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Archive for May, 2010

Little-known issues considered by Washington Legislature become or remain Law: Who Benefits? Part 2

Another piece of 2010 legislation that is destined to affect the  pocketbooks of consumers was a measure backed by the Washington State Medical Association to allow doctors to engage in “balance billing. ” This practice now banned in 47 states for insurance plans’  in-network providers, and for the entire Medicare program. Balance billing  refers to charging patients for the difference between the  dollar amount that a physician or other provider bills for a service, and the amount that an insurance company is willing to pay. Despite the fact that both parties, i.e. providers and insurers ,may have negotiated an agreed amount per service, some providers persist in billing the patient for the remaining balance above the contracted price. According to the recent report Unexpected Charges: What States Are Doing about Balance Billing,–prepared for the California HealthCare Foundation by Georgetown University’s Health Policy Institute, and the National Academy for State Health Policy –laws to regulate balance billing began focusing on managed care plans, and increasingly extended the scope of consumer protections to HMOs and also PPOs.

Balance billing can bankrupt insured patient families, as the Kaiser Health News reported early this year:

The Price They Paid :How a Virginia family got permission to get out-of-network treatment for one son’s heart defect, and still ended up drowning in debt.

Other major media reports on the topic included 2008 articles in Business Week and the Wall Street Journal. A blog piece and companion article in were just published  April 30 in the New York Times, describing the controversial and often illegal practice of balance billing. A Medical Bill You May Not Have to Pay links to the article on troubleshooting one’s medical bills, and also discusses the additional problem that the new federal health care reform law does not directly remedy unfair business practices like balance billing.

There seems to be limited information available in the public domain about the lobbying efforts that went into the success in blocking the proposed ban on balance billing in Washington.  The legislative analysis section of the Washington State Medical Association‘s website is restricted to members only. A brief legislative report on the topic is available on the site of the Washington Association of Health Underwriters:

House Kills Controversial Measure Regarding Coverage for Emergency Health Care Services. The House Ways and Means Committee has killed HB 2779—a measure that was intended to clarify the circumstances involving coverage for the delivery of health care services by non-participating providers, and to prevent balance billing. The bill was killed when it was not brought to a vote before the cut-off for committee action. The measure was introduced by Rep. Eileen Cody, Chair of the House Health Care & Wellness Committee. Rep. Cody argued that consumers need to be protected from balance billing by non-participating providers. The Washington State Medical Association, together with the Washington State Hospital Association and the American College of Emergency Physicians testified in opposition to the measure. The WSMA hired former Insurance Commissioner Deborah Senn to testify in opposition to the bill. Opponents argued that the bill amounts to price-fixing, and damages Washington health care providers who are already paid less than providers in other states under Medicare. A companion bill in the Senate—SB 6400—was also killed in committee when it was not brought to a vote before the cut-off for action

It is of note that  banning balance billing at the very least for emergency care, is considered best practice, as patients need to be able to receive care based on proximity. And in the case of accidents, patients are brought to a facility by first responders. It should go without saying that ER patients, even if conscious, certainly cannot  be expected to interview the members of a facility’s medical team to determine if all of them participate in the network of a patient’s insurance plan. Even for planned surgeries, it is usually impossible for patients to learn whether or not all providers who will be involved in every step of the procedure, belong to the patient’s insurance network.

The  defeat of  this Washington legislation was hailed at the national level by the American Medical Association:

Physicians’ right to balance bill protected in Washington State,  AMA Advocacy News, March 22, 2010.
The Washington State Medical Association (WSMA) achieved an impressive legislative victory this month. WSMA defeated three bills (H.B. 2779, S.B. 6400 and S.B. 6532) that would have prohibited physicians’ right to balance bill. The AMA worked with WSMA for several months on the balance billing issue and will continue to work with WSMA and others to defeat similar proposals this year and in 2011

Conclusion:  Parts 1 & 2

What do the developments discussed these two posts mean for Washingtonians? For starters, we need to learn more about these issues, do the necessary opposition research, and take action to make sure that access to care is genuine.

Regarding medical innovations, without access they are meaningless.  And whether it’s providers or insurers who are not playing fair with medical bills, they must be held accountable, with genuine regulation. We need to get hard data on whether Washingtonians are benefiting from the treatment advances developed in our state; the same holds true here and nationwide for all R&D supported by us via federal and other public funding.  We know that Big Biopharma’s lobbying efforts on the biologics pathway got their desired results from Congress in healthcare reform; the states are targets too.   If anyone still is wondering what’s next, headlines like the following are strong indications of what’s in store, unless popular efforts can restore the political will to do what’s right :

Gaps in insurance policies make oral drugs too pricey for some cancer patients

Despite the somewhat misleading title attributing the access problem just to insufficient insurance coverage, the article goes on to discuss the cost problem and how industry justifies the exorbitant prices.

Another new item of note is this one ,written after the approval last week of  a prostate cancer vaccine whose medical value may still be uncertain, developed by Seattle biotech company Dendreon:

Provenge, a New $93K Cancer Drug, Will Be Extremely Effective — on Taxpayers

This is one reason the price of Provenge was set so much higher than analysts expected: Dendreon knew that patients were covered mostly by Medicare and not private insurance, and that the government’s own rules prevent Medicare from negotiating prices.

’nuff said.

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Little-known measures passed by Washington Legislature now Law: Who Benefits? Part 1

The 2010 Washington State Legislature adjourned on April 12, after the special session called by the Governor to work on budgetary issues still pending at the end of this year’s regular short session. The arduous session focused primarily on filling the gaps created by this year’s $2.8 billion budget shortfall, coming on the heels of the $9B state deficit of last year.  In the realm of health and human services, most state-level advocacy attention naturally was devoted to preservation of the basics and safety net services, and monitoring developments with the federal health care reform legislation. But some bills that became law received limited public attention, including those which can directly impact Washington’s goal of access to affordable and appropriate health care for all by 2012 , and for all children by 2010.

