Time: Bitter Pill: Why Medical Bills Are Killing Us

[gbear]

What scares me most in the article is the lack of knowledge the consumers have by design. First there are the doctors and hospitals with incentives to promote treatments whether because of kick backs or to pay for the new equipment. How should a patient know what is in fact needed/best for their condition and their pocketbook? Then we add on the crazy billing for services and treatments, often with double or triple billing. I spent a long time going through my hospital bill to get it correct when I was hospitalized for my MS. I've spent dozens of hours in just the past year fighting billing errors and even stopping going to an infusion site over their insistence I get additional blood work every month. I fought the extra needle because I saw and felt it, but the cost was hidden in their bills to my insurance.

As I look at our healthcare market, I see a broken attempt to allow consumers to navigate. We haven't the information, and often when we take the time to try and get the information, we haven't the understanding. The irony with MS is those with MS often have cognitive issues making navigation of the system even harder. The thing is, it's not just MS. Most of us aren't going to the doctor because we are healthy and in the best mental place to make complicated choices. I find the expectation that we the patients should be able to make these decisions in a rational manner to be unreasonable.

When consumers can no longer be expected to make rational decisions to advance their best interest, how can one expect a free market to work? Why do we keep trying to force the square through the circle hole?

[Wrong Direction]

What scares me most in the article is the lack of knowledge the consumers have by design.
...
As I look at our healthcare market, I see a broken attempt to allow consumers to navigate.
...
When consumers can no longer be expected to make rational decisions to advance their best interest, how can one expect a free market to work? Why do we keep trying to force the square through the circle hole?

I think what should scare you most from that article is the fact that healthcare lobbying dwarfs all other lobbies in Washington. They say you can't cut defense because the industry has placed itself in so many congressional districts. Well, healthcare interests are in every single congressional district and in every district of every state and county politician, and every district of every school board.

This isn't about the failure of consumers to operate in a free marketplace. It's about lobbies getting politicians to deliberately fixing the marketplace so it's not free.

This is where politics need to be separated from reality. Truly free markets are based on transparency. If government wanted to drive more competitive pricing, they'd require all providers to post and explain costs and options prior to delivering any non-emergent care. They'd also re-define emergeny care and provide no relief for non-emergent uncompensated care.

Look at spine devices as one example. The feds don't require a unique device identifier despite the fact that requiring such an identifier would clearly allow better safety monitoring. However, it would also allow more transparency in the marketplace respecting pricing.

The notion that markets don't work just rings hollow to me. The Medicare Modernization Act (2003) established 1) Part D and 2) Competitive Bidding for a lot of DME. In each case, savings are larger than expected (or costs are lower than expected). In Part D, it's a direct result of transparent pricing. Part D is filled with protections for seniors and costs are still lower than projections. For competitive bidding, CMS just released savings estimates saying Medicare will save 45% on the cost for DME. That's remarkable, and it's because of competition.

Now ask why CMS hasn't competitively bid labs, therapy, devices in the hospital setting, maintenance nursing, home health...all things with enough supply to allow competition to lower prices. Why are the exchanges forced to cover things like chiropractors? Why are hospitals the focal point of so many "reforms" like payment demonstrations and ACOs? Why do so many states have so few insurance options? Why do so many municipalities basically provide a monopoly to certain insurance companies and disallow open competition. The answer in every case is the big lobbies.

There's no doubt in my mind that the cost of health care is in a massive crony-capitalist-government-created bubble right now. It's the worst of all Republican and Democrat voter nightmares, except for the Republicans and Democrats representing us are bought and paid for. This isn't different than what went on in the housing bubble, or what's going on with college tuition costs today. All of our healthcare could be provided at massive discounts from what we're paying today, but our political system is broken and won't allow it.

[PeterMP]

The notion that markets don't work just rings hollow to me. The Medicare Modernization Act (2003) established 1) Part D and 2) Competitive Bidding for a lot of DME. In each case, savings are larger than expected (or costs are lower than expected). In Part D, it's a direct result of transparent pricing. Part D is filled with protections for seniors and costs are still lower than projections. For competitive bidding, CMS just released savings estimates saying Medicare will save 45% on the cost for DME. That's remarkable, and it's because of competition.

There's no real evidence that Part D came in under budget because of competitive pricing. The two best and only really documtented reasons it has come in under budget are because fewer people signed up for it than expected and because drug costs increased less than expected (which is related to the "patent cliff" and important and common drugs being switched to generics and not many knew patented drugs coming onto the market).

