Tag Archives: Health Policy

AMA: Nearly 70% of payer markets ‘highly concentrated’

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http://www.healthcaredive.com/news/ama-nearly-70-of-payer-markets-highly-concentrated/507916/

Dive Brief:

  • A new American Medical Association (AMA) report found that one health insurer has at least a 50% market share in 43% of metropolitan areas. Nearly 90% of markets have at least one insurer with a 30% or greater market share.
  • Anthem, a major Blues payer and one of the largest insurers in the country, had the largest geographic footprint. The payer had the highest market share in 82 metropolitan areas.
  • The report found that 69% of markets are “highly-concentrated.”

Dive Insight:

The AMA study looked at where payer consolidation “may cause anti-competitive harm to consumers and providers of care.”

The authors said market concentration is a “useful indicator of competition and market power” and is an area the U.S. Department of Justice and Federal Trade Commission analyze when evaluating proposed mergers.

The annual report found a further consolidation of markets. The percentage of markets with one dominant insurer increased by 8% over the past two years.

Consolidation of insurers can affect premiums and reimbursements. A recent Health Affairs report found mergers involving hospitals, providers and payers resulted in insurers achieving more bargaining power to reduce provider prices in highly concentrated markets. That report said hospital admission prices were 5% lower in highly consolidated provider and insurer markets compared to those that are not as dense.

The AMA report warned along a similar theme. “We find that the majority of U.S. commercial health insurance markets are highly concentrated. These markets are ripe for the exercise of health insurer market power, which harms consumers and providers of care,” according to the report.

The AMA said major mergers like Anthem-Cigna and Aetna-Humana are reasons why the organization conducts the annual report. Neither merger ultimately happened, but they would have further consolidated the payer market.

The AMA warned about further consolidation. “Our findings should prompt federal and state antitrust authorities to vigorously examine the competitive effects of proposed mergers between health insurers. Given the uncertainty in predicting the competitive effects of consolidation, some mergers that are allowed cause competitive harm,” according to the report.

Anthem’s growing market share comes as the payer is creating policies that attempt to bring down health costs by pushing services away from hospital inpatient settings. Anthem announced this year that it won’t reimburse for emergency department visits deemed unnecessary and will no longer pay for MRIs and CT scans at hospitals in 13 states unless the tests are an emergency.

Given Anthem’s footprint, the payer’s new policies may mean other payers competing in the same markets will follow suit.

How Well Does Insurance Coverage Protect Consumers from Health Care Costs?

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http://www.commonwealthfund.org/publications/issue-briefs/2017/oct/insurance-coverage-consumers-health-care-costs

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Abstract

  • Issue: The United States has made historic progress on insurance coverage since the Affordable Care Act became law in 2010, with 20 million fewer people uninsured. However, we must also measure progress by assessing how well people who have insurance from all coverage sources are protected from high health care costs.
  • Goals: To estimate the number and share of U.S. insured adults who are “underinsured” or have out-of-pocket costs and deductibles that are high relative to their incomes.
  • Method: Analysis of the Commonwealth Fund Biennial Health Insurance Surveys, 2003–2016.
  • Findings: As of late 2016, 28 percent of U.S. adults ages 19 to 64 who were insured all year were underinsured — or an estimated 41 million people. This is more than double the rate in 2003 when the measure was first introduced in the survey, and is up significantly from 23 percent, or 31 million people, in 2014. Rates climbed across most coverage sources, and, among privately insured, were highest among people with individual market coverage, most of whom have plans through the marketplaces. Half (52%) of underinsured adults reported problems with medical bills or debt and more than two of five (45%) reported not getting needed care because of cost.

Background

The Affordable Care Act (ACA) has transformed the health insurance market, allowing Americans who lack job-based health benefits access to affordable health insurance options. The law’s coverage expansions and protections have reduced the number of uninsured adults by more than 20 million.

Congress intended for the ACA to do more than expand access to insurance; it aimed for the new coverage to allow people to get needed health care at an affordable cost. Accordingly, for marketplace plans, the law includes requirements toward that end: an essential health benefit package, cost-sharing reductions for lower- income families, and out-of-pocket cost limits.1For those covered by the law’s Medicaid expansion, there is little or no cost-sharing in most states.2

For people covered by employer-based insurance — which includes more than half of Americans under age 65, or more than 150 million people3 — plans were historically far more comprehensive and cost-protective than individual market coverage.4 However, over the past decade, premium cost pressures have led companies to share increasing amounts of health costs with workers, particularly in the form of higher deductibles.5 At the same time, income growth has been sluggish, leaving families increasingly pinched by health care costs.

In this issue brief, we focus on how well health insurance protects people from medical costs, using a measure of “underinsurance” from the Commonwealth Fund’s Biennial Health Insurance Survey to examine trends from 2003 to 2016. Adults in the survey are defined as underinsured if they had health insurance continuously for the preceding 12 months but still had out-of-pocket costs or deductibles that were high relative to their incomes (see Box). The survey was conducted between July 12 and November 20, 2016. We examined underinsured rates across all coverage sources, including private (employer and individual market) and public (Medicaid and Medicare). It is the first time in this survey series that we are able to estimate underinsurance in the ACA’s marketplace plans.

Who Is Underinsured?

In this analysis, we use a measure of underinsurance that takes into account an insured adult’s reported out-of-pocket costs over the course of a year, not including premiums, and his or her health plan deductible. The measure was first used in the Commonwealth Fund’s 2003 Biennial Health Insurance Survey. These actual expenditures and the potential risk of expenditures, as represented by the deductible, are then compared with household income. Specifically, a person who is insured all year is underinsured if:

  • out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 10 percent or more of household income; or
  • out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 5 percent or more of household income if income is under 200 percent of the federal poverty level ($23,760 for an individual and $48,600 for a family of four); or
  • deductible is 5 percent or more of household income.

The out-of-pocket cost component of the measure is only triggered if a person uses his or her plan. The deductible component provides an indicator of the financial protection the plan offers and the risk of incurring costs before a person gets health care. The definition does not include people who are at risk of incurring high costs because of other design elements, such as exclusion of certain covered benefits and copayments. It therefore provides a conservative measure of underinsurance in the United States.

