Is EPO worth the price?


Matt Stroller's post on 4/28
points to recent reports regarding the drug Epogen manufactured by Amgen. Matt's take is pretty well summed up by the post's title "Killing Patients and Bilking Taxpayers" ... I take Epogen - I'm not dead and I do not think I'm ripping off the tax payers.

Matt quotes a study that showed that patients at for profit dialysis providers (80% of all US dialysis treatments are provided by for profit companies) "are given the highest doses" of Epogen, as compared to not for profits. This could indicate the for profits are "gaming" the system or it could indicate that patients at not for profit clinics are getting more/better dialysis. However, Matt links the quote to HR 1193 which does not address Epogen use or reimbursement. One thing at a time ... but the rampant conflating is instructive.

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MedPAC and dialysis payment adequacy

Commenting on my previous post Matt points to MedPAC to dispute my contention that Medicare is not paying its way in the provision of diaysis.

The March 2007
MedPAC report (pdf)
the summary is:
"In summary, most of our payment adequacy indicators are positive. Therefore, the recommendation is to update the composite rate" The final recommendation is to update the Composite Rate by 1.2%. Sounds like payments are about right but there's a catch.

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Dialysis Entitlement - who's "Primary"

Matt Stoller's post April 25th post "Budget Bribery and Medical Costs" includes the statement, "Anyway, Medicare pays for dialysis, which is a good thing." Yes the US dialysis entitlement, the ESRD (End Stage Renal Disease) program in Medicare-speak, is a good thing but it is incorrect to say "Medicare pays for dialysis".

Medicare is the "Primary" insurer for people who already have Medicare - due to age - who then need dialysis. However, half the people who start dialysis each year (about 40,000 of the 80,000 people total who start) are under 63 years of age. For these people, who are not otherwise eligible for Medicare, other insurance is "Primary" for 33 months after starting dialysis (a thirty month clock starts after three months).

Other insurance can be Employer Group Health Plans, Medicaid or other state plans but for someone who is under the age threshold their dialysis is not funded by Medicare until well into the third year of treatment. Under the Bill HR 1191, the waiting period would be extended to 42 months. This extension would save Medicare money - 1 to 2 billion over ten years - but it would increase dialysis provider revenues by much more than the savings seen by Medicare.

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A Backdoor for Medicare gutting?

I was reading the summary of the trustees' report and noticed this under the Medicare heading:

The Act requires that an affirmative determination in two consecutive reports be treated as a "funding warning" for Medicare that would, in turn, require a Presidential proposal to respond to the warning and expedited Congressional consideration of such proposal. The 2007 Report projects that the difference will surpass 45 percent in 2013 and therefore makes a determination of excess general revenue funding. Because the 2006 report also made such a determination, a "Medicare funding warning" is hereby triggered that requires the President to propose legislation that responds to this warning within 15 days of the submission of the Fiscal Year 2009 budget and for Congress to consider the proposal on an expedited basis. This requirement will help call additional attention to Medicare's impact on the Federal budget.

Was this a back door to gutting Medicare assuming a Republican congress?  What exactly does the trigger and the 'expedited basis' mean?  It sure doesn't sound good.  I dug into US code as best I could. I've looked through the

MEDICARE PRESCRIPTION DRUG, IMPROVEMENT, AND MODERNIZATION ACT OF 2003

at http://frwebgate.access.gpo.gov/cgi-bin/ getdoc.cgi?dbname=108_cong_public_laws&a mp;docid=f:publ173.108

With the caveat that I have no legal training it looks like it bakes in Senate and House rule changes to facilitate pushing through a proposal for eliminating excess general revenue medicare funding by limiting debate. This is accomplished through overriding House and Senate rules for the purpose of acting on a Presidential proposal to respond to a "Medicare funding warning". The house and the senate can re-override the rule changes, but the existence of the rules in the bill will make it easier for future congresses to force through changes, be they increased taxes or decreased services. I feel this expediting process needs to be removed as soon as possible. 

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Critical Prescription Drug Vote Expected Tomorrow -- Your Voice Needed

Tomorrow, a Senate vote is expected to try to break a planned filibuster against a bill empowering Medicare to negotiate for lower drug prices. CQ Today reports that Senate leaders are "just short" of the needed 60 votes, and the final outcome remains uncertain.

With the pharmaceutical companies flooding Washington with dishonest ads and an army of lobbyists, if we are to beat back the filibuster, your Senators need to hear your voice now.

Campaign for America's Future has an action page where you can easily write your Senators and tell them, "Side with the people, not the big drug companies."

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Diaries

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