The only people pushing that Part D came in under budget because of design are people that are tied to passing it.

http://www.politifact.com/truth-o-me...nder-budget-b/

That healthcare isn't a free market can be demonstrated with some real simple questions.

Is your doctor "good"?

What data do you have to support that (do you have any data on the health of their patients vs. the costs to the patients)?

The idea that a free market requires that people can make good decisions to operate is basic economics and decisions based only on immediate pricing aren't good decisions.

(IF this works with drugs, it is because of the actions of the FDA (that tries to assure at least some level of quality), which is very non-free market. The FDA takes decisions out of the hands of the drug manufactures in a way that people throw a fit and start talking about "death panels" if they did to individual doctors/hospitials.)

[Wrong Direction]

There's no real evidence that Part D came in under budget because of competitive pricing. The two best and only really documtented reasons it has come in under budget are because fewer people signed up for it than expected and because drug costs increased less than expected (which is related to the "patent cliff" and important and common drugs being switched to generics and not many knew patented drugs coming onto the market).

Politifact is a joke, but that's off topic.

I'll address the substance of your post, but we should be clear that the goal posts on this conversation are nowhere near where they are on any other entitlement spending.. We're actually discussing the reasons that a government program came in either 28% or 40% below budget. Politifact doesn't project how much under budget Part D would have been with other enrollment assumptions, but in any case we're discussing a program that would be, at worst, on budget if the flawed assumptions were correct. That would be a success all by itself.

Democrat versions of alternative legislation/amendments wanted to guarantee a $35/month premium in the first year, and that would escalate annually based on a growth factor. Seven years after implementation, there are still many plans available for cheaper than that.

Why is enrollment lower? Two reasons:

1) the tax free retiree drug subsidy (RDS) has proven to be effective. This is not free to the government, but in fairness it's also not a 1:1 offset of what costs would be if those beneficiaries chose to enroll directly in a Part D Plan. So, people subsidized by the retiree drug subsidy are getting ~60% of the subsidy amount from the government that they would have if they enrolled (going by memory, and after considering the 28% subsidy is tax free).

2) many plans would drop medical coverage for spouses if their member chose Part D only, so people basically got stuck in their employer plan. Most of those folks have employers who are also getting the RDS, so the savings resulting in lower Part D enrollment are mitigated.

After you look at all the data, something like 91% of Medicare beneficiaries have "creditable coverage." That figure is incredibly close to original estimates.

Generic pricing and overall pricing is a chicken and the egg type of argument. People who were against the plan (from both parties) like to say that generics took off and lack of block busters had an effect. However, the evidence on their side is slim to none. First of all, Part D outperformed Medicaid programs with respect to generic utilization, and that includes states that mandated use of a generic. I know this for a fact because I cobbled together that data myself as part of my job at the time. The transparency with respect to patient options, required patient cost sharing and the donut hole all drove this. Only a nincompoop would deny those economics.

With respect to new blockbusters, there aren't a ton of blockbuster surprise drugs out there. Development is slow and predictable. I know price estimates came out higher than what eventually happened, but that's not primarily because new blockbusters didn't hit the market; it's because 1) pricing competition between brands, 2) from generics, 3) between pharma companies and plans as it related to formulary placement and patient cost sharing and 4) pharmacy network competition happened throughout Part D. Those plan/pharma and plan/pharmacy negotiations drive lower plan costs and thus lower premiums, and lower premiums have driven enrollment.

And these various pricing competitions had a downstream (non-Medicare) effect because the size of the Medicare market drove down the various index pricing standards (AWP, AMP, WAC).

I don't blame politifact for not understanding this stuff. I blame them for speaking with authority about something they don't understand. The least they could have done is try to quantify the cost difference by having less people purely part of Part D, but I frankly even question the details he presented around that "fact" simply because overall coverage ended up very close to the number he cited.

Really, the truth about beneficiary choices is in the enrollment data. Beneficiaries, in large numbers, chose cheaper plans, they got the coverage they wanted and they responded with incredibly high satisfaction rates. The market delivered them the price and coverage they need.

[chipwhich]

The real bitter pill can be seen in real life. Go to a CVS, and walk back to their pharmacy, look at all the prescription drugs waiting to be picked up. Then literally walk across the street to Walgreens and do the same. Then literally walk to the other corner to Rite Aid and do the same.

This doesn't even address mail order.

Over prescribed and unhealthy America. The new American way.

No other country could support 3 drug stores on the same street/corner.