Conclusion and Policy Implications

Since the passage of the Affordable Care Act in 2010, the nation has experienced gains in coverage, as well as improvements on key indicators of access and medical bill problems.15 These improvements reflect coverage gains — fewer people are exposed to the full cost of health care — as well as more comprehensive health plans with greater cost protection. This is especially true for low-income people covered by Medicaid and marketplace plans. But, as this analysis shows, the United States has not eliminated cost-related barriers to timely health care or protected people from medical debt. While these problems continue to be most apparent in the individual insurance market, they are increasing in the employer group market. Even public insurance programs like Medicare, which covers seniors and disabled people under age 65, leave many struggling to pay for health care.16

The latest Republican-led effort to repeal and replace the Affordable Care Act would have significantly increased the cost of health care for many Americans. After that effort failed in September, the Trump administration took two major actions in October, which could also have the effect of increasing costs. The first was an executive order to federal agencies to write new regulations that would allow the sale of insurance products that skirt the ACA’s consumer protections and cost-sharing standards.17 In the second action, the administration ended the federal payments for the ACA’s cost-sharing reductions.18 At the other end of the political spectrum, Senator Bernie Sanders has introduced legislation that would phase out the ACA and eliminate most cost-sharing in a Medicare-for-All framework. Seeking middle ground, Senators Lamar Alexander and Patty Murray held hearings on stabilizing the marketplaces in September, which included an appropriation for the cost-sharing reductions. To reduce the number of underinsured people in our health system, we also suggest the following policy options:

For people in individual market and marketplace plans

  • Increase the cost coverage of health plans. The law’s cost-sharing reductions (CSRs) increase the actuarial value (the percentage of medical costs covered on average by a health plan) of the marketplace’s silver level plans from 70 percent to as high as 94 percent for people with incomes under 250 percent of poverty ($30,150 for an individual and $61,500 for a family of four). The Commonwealth Fund has found that these reductions have been effective in lowering deductibles for those eligible to levels in employer plans.19 To counteract the administration’s executive order, Congress can immediately reinstate the cost-sharing reduction payments by making an appropriation. Since the Congressional Budget Office (CBO) has already assumed the cost of the CSRs in the federal budget baseline, the appropriation is a formality: it would not increase the federal deficit. To make health care more affordable for middle-class families, Congress could then consider extending the CSRs higher up the income distribution.
  • Increase the number of services excluded from the deductible. Most plans sold in the individual market nationwide exclude certain services from the deductible, such as primary care visits and certain prescriptions.20 In 2016, the U.S. Department of Health and Human Services (HHS) provided a standardized plan option for insurers that excluded eight services from the deductible at the silver and gold level. These include primary and specialty care visits, urgent care visits, mental health and substance-use disorder outpatient visits, and all prescription drugs. HHS or Congress could make these exceptions mandatory for all plans. Covered California, the California marketplace, requires all health plans sold in the marketplace to exclude all physician visits and outpatient services from the deductible.
  • Simplify the metal tiers and increase premium tax credits. As an alternative to extending cost-sharing reductions to people above 250 percent of poverty, Congress could lower the number of metal tiers in the individual market from four to two at higher actuarial values. For example, insurers could be required to sell just gold and platinum plans, which have actuarial values of 87 percent and 94 percent and much lower deductibles and copayments than silver and bronze plans. Tax credits would adjust to reflect the plans’ higher premium costs. This avoids the circuitous route of covering insurers’ costs through the cost-sharing reductions. Premium tax credits could be increased and extended to people earning more than 400 percent of poverty.21

For people in employer plans

  • Set a standard actuarial value for employer plans. Currently under the ACA, people in employer plans may become eligible for marketplace tax credits if the actuarial value of their plan is less than 60 percent. Congress could increase this level to 70 percent (the level of silver plans) or higher.
  • Set standards for deductible exclusions in employer plans. Most employer plans exclude at least some services from their deductibles.22 Congress could set a minimum set of exclusions that could resemble the current standard plan option for the marketplaces.

Addressing the Key Driver of Insurance Costs: Health Care Cost Growth

Health care costs are the single largest factor in the growth of private insurance premiums in the United States. Insurers and employers have tried to manage premium growth by making consumers increasingly responsible through higher deductibles and other cost-sharing vehicles. Advocates of this approach argue that with more skin in the game, consumers will help to slow cost growth by choosing more-efficient providers and being more selective in the services they use. But years of experience with high-deductible health plans in the U.S. has yielded scant evidence that such a strategy is effective. Instead, as the survey findings indicate, many consumers have responded to higher deductibles by avoiding needed health care and skipping their medications.

Innovations under way in the delivery system, some of which stem from the ACA, have helped slow the rate of growth in health care costs in the past few years. But moving the nation closer to the performance of other countries on both cost and health outcomes will require considerably more work.23 While targeted consumer cost-sharing may help to reduce use of low-value health services, this approach is unlikely to be successful unless consumers are better informed on prices and the value of alternative approaches to their health care problems. Such information is largely unavailable. Evidence suggests that consumers cannot do the heavy lifting required to reduce the rate of growth in medical costs in the United States.

 

Top 5 Concerns of Healthcare CFOs

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http://www.healthleadersmedia.com/finance/top-5-concerns-healthcare-cfos#

Planning for a HealthLeaders Media gathering of hospital and health system chief financial officers reveals the weightiest issues on their minds.

Preoccupying the minds of healthcare financial executives are prevailing problems engulfing the industry’s business climate: uncertainty about healthcare reform, declining public and private reimbursement, accelerating operating expenses, and access to capital.

This August, 50 healthcare finance leaders will collaborate on fortifying their organizations’ fiscal health at the 2017 HealthLeaders CFO Exchange in La Jolla, CA.

In pre-event planning calls, CFO Exchange attendees, representing integrated health systems, academic medical centers, community hospitals, and safety net providers, have mentioned some of the struggles they’d like to know how others are tackling.

During the two-day event, a series of moderated, peer-to-peer roundtables will explore how organizations are addressing the top five issues.
1. Dismantling of the Affordable Care Act

CFOs foresee the negative financial impact a repeal will generate and are interested in knowing how others are preparing for anticipated changes in Medicaid for expansion and non-expansion states.

2. Enhancing and Supporting Population Health

CFOs are concerned about building the right infrastructure to support population health, including integrating physicians, retooling their workforce, realigning the financial tracking of population health efforts, incorporating behavioral health in primary care, and determining how much payer risk to assume.

Executives expressed their concerns about knowing how and when to invest resources in a relatively uncharted path.

In addition, they are interested in how to bring disparate goals together to align with population health efforts.

