How To Save Big Money on Prescription Drugs.

If I were King of Medicare.

I am still learning how best to extract useful information from the public-use Medicare Part-D Drug Utilization and Cost files. I view these as experiments of nature worth mining for what they can tell us about the clinical and business aspects of healthcare.  The last few articles I have written focused on the utilization and cost of Insulin, highlighting the seemingly unjustified increases in this life-saving drug for diabetics.  In this tweak, I learn how to combine data from drugs in the same therapeutic category including all the brand and generic versions of individual drugs within categories. I am still wrestling with technical issues related to presenting multiple groups in a single TreeMap visualization, but as an example, I will show that in 2015 three groups of drugs– insulin, opioids, and drugs used to treat Hepatitis-C–  cost the Medicare program 17.6% of the total cost of all Part-D drugs but comprised only 7.2% of all prescriptions.  These drugs were expensive for different reasons that I will illustrate.

I particularly like the TreeMap data-visualization format because it allows hundreds if not thousands of drugs to be compared at the same time and facilitates identification of unexpected or unjustified outliers much easier.  Since Medicare is now standardizing the formats of these drug files, changes in utilization and cost can be tracked over several years.  I believe that placing such analyses into the service of policy makers and payers can allow savings of billions of dollars without compromise of care. Continue reading “How To Save Big Money on Prescription Drugs.”

Our Unregulated Militia Is Killing Our Children.

Special interest  or public health issue?
I cannot conceive that any health professional would consider the incidence of death and injury from firearms as other than a public health issue. Surely the absolute numbers of people killed or injured (in excess of 100,000 per year); whether self-induced or by others; by accident or on purpose places the matter squarely before us on a regular basis no matter where we live. This uninterrupted endemic parade of victims is punctuated by epidemic outbreaks in crowded places like schools or workplaces.  There are carriers of this disease in all 50 states. No cure has emerged for this essentially American pandemic. The most recent outbreak which stimulated me to write this article occurred last month in Florida at the Marjory Stoneman Douglas High School in Parkland where 17 students were killed by another student, and 17 others wounded by an AR-15 military machine gun– a.k.a. assault rifle. The damage caused by this gun unnerves even hardened professionals.

Unlike most other epidemics of disease, reliable information about how to prevent non-military people from death-by-bullet is scarce because of a bizarre broad governmental prohibition to even study the matter. The self-censorship is deafening in a recent 476-page report from the U.S. Department of Health and Human Services.  It is titled, “Health, United States, 2016” but the words “gun” or “firearm” are not to be found in it. Disturbingly, it remains unclear that any meaningful national attempts to control this epidemic will be made or even that individual states will be permitted to do so.   Undeterred, advocacy groups are increasingly demanding that immediate and definitive action be taken to protect themselves and the rest of us.

Our young adults step forward.
Last Monday evening, I unexpectedly met a group of students from St. Francis High School here in Louisville who had come out for a program of Kentucky to the World to hear Nobel Laureate and scientist Phillip Sharp talk about the value of education for individuals and our communities. In chatting with the students, I learned that they were planning to participate in the National School Walkout to protest against gun violence and to demand gun control. I was touched by their commitment, and as a father of former students of St. Francis how could I not stand with them? Continue reading “Our Unregulated Militia Is Killing Our Children.”

Updated Look at the Rapidly Rising Cost of Insulin in Medicare Part-D Program.

The cost of Insulin to the Medicare program is frankly staggering. In brief summary, insulin is not only one of the most important drugs for beneficiaries, but also, in aggregate, one of the most expensive set of drugs used by Medicare patients.