[Wrong Direction]

We definitely have an issue with using too many prescription drugs. It's easier to lament when it's not your or your family member faced with those decisions.

[chipwhich]

We definitely have an issue with using too many prescription drugs. It's easier to lament when it's not your or your family member faced with those decisions.

Or, when your family has faced those decisions it's not easy to lament the fact that we are in this position.

My family hasn't been avoid of this lifestyle, I assume yours hasn't either.

[PeterMP]

1) the tax free retiree drug subsidy (RDS) has proven to be effective. This is not free to the government, but in fairness it's also not a 1:1 offset of what costs would be if those beneficiaries chose to enroll directly in a Part D Plan. So, people subsidized by the retiree drug subsidy are getting ~60% of the subsidy amount from the government that they would have if they enrolled (going by memory, and after considering the 28% subsidy is tax free).

2) many plans would drop medical coverage for spouses if their member chose Part D only, so people basically got stuck in their employer plan. Most of those folks have employers who are also getting the RDS, so the savings resulting in lower Part D enrollment are mitigated.

The end result is that spending on Part D is lower partly because of decreased enrollment.

Generic pricing and overall pricing is a chicken and the egg type of argument. People who were against the plan (from both parties) like to say that generics took off and lack of block busters had an effect. However, the evidence on their side is slim to none.

First of all, Part D outperformed Medicaid programs with respect to generic utilization, and that includes states that mandated use of a generic. I know this for a fact because I cobbled together that data myself as part of my job at the time. The transparency with respect to patient options, required patient cost sharing and the donut hole all drove this. Only a nincompoop would deny those economics.

With respect to new blockbusters, there aren't a ton of blockbuster surprise drugs out there. Development is slow and predictable.

First, new drug applicants to the FDA (NDAs) are down and the exculsivity period of the NDAs granted by the FDA have been declining. This wasn't predicted and isn't the result of a proces that is slow, but steady.

http://www.nature.com/nbt/journal/v2.../nbt.1993.html

Second, spending on drugs in the general population has not increased as much as expected, while non-generic prices have gone up because of increased use of generics tied to drugs that were not generic before becoming generic.

"The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts."

"Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said."

If you were taking Lipitor, you now can take a generic and save money and things like Lipitor "blockbuster" drugs are among the most common drugs taken.

And not surprisingly the generic market share has increased:

http://www.manhattan-institute.org/html/mpr_11.htm

This has nothing to do with Part D and just due to the patent cycle/the FDA approval process (the exclusivity periods granted by the FDA).

"Lower-Than-Expected Medicare Drug Costs Mostly Reflect Lower Enrollment and Slowing of Overall Drug Spending, Not Reliance on Private Plans"

http://www.cbpp.org/cms/index.cfm?fa=view&id=3775

"Actual net Part D costs per beneficiary in 2010 were 22 percent lower than the Medicare trustees originally projected and 16 percent lower than CBO had estimated. But overall prescription drug spending per capita in 2010, as measured in the National Health Expenditures estimates, was 35 percent lower than the actuaries at the Centers for Medicare & Medicaid Services (CMS) projected when Congress enacted the drug benefit."

Accross the board the US population spent less money than projected for prescription drugs. The costs of drugs is not increasing as fast as expected.

"Indeed, overall drug spending per capita grew an average of only 2.8 percent a year between 2006 and 2010. Overall retail drug spending per capita in 2010 was 35.3 percent lower than had been projected in 2004."


I guess those people don't know what they are talking about either.

Oh and here's more for you:

"For example, in 2009, on a per-unit basis, Medicaid drug rebates were three times larger than the median rebates negotiated by private insurance plans for the top 100 drugs used by Medicare Part D beneficiaries, according to the Department of Health and Human Services' (HHS) Office of the Inspector General. As a result, Medicaid drug rebates reduced total Medicaid spending for these drugs by 45 percent, while the discounts negotiated by private plans reduced Part D costs for the same drugs by only 19 percent. Ensuring that Medicare gets the same rebates for drugs dispensed to low-income Medicare beneficiaries that Medicaid obtains for those drugs would reduce Part D costs by $137 billion (or nearly 12 percent) over the next ten years, according to CBO — striking evidence of the extent to which Part D overpays for prescription drugs."

Simply by going to government run Medicare prescription drug and mandating the same reduction that Medicaid got, we'd save money.

(The idea that ONLY private industry can negotiate with the Pharma industry and get rebates is laughable. The US military does it, Medicaid does it, Canada does it.)