3. Curtailing Clinician Costs

Optimizing access and productivity to ensure profitability among acquired physician practices, reducing clinical practice variation and cost-per-case, and lowering costs associated with filling in with agency labor due to the nursing shortage are challenges for senior executives.

Organizations will be requesting and sharing strategies for seizing the reigns on clinician expenses.

4. Increasing Revenue

Overcoming reimbursement struggles, uncovering innovative ways to cut costs, and ascertaining solutions to avoiding readmission penalties are common goals for CFOs.

5. Determining Gaps and Opportunities

Another goal shared by CFOs is the desire to share the most useful data analytics and business intelligence platforms for improving quality-of-care and outcomes.

In addition to their larger concerns, participants at the invitation-only event will talk about consumerism, direct contracting for healthcare with employers, charting a financial strategy on value-based care, and ideas about what competition will look like in the future.

Instead of health care for all, Assembly has a do-nothing committee

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http://www.sacbee.com/opinion/op-ed/soapbox/article179847606.html

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With the turmoil and chaos caused by the ceaseless efforts of Congress and the Trump administration to shred the Affordable Care Act, shouldn’t our legislators show more urgency to provide health security for Californians?

On Monday, an Assembly select committee will hold its first hearing “to determine the best and quickest path forward toward universal health care,” in the words of Assembly Speaker Anthony Rendon.

However, the committee has no authority to act on legislation. It is essentially a discussion group designed to give the appearance of moving forward on reform, rather than act on an existing bill, Senate Bill 562, which would guarantee health care for all Californians without huge out-of pocket costs hurting so many.

A legislative study has already concluded that a Medicare for all/single-payer approach, as SB 562 advances, is superior to all other models of health care financing.

Further, a study released in June documented the bill’s additional cost to the state budget is closer to $100 billion, not the misleading $400 billion cited by opponents. The study also offered financing proposals under which nearly all families and businesses would pay less for health care than they do now.

It is also troubling that select committee co-chairmen Jim Wood, a Healdsburg Democrat, and Joaquin Arambula, a Fresno Democrat, are the two of the three largest Assembly recipients of campaign contributions from the health care and insurance industries.

Unlike the powerless committee, SB 562 has the enormous advantage of having already passed the state Senate in June. The Assembly can take it up immediately early next year with any amendments members want to propose.

Further delays leave Californians at the mercy of the Trump administration. Consider the latest executive orders to encourage the sale of insurance plans that evade the extensive protections established by California legislators, and to cancel subsidy payments to insurers to sabotage the ACA marketplaces.

Premiums in California for “silver” plans, by far the most common under Covered California, are going up by 25 percent on average. Anthem Blue Cross rates are jumping by 37 percent, and it is pulling out of about half of California counties.

The specific impact on individuals and families varies depending on where you live, your income, how much coverage you want, and who your current insurer is. Or you may need to shop around for a non-silver plan – all with differing levels of coverage, deductibles and co-pays and that may or may not include your doctor, hospital, or other providers in its network.

Or Congress may or may not pass supplemental legislation to reverse Trump’s orders, which he may or may not support, with its own set of uncertain impacts. Everyone clear?

There’s a fix that would end Californians’ anxiety over their health coverage and cost, and establish protection for all. The people are ready. Earlier this month, nearly 1,000 activists attended 100 events in all 80 Assembly districts to talk to their neighbors about SB 562, and 10,000 people signed petitions urging its approval.

Concord resident Emily Chandler was among them. She told us she pays $800 a month for insurance but sometimes avoids going to the hospital because she can’t afford the co-pays and deductibles. She is one of 15 million Californians who, even under the ACA, are without coverage or who don’t get the care they need due to rising costs.

Californians don’t need a committee that can do little more than talk. They need real relief, SB 562.

Keeping the Alexander-Murray health care bill in context

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https://www.axios.com/keeping-the-alexander-murray-health-care-bill-in-context-2498670199.html

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As debate continues about a bipartisan fix for the Affordable Care Act marketplaces, Drew Altman’s latest Axios column describes the scale of the problems in the ACA marketplaces and the public’s confusion about whether they are impacted. He says that the news media, experts and policy makers can do more to put the marketplace problems and fixes in context as debate evolves.

As the debate unfolds about the bipartisan bill by Senators Lamar Alexander and Patty Murray to repair the Affordable Care Act marketplaces, the public could be just as confused as they have been about the ACA’s marketplaces. That’s why it’s important to debate it in the right context: It’s aimed at an urgent problem affecting a relatively small sliver of the health insurance system, not all of the ACA and not the entire health system.

The bottom line: It’s a limited measure that will never give conservatives or liberals everything they want.

Reality check: Many people will think it affects their insurance when, in actuality, it will have no impact on the vast majority of Americans who get their coverage outside of the relatively small ACA marketplaces.

The chart based on our new Kaiser Tracking Poll shows the confusion. Just 23% of the American people know that rising premiums in the ACA marketplaces affect only people who buy their own insurance. More than seven out of 10 wrongly believe rising premiums in the marketplaces affect everyone or people who get coverage through their employer.

The public will be susceptible to spin and misrepresentation of the limited goals of Alexander-Murray: a bipartisan effort to stabilize the marketplaces by funding the cost-sharing reduction subsidies, providing more resources for open enrollment outreach, and expediting state waivers.

President Trump has added to the confusion. He recently pronounced the ACA “dead”, adding, “there is no such thing as Obamacare anymore.” Possibly that’s because he wishes it was dead. More likely, he was referring to the problems in the ACA marketplaces, which he has exaggerated.

Like thinking your whole house is falling down when just a part of the foundation needs shoring up, both he and the American people have an inaccurate picture of where the marketplaces fit in the ACA and where the ACA fits in the health system.

A few facts:

  • There are just 10 million people enrolled in the ACA marketplaces.
  • The law’s larger Medicaid expansion and consumer protections are popular and working well.
  • The far larger Medicare and Medicaid programs and employer based health system combined cover more than 250 million people, and are largely unaffected by developments in the ACA marketplaces.
  • Premiums for the 155 million people who get coverage through their employers rose a very modest 3% in 2017.

Some conservatives in Congress will hold out for repeal, and they’ll resist any legislation that they view as propping up Obamacare. But for everyone else, it’s important to understand the problem and get the facts.

 

Undocumented 17-Year-Old Must Delay Abortion, Court Rules

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An undocumented 17-year-old caught in a legal standoff with the federal government must further delay plans for an abortion after an appeals court ruled on Friday that the Department of Health and Human Services had 11 days to find a sponsor to take custody of the teenager.