I want to use this post to explore enhancements to Medicare’s Part-D drug utilization-and-cost files using Insulin as an example.  I have previously dissected the public use files released by the Centers for Medicare and Medicaid Services (CMS) to explore a number of health policy issues.  These included utilization and cost of medical services by hospitals and other providers; quality and safety issues related to hospitals; the overall monstrous rises in prices of generic and other drugs; and prescribing patterns of opioids by individual practitioners. Other analyses examined insulin utilization and cost for Medicare and Medicaid beneficiaries. The rapid (and large) increases in the price of insulin are exemplars of the gut-punch impact of drug prices on individuals and our healthcare system.  Drug companies have diabetics and their public and private payers over a barrel.  Large numbers of patients with diabetes need the drug to keep them healthy if not alive.  In mid-2016, CMS updated and standardized their Medicare Part-D databases making them comparable for the three initial calendar years of 2013 through 2015.  I took this opportunity to take another look at Insulin.   Although only some 70% of all Medicare beneficiaries are enrolled in Part-D Drug benefit programs, I suggest that prescribing patterns to these Medicare beneficiaries are not very different than those for non-Medicare adult patients and can be generalized.  To make the initial data available to some new colleagues and simply just to get a start somewhere, I placed my first peeks into the enhanced Medicare databases on my Tableau Public Site in three sets of interactive tables and visualizations individually for 20132014, and 2015. Continue reading “Updated Look at the Rapidly Rising Cost of Insulin in Medicare Part-D Program.”

More Expensive Medical Services or Products Does Not Equate To Better.

I have been writing articles for this health policy blog since 2009– almost all of the 390 posts since 2011. Of them, the one most frequently accessed by the public is a 2012 article titled “Horse Liniment for Your Arthritis and Healthcare Reform.”  I encourage you to read it also, because it provides my background for this article, and explains why I write a lot about how pharmaceutical companies – with the active consent of our elected government officials – are gouging the public. The earlier article caught my attention because of a tiny advertisement in the Courier-Journal notifying me that an “arthritis pain mystery” had been solved and that the secret was horse liniment. In my studied professional opinion, the claims were vastly overblown and that in any event, the “secret” was not a secret at all. The ingredients in the horse liniment were available in a variety of over-the-counter joint-rub-ons at a fraction of the cost of the “miracle” liniment offered for sale. I lament the fact that the public at large could be motivated to part with their money in such a way, but alas, physicians are equally as vulnerable to bamboozlement by the traditional pharmaceutical industry– think OxyContin. Sadly, the marketing approaches I wrote about in 2012 are still alive and well. Such advertisements in the Courier-Journal are now bigger and more numerous than ever.  A recent such sparked today’s article. Continue reading “More Expensive Medical Services or Products Does Not Equate To Better.”

City Air Makes You Free. A Public Health Case for Sanctuary Cities.

The following is extracted (with permission) from an article first published in

In the printed edition of the Courier-Journal on January 25, a letter-writer contributed the following:

‘Dignity of Labor’ to get healthcare is wrong.
According to your report of Jan/ 13, Gov. Bevin wants to change Medicaid requirements to enable the “able bodied” poor to learn the “dignity of labor.” It was a teaching of the Nazis that “Arbeit macht frei.”  The similarity between these two simplistic positions is too dangerous to ignore.  Stephen Schuster, Louisville.

Based on reflection over the past two years, I do not deem Mr. Schuster’s reaction to be overblown.  I submitted my own letter in response, but it appears that it was not accepted. Having my own “barrel of ink,” I publish it below.

Dear Courier Journal.
A recent correspondent to these letters drew uncomfortable attention to a similarity of phrasing used by Gov. Matthew Bevin and the German Nazis.  To obscure an ultimate goal of decreasing Medicaid enrollment, he and other governors would require “able-bodied” beneficiaries to either work or provide compulsory volunteerism [an oxymoron?] under the dissembling cover of gifting the poor with the ability to learn “the dignity of labor.”  Mr. Schuster and I were both reminded of the phrase Arbeit macht frei (Work sets you free) posted by the Nazis at the entrances to their Arbeitslager (labor camps) which evolved into the death camps of Europe.

A much older German phrase entered my mind as President Trump and his acolytes scold and sue cities like Louisville for protecting their inhabitants born under other suns.  Stadtluft macht frei  (City air makes you free.) expresses a centuries-old common law concept of medieval Europe whereby slaves, serfs, or peasants who entered a self-governing city were protected against involuntary repatriation to the rural countryside or servitude by their owners or landlords.  Remaining in such a city for a defined period ruptured the physical and economic bondage of structural rural poverty. Those so sheltered could become Bürger, or citizens.  Cities were places of opportunity!  The concept of a path to citizenship in a sanctuary city has a long and honorable history.

