat; and celebrity Chef Jose Andres, whose work with the relief organization World Central Kitchen earned him the Ukrainian Order of Merit award from Zelenskyy last year.

◀︎▶︎

Image 1 of 4

New England Patriots owner Robert Kraft reacts before a game against the Las Vegas Raiders at Allegiant Stadium Dec. 18, 2022, in Las Vegas. | Getty Images

The people say the meeting could be called off at the last minute given Zelenskyy’s scheduled meeting in Washington, D.C., with President Biden. It's also unclear if all those on the list have committed to attend.

JPMorgan executives in charge of the meeting didn't respond to a call for comment.

The meeting, which hasn't been publicly announced or reported on, was the brainchild of JPMorgan's Mary Erdoes, who runs the firm's asset and wealth management unit, and Vince La Padula, CEO of the firm's wealth solutions unit. It's scheduled to take place at around 4:30 p.m. ET at the Permanent Mission of Ukraine to the United Nations in midtown Manhattan.

Ukrainian President Volodymyr Zelenskyy addresses the 78th United Nations General Assembly at the U.N. headquarters in New York City Sept. 19, 2023. (Timothy A. Clara/AFP via Getty Images / Getty Images)

On Tuesday, Zelenskyy addressed the U.N. General Assembly, calling on the world body to help his country prevail in its war against Russia, now seen as a stalemate between the two sides. He also discussed a plan to end the war and called on the U.N. to strip Russia of its powers over what he called war crimes against the Ukrainian people in its effort to annex the country.

Zelenskyy is expected to meet with Biden later this week to discuss U.S. aid to the country. The U.S. has given tens of billions of dollars in military and humanitarian assistance to Ukraine since Russia invaded the country in February 2022.

But before he travels to D.C., as expected later Wednesday night, Zelenskyy is scheduled to meet with JPMorgan's bankers and some of the nation's richest people — many of them billionaires — to discuss how private capital could be used to rebuild his country once the fighting ends, or even before, these people say.

Ticker	Security	Last	Change	Change %
JPM	JPMORGAN CHASE & CO.	147.14	-1.16	-0.78%
Powered By

In February, JPMorgan bankers met with Zelenskyy and his senior staff in Ukraine, where they discussed the creation of a fund seeded with $20 billion to $30 billion in private capital, according to people with direct knowledge of the matter.

Other ideas discussed with the Ukrainian president were the creation of a bank administered by Wall Street firms that would make investments in oil refineries, roads, bridges and other economic infrastructure destroyed during the fighting, these people add. 

But bankers have been telling Zelenskyy the war is a significant obstacle in attracting private capital, given the uncertainty it creates. Another obstacle: Ukraine’s long history of corruption. Zelenskyy was said to be receptive to the advice and understood that, at some point, the vast amounts of Western aid to the country will come to an end and that private capital — which will demand a return for its investment — will be needed to rebuild, these people say.

As previously reported, JPMorgan bankers were on the ground in Kyiv and other cities dodging bombs and witnessing firsthand how the war has crippled the country’s economy. As a gesture of goodwill on the eve of the 2023 Super Bowl, the bankers also presented Zelenskyy with a New England Patriots jersey with the number 91 to signify the year Ukraine gained independence from the Soviet Union, these people say.

Kraft's scheduled attendance at Wednesday's planned meeting is interesting because the Patriots owner once claimed Putin stole one of his Super Bowl rings after a private meeting.

https://www.foxbusiness.com/politics/ukraines-zelenskyy-to-meet-with-nations-top-financers-diplomats-in-new-york-city