"For example, one report argued that private Part D plans have been especially successful at encouraging the use of generic drugs.[19] Yet, the use of generic drugs among Part D plans appears to have been no different than the rates of generic utilization in state Medicaid programs during the early years of the drug benefit.[20] "

I know price estimates came out higher than what eventually happened, but that's not primarily because new blockbusters didn't hit the market; it's because 1) pricing competition between brands, 2) from generics, 3) between pharma companies and plans as it related to formulary placement and patient cost sharing and 4) pharmacy network competition happened throughout Part D. Those plan/pharma and plan/pharmacy negotiations drive lower plan costs and thus lower premiums, and lower premiums have driven enrollment.

1. I can demonstrate that the number of NDA approved by the FDA have decreased over the last 10+ years and that there are fewer years of exclusitivity being granted.

2. I can demonstrate that the percentage of generic drugs being sold in the US (not just through Medicare) has gone up.

3. I can demonstrate that the rate at which prescription drugs costs are increasing has slowed even though the price at which non-generics has not and that the prices of generics has actually declined.

None of this has anything to do with Part D. For anybody that you predicted prescription drug costs for over the last decade assuming a similar rate of NDA and usage and exclusitivity length of time over the last ten years, the net effect is that you would have had a pretty large over-estimate.

Only a nincompoop would claim that things that can be rigorously documented and demonstrated didn't happen or weren't having an effect.

What can you document?

(Oh and again, this only works because generics actually work, which only happens because the FDA works to help ensure their quality (though they are held to much lower standards than non-generics (e.g. the variation in the amount of active ingredient can be much higher in non-generics)).

[NoCalMike]

From what I hear from people, going to the doctor, whether or insured or not usually consists of a 2 minute session where the patient describes their symptoms, followed by the Doctor authorizing a prescription. In & out in 5 minutes, barely any conversation or examination let alone advice on how to possibly makes lifestyle changes to get rid of whatever is ailing them. (As far as patients living unhealthy lives go)

Pharmaceutical companies don't want a healthy population, they want folks to be ailing, just not terminal. They want a situation where taking pills makes you temporarily feel better.

This I understand is just one tiny aspect of how the healthcare system is messed up, but it is very real.

[chipwhich]

This I understand is just one tiny aspect of how the healthcare system is messed up, but it is very real.

Well according to PeterMP it's a check box on a voting form.

Meanwhile back at the ranch.....

[Special K]

The real bitter pill can be seen in real life. Go to a CVS, and walk back to their pharmacy, look at all the prescription drugs waiting to be picked up. Then literally walk across the street to Walgreens and do the same. Then literally walk to the other corner to Rite Aid and do the same.

This doesn't even address mail order.

Over prescribed and unhealthy America. The new American way.

No other country could support 3 drug stores on the same street/corner.

Just curious, who and/or what do you attribute this problem to?

[gbear]

"Pharmaceutical companies don't want a healthy population, they want folks to be ailing, just not terminal. They want a situation where taking pills makes you temporarily feel better."

I see this sentiment often, especially on message boards for MS and other chronic medical conditions. When I worked for a consulting firm looking at the market for new medical technologies, the concern with holding anything back was progress with existing compounds and treatments is inevitable. It made no sense to go through a fairly expensive approval process if somebody would release something better than you had in a month. There was a push to define the ideal target niche where your drug works best. I just can't see the situation where it would make sense to sit on a cure.

The problem as I see it comes when the cure has been around forever, but it was a cure for something else. The incentive to go through trials to test the efficacy of a drug which has been out for 30 years treating another condition just don't seem to exist. Without the trials, the drug won't be used or covered.

[Wrong Direction]

The end result is that spending on Part D is lower partly because of decreased enrollment.

A little bit, but the degree of that difference is not reported, and the politifact article preditably plays that angle up while somewhat discounting the other side.

First, new drug applicants to the FDA (NDAs) are down and the exculsivity period of the NDAs granted by the FDA have been declining. This wasn't predicted and isn't the result of a proces that is slow, but steady.

This takes 7 years of program context into account, but ignores that costs in year 1 were lower than projected. There wasn't a massive withdrawal of pharmaceutical trials from the FDA or a massive unplanned ending of exclusivity periods coinciding with the start of Part D. The truth is that most of the exclusivity periods and new labels were on the radar forever. I generally think the difference between Part D and B funding has driven manufacturers more toward biologic injectibles (BLA) and less toward traditional oral agents, but that too is driven by the economics of Parts B and D.