The decision by the United States Court of Appeals for the District of Columbia Circuit could put her health at risk, doctors say, especially now that she is about 15 weeks pregnant.

“While first-trimester abortion is over 10 times safer than childbirth, the risks gradually increase in the second trimester to those of childbirth,” Dr. Nancy L. Stanwood, the chief of family planning at the Yale School of Medicine, said in an email. Forcing her to wait, she added, “harms her physical health, period.”

Further complicating matters, the teenager only has about a month to get an abortion in Texas, where she is being held. The state has banned abortion after 20 weeks of pregnancy unless there is a medical emergency.

The teenager, referred to as Jane Doe in court documents, found out she was pregnant last month after she was apprehended while entering the United States without her parents.

She decided to end her pregnancy, but Texas law requires a minor to get parental consent or a judicial waiver to do so. She obtained a waiver, but the government prevented her from going to any abortion-related appointments, the American Civil Liberties Union said in court documents, and forced her to visit a religiously affiliated crisis pregnancy center where she was asked to view a sonogram.

An undocumented 17-year-old being held by the federal government is seeking an abortion.

President Trump has worked to restrict abortions since his first days in office by expanding the so-called global gag rule, which withholds American funding from international organizations that discuss or perform abortions; taking aim at Planned Parenthood funding; and appointing several leaders who are anti-abortion, including E. Scott Lloyd, the director of the Office of Refugee Resettlement at the health department, and one of the defendants in the Jane Doe case.

The federal government said that it was not its role to facilitate abortion, and that the teenager still had the option of returning to her home country.

“Ms. Doe has options for leaving federal custody — either by requesting a voluntary departure to her home country (which the federal government is willing to expedite if requested) or by being placed in the custody of a sponsor,” the defendants stated in a memorandum on Tuesday. “Given these options, the government is not causing Ms. Doe to carry a pregnancy to term against her will.”

On Wednesday, a federal judge ordered the government to allow the teenager to get an abortion.

Tanya S. Chutkan, the United States District Court judge who initiated the temporary restraining order, said she was “astounded” by the government’s position.

“She can leave the country or she cannot get her abortion, those are her options?”

The government next argued for the right to appoint the teenager with a sponsor, which would release her from government custody, and said in court documents that the process of securing a sponsor would not unduly burden the teenager’s right to an abortion.

On Friday, the appeals court agreed.

The health department has until Oct. 31 to find a suitable sponsor; if it does, Jane Doe would be able to have an abortion. If she is not released to a sponsor by then, the government has the option of appealing once more.

The 11-day timeline to find a sponsor “seems far-fetched,” said Brigitte Amiri, one of the A.C.L.U. lawyers representing the teenager.

Sponsors are typically family members, according to the health department’s website, who help care for a child who has entered the United States illegally without their parents — often because the child is fleeing an abusive or violent situation.

The vetting process, which includes a background check, can take months, Ms. Amiri said, and earlier attempts to find a sponsor for Jane Doe were unsuccessful.

“They kicked the can down the road, and in this case they kicked the woman down the road,” Dr. Stanwood said. “They are just delaying her care to no end but their own ideology.”

A spokesman for the Administration of Children and Families, which is part of the health department, said in a statement that the care of minors like Jane Doe was important.

“For however much time we are given, the Office of Refugee Resettlement and H.H.S. will protect the well-being of this minor and all children and their babies in our facilities, and we will defend human dignity for all in our care,” the statement said.

The teenager will be 16 weeks and five days pregnant at the end of October, according to the nonprofit legal organization Jane’s Due Process, which has been working with the A.C.L.U. If the appeals process continues into November, the teenager will reach the 20-week mark, which would prevent her from having an elective abortion in Texas.

The sooner the teenager can have the abortion, “the safer it will be for her,” said Dr. Hal C. Lawrence, the executive vice president of the American Congress of Obstetricians and Gynecologists, who practiced obstetrics for nearly three decades.

As the uterus gets bigger, he added, the walls of the uterus get thinner, which increases the possibility of perforation and puts women at risk of additional blood loss during an abortion.

Health risks aside, delaying an abortion can cause emotional trauma.

“Women don’t just wake up one morning and decide they’re going to have an abortion,” Dr. Lawrence said. “And so to make her continue to struggle and be denied access to something which is legal — all that does is increase the psychological stress for her, and that’s not healthy.”

The United States has one of the highest rates of maternal mortality in the developed world, and abortion has been shown to be safer for women than childbirth.

The A.C.L.U. is considering several options, including further appeals.

For the teenager, the process has been exhausting, Ms. Amiri said.

“She talks about feeling very tired.”

 

Are implants for opioid addicts a new hope or a new scam?

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Are implants for opioid addicts a new hope or a new scam?

OCR-L-IMPLANTS-1022

If a stake could be driven through the vampire heart of the nation’s opioid epidemic, it might look something like this: Four tiny spines, each smaller than a matchstick, sunk into a drug addict’s upper arm.

These implants remain beneath the skin for months, delivering a continuous dose of a drug called buprenorphine, which blunts the euphoria of an opioid high. Ideally, its manufacturer says, patients will get the implants replaced every six months, helping achieve the lasting sobriety that currently eludes an estimated 2.5 million Americans who are addicted to heroin or other opioids.

As the addiction crisis grows, implants that deliver buprenorphine, naltrexone and opioid-blocking drugs like them might offer light in an otherwise oppressive darkness. One recent study found that nearly 86 percent of the people who used the buprenorphine implant refrained from using opioids during a six-month window. And in Russia, more than half of heroin-addicted patients who got a naltrexone implant were abstinent over a six-month clinical trial.

But here in Southern California — a region known as Rehab Riviera because there are so many drug and alcohol recovery centers — implants might also be a new way to turn an illicit buck.

In one of the latest twists on the profit-before-patient mindset so common in the addiction treatment industry, addicts are demanding to be paid for agreeing to get implants, knowing that rehab centers and the doctors who surgically insert the devices can bill insurance providers thousands of dollars per patient, according to professionals in the rehab industry.

“Hey Bud. I have at least me and 3 other people looking to come … and all 4 of us want the implant,” said a text from an addict to an executive with New Existence Treatment Center in Fountain Valley, according to screen shots of a text exchange reviewed by the Southern California News Group.