While the  language of SESSB 6143, said that it was about Modifying excise tax laws to preserve funding for public schools, colleges, and universities, as well as other public systems essential for the safety, health, and security of all Washingtonians, in it’s final version,  Section 1101 , subsections 2a & 2b, contain an exemption from the temporary Business & Occupation tax surcharge for hospitals and institutions engaged in scientific research and development. For readers who are not Washingtonians, this temporary fix was proposed to help fill the dire budget shortfall, because our state does not have an income tax  and relies heavily on sales tax revenues — now greatly diminished– to fund services.

While the bill was being considered, the Seattle Times reported only that

It would increase from 1.5 to 1.8 percent the B&O tax paid by service businesses, with exemptions for hospitals and research and development. A tax credit for small businesses would be doubled.

Meanwhile, GenomeWebNews ran a feature story entitled Non-Profits, Investors Worry About Proposed Washington State Tax Surcharge Increase, describing how venture capital firms along with many research institutes and spin-off companies, joined forces  in fighting the proposed B&O tax surcharge hike.

After passage, the Times wrote about Why the Legislature ended up relying on ’7-11′ taxes explaining that

Instead, the Legislature passed a $780 million tax package that included more than $250 million in new taxes on candy, mass-market beer, cigarettes, bottled water and soda pop. In other words, the vices of the Average Joe.

GenomeWebNews, to date one of the very few outlets to report details of the outcome of this proposed legislation, described in an April 22 article  Institutes, Companies Exempted from Washington State Tax Surcharge Increase how the thriving biotech  and biomedical sectors got their way:

Chris Rivera, president of the Washington Biotechnology and Biomedical Association, told GenomeWeb Daily News his 460-member organization organized its government affairs council, its Board of Directors, and key life-science organizations to lobby for an exemption to the tax hike.

“Literally within 48 to 72 hours, we mobilized our members in the life science community. And probably within a week to 10 days, we had an exemption,” Rivera said.

In 2008, the Washington life sciences sector is reported to have generated an estimated $6.4 billion in revenue. statewide. On the national scale, the University of Washington is the  #1  public university recipient of federal research funding, and the #2 such recipient of funding from the  National Institutes of Health. According to the state website on the sector, Washington is home to over 190 nonprofit organizations and 594 companies engaged in life sciences research and development, and employs some 14, 300 people. Big institutional names  here include the Fred Hutchinson Cancer Research Center, PATH, the Bill & Melinda Gates Foundation. Seattle BioMedical Research Institute ,WSU,and the Institute for Systems Biology, along with many smaller nonprofits and companies. Many of them will also be found listed as among major recipients of taxpayer funding, Washington was said to rank 7th among all states as a recipient of NIH funding, having received a total of $755 million in 2008.

The high tech sector has been receiving  state tax breaks (and from some cities and counties as well) for some time now. Since 1995, per legislation that became RCW 82.63,  there have been state sales tax exemptions for facility construction and purchases of eligible equipment , followed by  later legislation authorizing B & O tax credits for tech R & D expenditures. Entities that utilize benefits of these programs must report details annually to the WA State Legislature. The Descriptive Statistics for Tax Incentive Programs  2009 Report for calendar year 2008, published by the state Dept. of Revenue, reveals that dollar value of the sales tax exemptions  for this sector was $122.5 million out of a total  $194.1M  for all participating industries;  and that 481 companies received B&O tax credits that saved them some $22M . The other state tax incentive programs are primarily for the farming and timber sectors. The report explains in detail how the program works, and that

The original law provided the deferral/exemption only for a ten-year period.  In 2004 the
expiration date was extended to January 1, 2015.

Interestingly, at that time (2004) the Seattle Times commented:

.….the industry’s political clout has never been stronger. Along with high-tech lobbyists, the biotech group won a battle in Olympia earlier this year to extend multimillion-dollar tax breaks for the industry to 2015, despite the state’s budget woes.

A March 2010 editorial by local venture capitalist  Robert Nelsen in Xconomy-Seattle, entitled  Olympia: Don’t Crush Biotech With New Taxes. opined that the exemption from the temporary B &O surcharge would cure the problems of both high unemployment and high healthcare costs in Washington, all while improving the national economy.  However, the evidence he offered in support of his belief that that the “wrong” action by state legislators  would be the death of the industry seems pretty thin. In addition to the usual warning that jobs will be lost because companies will locate or, relocate, to locales with more favorable tax laws, the sole examples he offered about how the bioscience  industry reduces healthcare costs were

Pharmaceuticals have long been known to drastically reduce costs. New medications have brought down the cost of treating depression by mitigating the need for hospitalization. Likewise, cholesterol drugs have saved our health system billions of dollars by reducing the need for heart surgery…

If only controlling healthcare costs were so simple. While Nelsen has chosen to give examples only of pharmaceutical remedies, he doesn’t mention the problem of the affordability of so many of the newest medicines, most of which are biologics. Biologics are expected to account  for  50% of all new medicines by 2014, and now cost on average, 22 times more than ordinary drugs. Nelsen’s examples are of  2 types of small -molecule drugs, which also happen to be drugs about which there are concerns about effectiveness and safety.  Readers wanting  to learn more about  treatment for depression, and research on cholesterol-lowering drugs will find Consumer Reports Best Buy Drugs , and the Center for Evidence-Based Policy at OHSU to be helpful resources to get started.

Getting back to the topic of this post, the concept of sharing the pain in these tough fiscal times in order to promote the common good,  seems to have lost out once again.

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