Second, spending on drugs in the general population has not increased as much as expected, while non-generic prices have gone up because of increased use of generics tied to drugs that were not generic before becoming generic.

1) I've explained the economics of drug pricing within and beyond Part D. Spending hasn't increased as much as expected precisely because of that transparency. (caveat...since the economic downturn, spending across healthcare has diminished relative to expectations. However, this was already true in the drug world prior to the downturn). Second, it's certainly possible that brand manufacturers are trying to squeeze more profit out of their exclusivity periods since their profit after loss of exclusivity has diminished. I'm not sure what the point there is, and I'm certainly not sure that's a bad thing when considering the context of savings attributable to generics now that the marketplace is more driven in that direction.

"The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two"

Brand drugs have been rising faster than inflation for a very long time. Part D's drive to generics, coupled with similar benefit tiering now promulgating throughout health plans, has driven generic use up. That has resulted in more generic companies competing for more customers, and that has driven the price of generic drugs down. Interesting note...generic price negotiations occur between the generic company and the pharmacy in many cases. The growth of chain pharmacies has contributed to lower generic prices as well, as evidenced first by Wal Mart's $4 generic list.

If you were taking Lipitor, you now can take a generic and save money and things like Lipitor "blockbuster" drugs are among the most common drugs taken.

Lipitor is the biggest blockbuster drug ever. It's exclusivity period has been known forever. CBO can account for this stuff. If anything, Pfizer going the authorized generic route extended high prices for Lipitor longer than was previously predicted.

This has nothing to do with Part D and just due to the patent cycle/the FDA approval process (the exclusivity periods granted by the FDA).

This is just false; willfully ignoring the scope of Part D. Yes, the cycle has plenty to do with this, but that cycle has been known. The FDA approval process, if anything, has gotten faster, not slower over these years. I'm not sure why it's so hard for people to admit that real marketplace dynamics among the population that uses the most drugs has also contributed to pricing. It's crazy to think it hasn't.

"Actual net Part D costs per beneficiary in 2010 were 22 percent lower than the Medicare trustees originally projected and 16 percent lower than CBO had estimated. But overall prescription drug spending per capita in 2010, as measured in the National Health Expenditures estimates, was 35 percent lower than the actuaries at the Centers for Medicare & Medicaid Services (CMS) projected when Congress enacted the drug benefit."

Accross the board the US population spent less money than projected for prescription drugs. The costs of drugs is not increasing as fast as expected.

"Indeed, overall drug spending per capita grew an average of only 2.8 percent a year between 2006 and 2010. Overall retail drug spending per capita in 2010 was 35.3 percent lower than had been projected in 2004."

Come on Peter, from wikipedia..."While the CBPP claims to be non-partisan, journalists have characterized it as liberal or left of center." Note that there are 8 citations for that quote.

To hear detractors, they'd argue that this growth is purely a coincidence of timing that just happens to exactly coincide with a drug benefit that has tons of competitive mechanisms for a huge part of the highest drug users in the country. The least you can do is admit that people who are against the politics of the benefit have at least as much incentive to diminish Part D's achievements as its original supporters have to attribute all of its achievements to their ingenius benefit design. Politics goes both ways.

"For example, in 2009, on a per-unit basis, Medicaid drug rebates were three times larger than the median rebates negotiated by private insurance plans for the top 100 drugs used by Medicare Part D beneficiaries, according to the Department of Health and Human Services' (HHS) Office of the Inspector General. As a result, Medicaid drug rebates reduced total Medicaid spending for these drugs by 45 percent, while the discounts negotiated by private plans reduced Part D costs for the same drugs by only 19 percent. Ensuring that Medicare gets the same rebates for drugs dispensed to low-income Medicare beneficiaries that Medicaid obtains for those drugs would reduce Part D costs by $137 billion (or nearly 12 percent) over the next ten years, according to CBO — striking evidence of the extent to which Part D overpays for prescription drugs."

Squeeze the balloon. Medicaid can charge all the rebates it wants and all that does is raise WAC, which causes non-Medicaid drug programs to basically subsidize Medicaid. That's sort of good for Medicaid's bottom line, but not for drug costs in general. Force the same thing in Medicare and you'll just compound that effect. The difference between Medicaid rebates and Medicare rebates is pharmaceutical manufacturers are paying those rebates in Medicare because they need to pay them to get formulary access. If Medicaid wanted to have a positive global (in the US) effect on drug pricing they'd negotiate lower WAC/AMP pricing rather than bigger rebates. Manufacturer costs of rebating through Medicaid can be passed on to others. Causing actually lower AMP or WAC list prices would accrue to the benefit of other payers and against manufacturers, and it would still leave the competitive private rebating negotiations in place since they serve a totally different purpose. The more I think about Medicaid drug pricing, the more I remember how worked up I used to get about it. Their pricing schemes are purely designed to make Medicaid costs appear better than others. They actually hurt the marketplace in a bad way, particularly the details (like requiring best price be offered to Medicaid, which just removes the incentive for manufacturers to negotiate better prices with other payers).