“If I can get others with the same insurance any chance I could possible (sic) make little something, I got nothing… ”

Requested payouts for agreeing to the treatment, according to an apparently unsent text on the addict’s phone, were $700 for his implant plus $300 for each additional person he recruited to get implants.

Dylan Walker, one of New Existence’s owner-operators, was trading texts with the addict, and said he did nothing irregular. “If you actually read them, nowhere in there does it say I’m paying clients to get the implant,” Walker said when contacted about the exchange.

Later, in a prepared statement, the company said Walker simply offered encouragement and support to a former client, nothing more.

“New Existence has not and will not engage in any unlawful or unethical treatment or business practice such as payments to clients or other organizations for procedures or treatments,” it said by email.

“Unfortunately, the addiction treatment industry is fraught with questionable practices, and we have encountered similar requests or demands in the past—which have all been rejected.”

New Existence — a non-medical enterprise — also said it is carefully reviewing its own policies and procedures “to ensure that our communication with clients regarding treatment are clear, making sure that they understand their treatment plan as it relates to their own recovery process.”

Other addiction professionals say such demands aren’t unusual. Paying addicts to get implants – and other forms of insurer-covered treatments – is at least widespread enough to prompt some addicts to make the request.

“Does it surprise me? No. That’s part of toxic behavior.,” said Cynthia Moreno Tuohy, executive director of the National Association for Alcoholism and Drug Abuse Counselors.

The requests amount to, “Give me money to help me help you get money,” she said, and they constitute a basic corruption of how the industry should work.

“In our code of ethics, you can’t do that.”

Probuphine — the brand name of the implant that delivers buprenorphine — was developed by Braeburn Pharmaceuticals of New Jersey with partner Titan Pharmaceuticals in San Francisco. Company officials didn’t say if they’ve heard of the shakedown proposed by the addict, but promised to probe further.

“We take all reports of potential misconduct, violations of internal Braeburn policy or applicable laws, very seriously,” said Braeburn spokeswoman Nancy Leone by email.

Officials with BioCorRx, the Anaheim company that’s working on FDA approval for implants delivering naltrexone, said they have received demands for money directly from addicts.

“We have an 800 number and people just flat-out ask, ‘How much will you pay me to get your implant?’ ” said Brady Granier, the company’s chief executive. “We tell them we don’t treat people, and the people we work with don’t do that. It shouldn’t be happening.

“It’s a form of patient-brokering,” he added. “And it gives what we do a bad name.”

Naltrexone implants are inserted into the abdomen and last several months. They’ve been widely used in Europe for years and have been prescribed in the U.S. as well, even without the FDA’s official stamp of approval – which is usually required before health insurers will agree to pay for them.

The chatter is that some illicit implants are imported from overseas, Granier said.

“There’s a black market for them. Patients who are considering this should always ask their doctor, ‘Where are you getting your implants?’”

Billing opportunity

Probuphine is, for now, the only long-acting FDA-approved implant for opioid addiction. It got the green light last year, hit the market in January, and lasts six months.

A single Probuphine implant costs $5,000, and billings for follow-up care can run thousands more. It’s covered by most private and public health insurance plans and, in a recent statement, the FDA backed such coverage, saying “expanded use and availability of medication-assisted treatment is a top priority of federal effort to combat opioid epidemic.”

Since most insurance companies don’t cover naltrexone implants yet, those are often billed as surgeries, insiders said.

Health insurance officials confirmed that they’ve heard of irregularities connected to anti-opioid implants. Many insurers and treatment providers are embroiled in lawsuits over alleged billing fraud on other fronts, and insurers claim they’ve seen all manner of creative billings in the addiction treatment industry.

“We have heard anecdotally of a California facility that makes its own implants…  for use with its clients,” said Mark Slitt, spokesman for Cigna. “We would not cover that.”

Ashton Abernethy of AVA medical billing, a Costa Mesa company that works with behavioral health centers, said she started hearing about pay-for-implants scams over the last 18 months or so.

Abernethy, who said she works with rehab operators to help them understand the law, said the implant situation reminds her of the “sweaty palms” surgeries of about a decade ago. In those operations, doctors paid people with generous insurance policies to undergo unnecessary surgeries. Authorities later said the schemes generated $154 million in fraudulent billing.

The Southern California News Group recently investigated the addiction industry and found it peppered with financial abuses that bleed untold millions from public and private pockets, can upend neighborhoods and often fails to set addicts on a path to sobriety. The revolving door between detox centers, treatment facilities, sober living homes and, often, the streets generates huge money for operators who know how to game the system. And even obvious fixes prohibiting patient brokering can be hard to enact.

Some professionals in the industry, frustrated by what they see as abuses, are trying to force change from within.

David Skonezny created “It’s Time for Ethics in Addiction Treatment,” a closed Facebook group for industry professionals that has more than 2,000 members. It’s a destination for people to challenge themselves and have honest dialogue about ethics in the industry, he said, and where people are calling out what they deem as questionable behavior.

News of the pay-for-implant texts recently created a social media firestorm.

“Changing the face of addiction treatment needs to happen, and I’ve jumped on the grenade to do that,” said Skonezny, a certified drug and alcohol counselor who has served on the board of directors for California Consortium of Addiction Programs and Professionals.

“I’m ether in the process of doing really good work, or committing career suicide.”

Why implants?

Walter Ling, professor of psychiatry and founding director of the integrated Substance Abuse Programs at UCLA, says most people don’t really understand how much time drug addicts think about getting drugs.

It’s on their minds constantly.

When the freeway collapsed during the 1994 Northridge quake, he said, the panic for some addicts wasn’t about houses falling; it was about being unable to get to the local methadone clinic, where they could get at least a substitute for heroin.

The power of long-acting anti-opioid implants, he said, is that they can interrupt that pattern.

“Anything that can free (addicts) from the constant preoccupation with (their drug of choice) allows them to think about getting a life,” said Ling.

Implants can offer a consistency that’s lacking in other medications aimed at preventing relapse, he said. Methadone, the best known anti-opioid drug, must be taken daily and essentially marries an addict to a methadone clinic. Naltrexone blocks the effects of opioids by turning off pleasure receptors, and patients often hate it. Buprenorphine, Ling said, strikes something of a middle ground.

The current delivery systems for most of these drugs are pills or under-the-tongue film strips that a patient must keep in the mouth for 15 minutes, one or more times a day, to get the full dose. Addicts often grow weary of the routine and drop out. Pills and strips also become a commodity on the street, bought and sold from one addict to another.