In the late 19th century, the abstraction of Stadtluft was still being used to summarize the motivation of rural Germans wishing to escape the tyranny of their birthplace, their legitimacy, their institutionalized poverty, or limits imposed on their occupations and ability to make a living.  I am proud of the leadership in Louisville and similar cities which protects those living in their jurisdiction against the unleashing of the most ignoble of nationalistic urges.  Louisville should not reopen its workhouse of the early 20th century.

Peter Hasselbacher
29 January 2018

I take the liberty of reposting this larger part of my other article in this health policy blog because I believe it is relevant.  Individuals who in the current climate of immigration stings and deportation may be justifiably afraid to respond to demands of “show me your papers,” will correspondingly  be much less likely to seek medical care when they are sick.  This is not good for anyone!  As a people, we are no healthier than the sickest among us– regardless of place of birth.

KentuckyOne Health Has Already Sold Most of Its Real-estate Assets in Louisville.

KentuckyOne’s two acute care hospitals and its business operations in Louisville still remain on the sales block.

Soon after I clicked the button to publish last week’s update on the status of the sale of Catholic Health Initiative’s assets in Louisville, I was told by an anonymous reader that a group of capital investors was the last of potential buyers still in the game. Perhaps naively I have been assuming that only other hospital systems would be interested in acquiring the clinical operations of  Catholic Health Initiatives (CHI)/ KentuckyOne Health in Louisville. I was aware that at least parts of one of the doctors office buildings next to downtown Jewish Hospital had been transferred to a new landlord.  A quick look at the Jefferson County Property Valuation Administrator’s (PVA) website and a bit of Internet research revealed much more.  Beginning in 2015 and finishing in the spring of 2016, CHI sold all of its local medical office buildings and outpatient medical centers (of which I am aware) to a single, investor-owned, national real-estate investment trust (REIT) – Physicians Realty Trust and Physicians Realty L. P.  (Nasdaq- DOC).  I must be the last person in Louisville who knew the extent of these real-estate sales.   This third-party owner is now necessarily a major player in planning the future of not only the downtown medical Center, but the healthcare infrastructure of the Jefferson County region. The rents must flow! Continue reading “KentuckyOne Health Has Already Sold Most of Its Real-estate Assets in Louisville.”

The Search For A New President of UofL Must Be More Open.

The University of Louisville is trying hard to recover from what can arguably be considered its darkest hours.  It has, and is still weathering challenges to its accreditation at several levels.  It has been turned upside down by a string of scandals that may yet lead to criminal charges.  All of this has been well-reported publicly resulting in a community consensus that a lack of transparency and accountability at the highest administrative and governance levels allowed corrupt and abusive practices to fester for years.  Where there should have been openness, there was deliberate obfuscation.  It is against this background that the UofL’s Board of Trustees seeks to appoint a new President of the University using a process that could not be more opaque.  Faculty members, some administrators, and students who have the most skin in the game are openly critical.  I am too.

The descriptors ‘open’ or ‘closed’ in reference to such a search are by themselves poorly defined. However, the recruitment process selected by the Trustees would deliver us as Deus ex machina, a new president to solve our problems, but one who would not be named until after they were appointed.  Such a process meets my definition of ‘secret.’  More of the same is the last thing we need.  The Board is increasingly being criticized for its retreat into opaqueness generally.  Its meetings are carefully scripted and I have yet personally to hear a substantive discussion publicly.  I must conclude, as I have in the past, that all major discussions or decisions occur behind closed doors.  Perversely, even those Trustee representatives of faculty, staff, and students are prohibited from sharing information with their own respective constituencies – or for that matter even sharing their own opinions publically. The assumption of this posture by the Board beggars the concept of shared governance. Continue reading “The Search For A New President of UofL Must Be More Open.”

How Close Really Is KentuckyOne Health To Selling Its Louisville Assets?