(The idea that ONLY private industry can negotiate with the Pharma industry and get rebates is laughable. The US military does it, Medicaid does it, Canada does it.)

But you're not talking about negotiations with Part D. You're talking about price fixing (mandating equal rebates to Medicaid, even though they're only similar by name but not by function). Sure, if you price fix, you can achieve savings. Negotiations happen between two parties and are only actual negotiations if one party can walk away from the table. If you truly want to give Part D the ability to negotiate better rebates, you'd reduce the very high bar CMS has set in its formulary requirements. Correct me if I'm wrong, but I believe coverage requirements are broader in Part D than DoD, VA, Medicaid or Canada. That would increase competition to be on a formulary. That's what VA does...provide formulary access to much fewer drugs. People in the VA can eventually get the drugs they want, but they first have to overcome the processes designed to give them access only to their negotiated drug and then have to win an appeal. The hurdle is substantial.

"For example, one report argued that private Part D plans have been especially successful at encouraging the use of generic drugs.[19] Yet, the use of generic drugs among Part D plans appears to have been no different than the rates of generic utilization in state Medicaid programs during the early years of the drug benefit.[20] "

I literally created a table about this in 2007. Part D was ahead of Medicaid programs and outpaced projections for generic dispensing rates by just over 4%. I can't find it in my files...it was literally 6 years ago and I have changed jobs. In any case, if you wanted, you'd look for OIG reports about GDRs in Medicaid in 2005/2006 and compare to Part D and you'll find that Part D is ahead.

1. I can demonstrate that the number of NDA approved by the FDA have decreased over the last 10+ years and that there are fewer years of exclusitivity being granted.

Great, but exclusivity changes are relatively recent and much of this happened after Part D was already showing savings. Plus, are you accounting for BLAs? Genuinely asking on that latter point. ASP + 6 creates terrible pricing incentives.

2. I can demonstrate that the percentage of generic drugs being sold in the US (not just through Medicare) has gone up.

Just not as much as Medicare. Here's one old press release I did find. It doesn't mention Medicaid, but does show that Part D is outpacing private industry alone in this regard:
http://www.cms.gov/apps/media/press/...&cboOrder=date

3. I can demonstrate that the rate at which prescription drugs costs are increasing has slowed even though the price at which non-generics has not and that the prices of generics has actually declined.

And I explained how Part D marketplace dynamics contribute, and once again that the Part D savings were immediate and not dependent on datapoints from 2008-present.

None of this has anything to do with Part D. For anybody that you predicted prescription drug costs for over the last decade assuming a similar rate of NDA and usage and exclusitivity length of time over the last ten years, the net effect is that you would have had a pretty large over-estimate.

Only a nincompoop would claim that things that can be rigorously documented and demonstrated didn't happen or weren't having an effect.

Luckily I'm claiming no such thing. I'm able to point out that Part D was the leader in this regard and I've contextualized the difference in enrollment projections. Bottom line: Part D has been cheaper than predicted since day 1. It drove generic utilization in advance of the rest of the market. Formulary tiering, pharmacy networks and transparent premiums have contributed greatly to that.

I'm not discounting that out year projections (years 5-10) generally become less accurate. That's always true. It's a fact of scoring and assumptions. I'm happy to concede that point because it's not one I'm arguing. It doesn't change the fact that pricing and generic use were better in Part D immediately after implementation of the program, and that those lower costs have held ever since.

[SkinsHokieFan]

Just curious, who and/or what do you attribute this problem to?

Fat, unhealthy Americans?

TV, cars, lack of exercise, too much drinking, not walking enough, big macs, farm/ethanol subsidies and just a general laziness of our population

shall I go on?

[Wrong Direction]

Fat, unhealthy Americans?

TV, cars, lack of exercise, too much drinking, not walking enough, big macs, farm/ethanol subsidies and just a general laziness of our population

shall I go on?

Not enough attention drawn to the negative effects of prescription drugs, particularly their interactions.