Injectable drugs taken weekly or monthly, and implants, offer potential solutions to those problems. The addict isn’t making a daily decision about taking the anti-opioid, reducing the odds of relapse though not entirely wiping it out. Also, injections and implants can be invisible, meaning sobriety doesn’t include the stigma of visiting a methadone center or popping pills every day.

The manufacturers claim this helps addicts keep jobs, take care of their families and lead productive lives.

Ling is inclined to agree. He was the lead researcher on a study published in the Journal of the American Medical Association in 2010, which found that buprenorphine implants were indeed effective in treating opioid dependence over the six months following implantation.

“Of particular clinical importance are the favorable urinalysis toxicology results and the good patient retention—with 65.7% of patients who received the active implants completing 24 weeks of treatment without experiencing craving or withdrawal symptoms that necessitated withdrawal from the study,” the study said.

Naltrexone implants worked wonders as well. “The implant device, which releases a steady dose of naltrexone continuously for two months, averted relapse to heroin use three times as effectively as daily oral doses of the medication,” said the National Institute on Drug Abuse.

Drug abusers are notoriously ambivalent, said study co-leader Dr. George Woody, a professor of psychiatry at the University of Pennsylvania, in a NIDA statement. Just because they decide to quit using heroin one week doesn’t mean they’ll be motivated to quit a week later. The rationale for extended-release implants is to protect against that ambivalence.

The implants’ success in preventing relapse cuts a marked contrast to traditional social-based treatment approaches. Addicts have a relapse rate between 40 and 60 percent, according to the U.S. Surgeon General’s most recent probe, and it can take as long as 8 or 9 years to achieve sustained recovery.

Taking medication is the best guarantee that you don’t die from an overdose and actually stay off drugs, Ling said. “You can’t get a life if you can’t stay off drugs. And you can’t stay off drugs for long if you can’t get a life.”

Michael M. Miller, past president of the American Society of Addiction Medicine and medical director of the Herrington Recovery Center at Rogers Memorial Hospital in Wisconsin, also likes the idea of making it easier for an addict to get medicine for treatment, but says implants are only one way to do that.  He is on the manufacturer’s physicians advisory committee for Probuphine, a paid position, but  has not yet prescribed it.

“Implants probably have a role, but probably a fairly small role,” Miller said. “The 30-day injectables are going to have tremendous impact.”

On the street, stories about addicts who’ve cut implants out of their skin so they can get high are not uncommon, and some physicians worry about potential complications.  

Both Miller and Ling said many in the addiction field resist the idea of using drugs as a long-term treatment. That patients might need to be on medication for the rest of their lives to manage their addiction makes physicians and patients uncomfortable; Ling chalks it up to a strain of Puritanism that runs through American culture.

Moreno Tuohy, executive director of the NAADAC, the Association for Addiction Professionals, believes that medication is one piece of the treatment puzzle, but that counseling is essential to address the psychological, social and spiritual aspects of an addict’s behavior.

Medications may make patients more available to do the work they need to do in counseling to fully recover, she said. She also predicted that the number of medications designed to fight opioid and other addictions is going grow considerably over the next few years.

“The hope is it will help people to reduce cravings for marijuana and cocaine and other drugs, and become more available to comprehensive treatment,” Moreno Tuohy said. “That’s the goal, not just (short-term) recovery.”

Newsom, Villaraigosa separate over universal health care

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http://www.sacbee.com/news/politics-government/capitol-alert/article180299536.html

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The two leading Democrats for California governor on Sunday split over how to achieve universal health care, with Lt. Gov. Gavin Newsom defending his support for a government-run, single-payer system and former Los Angeles Mayor Antonio Villaraigosa dismissing as “pie in the sky” plans that don’t include viable financing methods.

At a union-sponsored health care forum, Villaraigosa credited the Assembly speaker for sidetracking a universal health bill, Senate Bill 562, in Sacramento, because it didn’t include a funding mechanism. He supports the concept, but argued the state’s immediate focus should be on protecting the 5 million people who could lose their coverage if Republicans and President Donald Trump succeed in repealing Obamacare.

“As governor, you gotta make the tough choices, you can’t just say ‘I want pie in the sky,’ because that doesn’t put food on people’s tables,” he said, advocating for a public option that allows people to buy into the existing Medi-Cal program.

“What I’ll never do is sell you snake oil,” added Villaraigosa. “The fact of the matter is we don’t have a plan yet.”

Newsom, a proponent of advancing the bill, cast the issue as one of leadership and commitment. He contended there is considerable “mythology” about the $400 billion annual price tag of enacting the system because the state currently spends about $368 billion a year on health care in California, nearly two-thirds of it borne by taxpayers.

“A single-payer system drives down the cost of health care; drives down the cost of prescription drugs through economies of scale; and provides more effective, efficient and universal access for those that are uninsured,” Newsom said, pointing to double-digit increases in Obamacare here. He said the financing will be worked out as the legislative process moves forward.

“It’s a question of leadership,” he added. “This is what they said about Social Security and Medicare: ‘You can’t do it …’ I’m not going to wait around for the debate to unfold in Washington, D.C. Sure, I support Medicare for all, but you got to shape the debate in California.”

The exchange between Newsom and Villaraigosa came at the forum hosted by the National Union of Healthcare Workers, which also included Democrats Delaine Eastin, a former state school’s chief, and Treasurer John Chiang.

Chiang largely sidestepped the debate over universal care, offering that the state should take an incremental approach to health care. He wants to see more “effectiveness and efficiency” in the current system.

“We have to figure out how to scale-up, the time frame we’re going to scale-up,” he said, adding, “We don’t have to go all in to provide all the services all at once. Let’s make sure that what we are implementing we can scale-up appropriately.”

Eastin, like Newsom, believes single-payer would cost “slightly more” now but far less in the long run.

“The fact of the matter is people are dying in California because we do not have affordable health care coverage for everybody,” she said, calling the solution “realistic,” and saying it could be paid for with a gross receipts tax and a partial income tax increase.

She added: “There’s nothing California can’t do if we put our minds to it.”

The single-payer measure, driven largely by the California Nurses Association, has divided Democrats and is emerging as a litmus test for 2018. Newsom, endorsed by the nurses’ union, has never trailed in public polls and fundraising, while Villaraigosa has been the second-place Democrat.