Catholic Health Initiatives (CHI) just published its financial report for the first quarter of Fiscal Year 2018– the three months ending Sept 31, 2017.  One initial media report led with what CHI would no doubt wish to emphasize, that the company has cut its “quarterly operating loss by more than half.”  The actual reported system-wide loss from operations in Q1-FY2018 was $77.9 million compared to a loss of $180.7 million in Q1-FY2017. This change is being attributed chiefly to more efficient purchasing and to decreased labor costs.  Indeed, CHI reported a decrease of 2,667 full-time-equivalent employees over the quarter.  Whether such cuts are healthy for the company in the long run remains to be seen.  I await more expert financial analysis than I am able to offer and to see how the financial markets or potential new partners or asset-purchasers react.  It appears these latter are not being hasty.  As I plow through the numbers, I see many other measures going in what appear to me to be the wrong directions.

The report gives special attention to what has been going on here in Kentucky.  [I extracted all mentions of Louisville or Kentucky from the 61-page report into a separate document available here.]  The percent of operating revenues contributed from the Kentucky Region was 7.5% this last quarter compared with 16.2% in 2013. This represents a drop from 2d place to 5th place among the 11 or 12 regions or operational segments.  Perhaps the most newsworthy item is the first notice of which I am aware that the anticipated (hoped for?) date for a closing on the sale of CHI’s KentuckyOne Health facilities in Louisville has been put off six months to June 30, 2018.  A reasonable person might conclude that KentuckyOne is having a difficult time finding a motivated buyer for its hospitals, outpatient medical centers, and physician practices here in Louisville.  I am not surprised. The return of control of University of Louisville Hospital to the University has not improved the financial performance of Jewish/Sts Mary & Elizabeth Hospitals.  With respect to apparently continuing discussions between CHI and Dignity Health to align their activities, the report uses the same language it did at the beginning of this year.  No substantive indication is given as to how things are going.  Although some media reports use the word “merger” to describe the process, that word seems to be carefully omitted in accounts by CHI itself. Continue reading “How Close Really Is KentuckyOne Health To Selling Its Louisville Assets?”

University of Louisville Hospital Pledges To Do Better.

I was both pleased and proud to read yesterday’s letter in the Courier-Journal by Ken Marshall, President of University of Louisville Hospital, recommitting to a higher quality of medical care for our community, including its most vulnerable citizens. Alas, under the clinical and management captivity by Catholic Health Initiatives and KentuckyOne Health, the hospital has performed unfavorably in virtually every quality-comparison with other hospitals, including other teaching and safety-net hospitals. Indeed, major layoffs of clinical and support staff by KentuckyOne, and concerns about quality of care by some staff physicians drew Federal attention that threatened the Hospital’s accreditation.

Various of the many items measured and methodologies used by the numerous evaluating entities have been criticized, and in my opinion sometimes rightly so. After all, what constitutes quality? One major criticism of current federal and proprietary hospital quality assments is that they do not adequately take into consideration the socio-economic status or severity of illness in the patient populations served. With all the valid current emphasis on the nonmedical determinants of health care status and outcomes, how can we not take these into consideration? Nevertheless, for University Hospital there is nowhere to go but up. Continue reading “University of Louisville Hospital Pledges To Do Better.”

VA Declares Brownsboro Site The Final Choice For New Hospital.

Is this the last word?

The Record of Decision dated May 30, 2017 and signed by the Secretary of the U.S. Department of Veterans Affairs on October 12 makes it sound like an easy decision. The 23-page document contains only three words or phrases in the text highlighted by the VA to draw attention to the central logic of the decision.

Page 1. “The purpose of the proposed project is to provide Louisville area Veterans with facilities of sufficient capability (functional) and capacity to meet their current and projected future health care needs.”

“The proposed project is needed because the current hospital and CBOCs [outpatient clinics] are operating at maximum capacity and are unable to accommodate the projected increase in the regional Veteran population. The configuration and condition of the existing 63•year-old Louisville VAMC facility offers limited options to expand to meet these needs, and parking at the Zorn Avenue VAMC is insufficient.”

Page 7. “For these reasons, VA does not view the general locations or sites suggested in public comments as reasonable alternatives warranting additional investigation and detailed evaluation in the EIS [Environmental Impact Statement]. Chapter 2 of the Final EIS includes a detailed description of the site selection process, as well as the reasons for eliminating the Fegenbush and Downtown sites, and for not reconfiguring the existing VAMC on Zorn Avenue.”

It has not been a straight path! Continue reading “VA Declares Brownsboro Site The Final Choice For New Hospital.”