The Republicans in the race, John Cox and Travis Allen, did not attend the forum, though the host National Union of Healthcare Workers, representing 14,000 workers in California, said they were invited. After Sunday’s forum, the union voted to endorse Newsom. Eastin was runner-up.

A New Plan To Rescue The ACA: Medicare-At-55

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http://healthaffairs.org/blog/2017/10/16/a-new-plan-to-rescue-the-aca-medicare-at-55/

On October 12, 2017, the Trump Administration announced that it would end subsidies that reduce out-of-pocket payments for low-income individuals. This action might drive insurers out of the exchanges and might encourage younger people to drop their individual insurance plans — thereby destabilizing the individual insurance market.

Extending Medicare to the 55-64 age group—who have relatively high health care costs—is a potential fix that could insure the near-elderly and provide stability to the marketplaces. It would remove expensive individuals and families from coverage by private insurance companies, who could in turn reduce premiums for individuals and families below the age of 55.

Under this proposal, Medicare-at-55 would be universal for people in the 55-64 age group and they would leave their current private insurance. It would require an increase in the Medicare payroll tax contribution which has not increased proportionately to increases in Medicare spending; other countries sustain their health insurance programs by gradually increasing their payroll tax contributions. To make this plan fiscally sustainable, the United States would need to do the same.

The Problem With Making Medicare-At-55 Optional

Medicare-at-55 is quite different from proposals suggested by Democrats in 2009 and 2017, which allowed people aged 55-64 to voluntarily buy into Medicare as an alternative to private insurance. The problem with the idea of Medicare buy-in is that relatively few of the near-elderly would choose it. Medicare premiums for this age group—about $8,200 per year for an individual—would be significantly higher than what they currently pay with employer-sponsored insurance and with individual insurance subsidized under the Affordable Care Act (ACA).

In addition, under an optional buy-in there would be confusion among potential enrollees on whether to use the buy-in and person-by-person enrollment would be administratively complex. Moreover, the buy-in would raise vexing legislative questions around premium levels, Medigap and Medicare Advantage policies, and whether people could buy-in to Parts A, B, and D separately.

Automatic Enrollment, Just Ten Years Earlier

 The better approach would be to implement a Medicare-at-55 concept in which everyone would be automatically enrolled in Medicare — just like the current system does for those 65 and above. Upon reaching the age of 55, eligible individuals (almost everyone in the 55-64 age group) would simply receive their red-white-and-blue Medicare card. Private insurers and employers would no longer be responsible for this age group, which would allow private insurers to reduce premiums on younger families because they would have a younger, and typically healthier, pool of people to cover. In 2015, per capita health care costs for people between 55 and 64 years of age were $9,707 compared with $6,637 for the 45-54 age group, $4,442 for the 26-44 cohort, and $2,915 for those between 19 and 25.

Once on Medicare at the age of 55, people could choose to get a Medicare supplement through their previous insurer or join a Medicare Advantage plan. While the 55-64 age group has higher health care costs than younger people, they have lower costs than current Medicare beneficiaries, which in 2015 incurred per capita spending of $11,904.

Keep in mind that this is not small group to be adding to Medicare’s risk pool. In 2015, there were 41.1 million people in the 55-64 age group. 24 million have access to employer-sponsored insurance, 3 million have subsidized individual insurance under the ACA, 2 million purchase unsubsidized individual insurance, and 3.4 million are uninsured. This leaves an estimated 8 to 9 million already on Medicare and/or Medicaid.

How Would We Pay For Medicare-At-55?

First, it is noteworthy that from 2010 to 2016, per capita Medicare spending growth was 1.3% compared with 3.5% for private insurance. Second, it would be impossible for most people in the 55-64 age group to pay for their Medicare plan and—given the high per capita costs of this age group—it would be very expensive for the federal government to subsidize their plan. The costs of Medicare-at-55 would have to be borne by the younger population, who would benefit greatly as they reached 55.

The best revenue source for Medicare-at-55 is the current Medicare financing model: payroll tax for Medicare Part A, individual premiums and general federal revenues for Medicare Part B, and Part D through general federal revenues and out-of-pocket costs. The same model could be extended to the 55-64 age group, with an increase in the payroll tax, for example, from 2.9% (half from employers and half from employees) to 3.9% and an increase in the higher-income payroll tax from 2.35% to 3.35%. The precise increases would have to be calculated by federal actuaries and these increases could also be used to extend Medicare’s life from the current date of 2029.

To add to these Medicare revenues, which are distributed throughout the entire population, the new 55-64 beneficiaries would still pay their Part B premiums ($134 per month for incomes of $85,000 or less, more for higher incomes) and Part D (prescription drugs) premiums. Their out-of-pocket costs would depend on whether they have a Medicare supplement or Medicare Advantage plan. The 55-64 population would be subject to the same Medicare rules as the over 65 Medicare population.

To pay for the 55-64 age group to be folded into Medicare, not only the payroll tax, but the portion of Medicare financing provided by general federal revenues, needs to increase. Employers that insure their employees would be required to contribute through Medicare-earmarked payments. Otherwise these employers would receive a windfall since they would no longer be responsible for the health care costs of their 55-64 year-old employees.

Medicare-at-55 is a reasonable proposal to stabilize the ACA while providing reliable health insurance for the 55-64 age group. As the most expensive group insured through the ACA marketplaces moves to Medicare, insurers could reduce premiums for the remaining younger and healthier age groups. The transfer of the 55-64 cohort from employer-sponsored insurance to Medicare would allow insurers to also moderate their premiums in the employer market.

Many questions have yet to be answered in developing the concept of Medicare-at-55, but the idea deserves to be added to the mix of proposals designed to extend our nation’s insurance coverage and repair the ACA marketplaces.

 

Traveling The Valley Of The Shadow Of Death In 2017

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http://healthaffairs.org/blog/2017/10/18/traveling-the-valley-of-the-shadow-of-death-in-2017/

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My mother has a letter from her mother written in 1942, telling of the death from pneumonia of a middle-aged neighbor with whom my grandmother had spoken at the post office just a week earlier. For most of human history, that sudden turn to death has been the common experience. Few managed to live into old age; and even for elders, the dying was usually fairly abrupt. There was little risk of living long with dementia, Parkinson’s disease, heart failure, cirrhosis, serious injuries, childbirth complications, or other fatal illnesses. Diabetes was fatal within a few months in 1900. Now, most of us will instead experience a long period of decline in advanced old age. The period of being unable to take care of yourself (mobility, dressing, feeding, toileting) averages more than two years in the last phase of life. During that time, we each will need another person’s help every day—often around the clock. And our society has not even figured out how to talk about the situation, much less how to reorganize to make this newly expectable phase of life comfortable and meaningful, or affordable.

US society seems stuck in an era of “happy talk.” When a fireman pulls a child from a swimming pool, it seems appropriate to call it “saving a life.” But how many times have you seen the newspaper headline touting a new drug or device that will “save X thousands of lives,” when, at best, it will delay the dying of very sick and usually elderly people by some months before something else causes death? That may be a good thing, but it is illusory to claim that it is “saving lives.” Advocacy organizations around each eventually fatal illness promote prevention and cure, but none say what would be a better way to come to the end of life. Influential authors tout odd claims such as “Toward a State of Complete Well-Being,” which persuasively argues for investments in prevention and social determinants of health but does not give voice to the limitations imposed by illnesses associated with aging. Public policy falls into the same pattern, with enthusiasm for supporting development of a costly drug that will delay the progression of heart failure, but inattention to issues such as the struggles of family caregivers, the waiting lists for home-delivered meals, and the misfit of available housing with disabilities.

My mother now lives through the peculiar torment of progressive disability from frailty in a “care system” that is not designed for her situation: losing nearly half of her weight, barely able to get up from a chair, having a plethora of symptoms with no treatable etiology, and yet having enough heart, lungs, kidney, and liver functions to go on for a while. There will be no letter from a neighbor who is startled when she dies; neighbors will be astonished that she lived so long with such severe disabilities. Hospital care is readily available and paid for, but medications after hours are not available, and she must pay out of pocket for personal care. Hospitals, physicians, pharmacists, and civic leaders have not made plans as to how to serve large numbers of elderly people living in the community with serious and worsening disabilities.

Making workable plans would require adopting some novel perspectives and taking account of some salient facts that are often set aside. First, the life possibilities of an elderly person with increasing disabilities is profoundly dependent upon the surrounding community. Is housing accessible? Can you readily get help with minor home repairs, such as changing a light or fixing a gutter? Can you get food delivered, and can you get prepared meals delivered? Can you stay engaged with other people—family, neighbors, and church or club members? Are you considered an embarrassment when out in public with a walker or wheelchair—or an adult diaper? Are walk lights lit long enough for you to cross the street? Are there personal care aides trained to deal with disabilities and challenging behaviors at home, and can elders in need afford them? Are there physicians attuned to your physiology and preferences who will, when needed, come to your home?

None of these things can be made available just for one person; they all are traits that affect whole communities, and they are available to all or most in the community, or to no one. Yet, communities have little voice or resources. Instead, what happens to be available is mostly the result of chance developments and leadership opportunities that vary over time and across communities. Health care has geographically overlapping hospitals, insurers, and other providers, none of which are involved in community planning for elder care and often none of which are actually anchored in any particular community.

Second, the preferences and priorities of elders in this phase of life vary much more than in earlier phases. A 50-year-old with gall bladder attacks is very likely to have about the same preferences for medical care as any other 50-year-old with gall bladder attacks. But two 90-year-olds with frailty syndrome are likely to require substantial customization of their care plans. It matters whether one has a volunteer family caregiver, or a home on one floor, or assets in the bank to hire help. So, elder-driven care planning becomes a central activity, and one that is not yet well-developed or commonly done. We do not yet evaluate care planning; we have aspirational sets of documentation requirements but little actual documentation, and we don’t assure that elders and their families are really driving the choices.

Third, we need more reliable and reasonable financing plans. Working-age people still don’t realize that they need to provide for themselves in old age. Policies need to change to make vehicles for saving affordable and reliable. The Bipartisan Policy Center, a Washington, D.C., think tank committed to balanced policy development, encouraged federal government catastrophic coverage for long-term care when the need for substantial personal care persists for more than a few years. That would make it plausible for many people to save or insure for the first few years of needing long-term supports and services, which is all that most people will need. Other approaches are appealing. For example, by providing flexible hours and part-time work, employers of family caregivers can make it much easier for them to stay at work and still provide care to an elderly family member. The range of possibilities is substantial but largely unexplored in public discourse and policy development.

Fourth, sick and disabled elders living in the community need continuity and reliability across time, instead of the cut-up care system we provide. Remarkable efficiencies are possible if services in the home were allowed to be organized geographically. As much as half of our spending on home care can go to supporting the inefficiencies of having each provider organization spread across a large area.

A substantial revision of Medicare and Medicaid that would put these observations and the existing research together is in order. Call it MediCaring Communities. What would be required? Allow some communities to take on responsibility for monitoring and improving their elder-care system’s performance and enable them to shift resources from medical care to supportive services when appropriate. Let them be able to develop their workforce and improve their built environment. Enable geographic concentration of home care services to capitalize on efficiencies. Help these pioneer communities develop metrics to monitor the local system’s performance over time and to guide setting priorities and monitoring the effects of changes. Explore the possibilities for reliable financing. We could learn a great deal from the first few highly efficient and highly reliable community-anchored care systems for elders. Everyone would want their community to follow suit!

Dozens of revisions in delivery arrangements for elder care have been proven to be effective in improving care and reducing costs. The most comprehensive is PACE, the Program of All-Inclusive Care of the Elderly. PACE serves people who are disabled enough to qualify for nursing home care but who continue to live in the community with substantial support, and PACE provides all Medicare and Medicaid covered services, from enrollment to the end of life. More limited fixes, such as transitional care, have been effective. Our MediCaring Communities reform proposal would incorporate whatever improvements in service supply, quality, and delivery serve the priorities of the community. What’s novel about it would be the development of a deliberate local entity capable of some management of the community’s “system.” This entity could assure elder-directed care planning, adequate supportive services, appropriate medical care tailored to this population, monitoring of system performance, local priority setting, shifting of some resources from overuse of medical care, and implementation of improvements with evaluation to assure learning.

Long-term survival with serious disabilities for very large numbers of elderly people is already a major challenge, and one which will grow with the aging baby boomer population. The models that worked to provide and pay for hospital care for acute illnesses will not work for this new situation. We need an era of innovation and testing, shaped by the facts of the situation. We need a new set of policies for our new way of living at the end of our lives. Let’s try substantial innovations, mostly by relieving communities of the burdens of past policies and regulations, and let’s learn quickly so we can count on living comfortably and meaningfully in the last years of our lives.