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A Tribute to My Brother Rob

My brother, Rob, passed away on Saturday, August 26, after a three-month battle with Glioblastoma brain cancer. At times, toward the end of a person’s life, he/she might share valuable life-lessons. When Rob knew his time would be cut short, he didn’t disappoint. He provided heartfelt insight of his time on earth. I was asked by his wife, Patti, to “say a few words” at his funeral. Below is my ‘eulogy’ for my brother, Rob:

The 3rd chapter in the Book of Ecclesiastes opens with “There is a time for everything, and a season for every activity under heaven.” This chapter is really about the seasons we experience in our lives – both good and bad.

How can I possibly share one, two, maybe three, poignant stories about my brother Rob in just a few minutes? I simply can’t.

Instead, I will provide my brief impressions of what I observed during Rob’s final few months while he was with us…as difficult as it may be.

Following Rob’s diagnosis and surgery in May, the reality of his longevity was no longer in question. Once he returned to Centerville from Des Moines, he wanted to spend quality time with family and friends – and many times it would involve the enjoyment of a cigar – or two, or three!

Now, to be honest, I am not a cigar aficionado – far from it. But in late June, I had the opportunity to enjoy a cigar with Rob.  During our “session,” I realized that my cigar had emboldened me to ask Rob a simple, yet possibly intrusive question – which I would attribute to my cigar being laced with a ‘truth serum!’

My question to my dying brother was simply this: “Rob, as you look back now, would you have done anything different in your life?” At that time in June, Rob’s mind was still extremely sharp, but he had great difficulty speaking, he often was only able to stitch a word or two together…which was a great source of frustration for someone who normally is very articulate with his thoughts. Rob looked at me with a resolute determination and responded, “HAVE NO REGRETS.”

Later in this same conversation, Rob was able to make a point that smoking a cigar was most satisfying or fulfilling during the final third of the cigar…I don’t know if the smoke gets thicker, smoother, or is loaded with additional flavor – but it seemed to be the best part of the cigar experience, according to Rob. I believe that Rob was making a point about his remaining time with us.

As I now look back at our simple, yet revealing discussion, I can’t help but make an analogy between Rob’s cigar experience and his own life. You see, maybe a full cigar represents one’s entire life. Each puff marks a season that defines who we ultimately become – whether by choice or by circumstances.

Once the cigar is lit, life’s journey begins, supplemented with a great amount of anticipation and hope, and yes, even peppered with setbacks and pain. Rob’s journey included countless joyous occasions, whether growing up in Fargo with his family and friends, his marriage to Patti, the birth of their four children and their marriages, and now their grandchildren. The tapestry of his life is full of so many examples.

Rob was a planter, both literally and figuratively.  We know about the greenhouse and his beautiful gardens – this was the literal part.  Every season at the greenhouse and with his garden, he would reap what he had sown.  But he also had the uncanny ability to establish (or plant) relationships with others that stood the test of time.

And, in the last few months of his life, he quickly learned that what he had sown with countless friends and acquaintances throughout his life, returned a bountiful harvest of love and cherished friendships that painted a beautiful landscape for him to enjoy. This most satisfying harvest, I truly believe, was Rob’s final puff in his life.

Patti, Liz, Pete and Alex, on behalf of our entire family and all who love Rob, thank you for taking such good care of him, especially during this most difficult time. Your love for your husband and father has been absolutely amazing!

To Rob’s friends and colleagues in Centerville and beyond, your outpouring of support and love for him has been both inspiring and gratifying – words cannot adequately express our feelings.

And, finally to Rob – thank you for sharing these life-lessons with us. You will be deeply missed.

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Prescription Drug Pricing – The Reenactment of Harry Houdini

Noted for his sensational escape acts in the late 19th and early 20th centuries, Harry Houdini used chains, ropes, locks, straightjackets under water and a host of other props to escape from assured harm, if not death. Crowds were enthralled with his heroics, and they paid him for this gross but thrilling form of entertainment.

To protect his unique career, he was a master on safe-guarding his escape secrets, and was very quick to sue others who imitated his escape stunts.

Fast forward to today. We continue to be entertained by protégé’s of Houdini, now better known to be ‘magicians.’ Some are quite well-known: David Copperfield, David Blaine, Ricky Jay, Penn & Teller, among others. One common rule that all legitimate magicians adhere to is quite simple:

NEVER reveal the magic secret.

The biggest magician we have today, is not really a magician, but certainly ‘appears’ to act like one.

The pharmaceutical industry – and many key middlemen side players, such as pharmacy benefit managers (PBMs) – are in the business of obfuscating facts from reality. In June, I wrote a piece about this problem on my The Health Autonomist blog. Like magicians, who know how to manipulate their audience into a false sense of free will, pharmaceutical players want the public to believe that efforts are being made to keep the medication costs as affordable as possible and, in return, ‘reasonable’ profits are justly-earned to keep costs down.

The chart below shows just how unbridled the costs of prescription drugs have become (found in the yellow line since 2013). Rarely do I repeat the same visual, as this one appeared in last week’s blog, but this chart demonstrates just how rampant drug prices have become when compared to other types of health services.

Yet, a host of games are being played that cause the patient to receive minimal benefit from their actions – with much of the financial gain being retained by the ‘altruistic’ players who tout their allegiance to the patient. One example is found on the Kaiser Health News webpage:

A very insightful report, “Getting to the Root of High Prescription Drug Prices,” was recently released by The Commonwealth Fund, that provides an in-depth description of the many problems inherent in drug pricing. More importantly, the report describes many possible actions that policymakers and stakeholders can agree on to find bipartisan solutions to many identifiable problems. By the way, regulating drug prices or purchasing drugs through Canada are not long-term solutions, just band-aid approaches to a persistent open wound.

A newly-published ProPublica article, “Take the Generic Drug, Patients are Told – Unless Insurers Say No,” reveals that pharmaceutical companies are increasingly cutting deals with PBMs and insurance companies to push more expensive name-brand drugs over their generic-equivalents. Such actions suggest that higher profits are being sought, often at the patient’s expense. ProPublica’s other new article about generic drugs serves notice that pharma continues to find innovative ways to make money at the public’s expense.

I enjoy infographics, as they can help make something that is very opaque appear a bit more understandable. Even within the insurance industry, the shenanigans that happen in the PBM world are often difficult to understand – leaving many of us to sort truth from fiction. Through Pembroke Consulting, SSR Health, Kaiser Health News et al., an infographic was produced that does a reasonably good job of exposing the secrets behind the curtain of obfuscation on drug pricing.

Like tricks performed by accomplished magicians, the drug-pricing profession profits from sleight-of-hand tricks that must never be revealed to the public.

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Healthcare Spending – Few Incur the Most in Claims

A country’s distribution of wealth can be eerily similar to its distribution of healthcare spending. For example, a larger portion of wealth of any society is owned by a small percentage of the people in that society. Likewise, the preponderance of healthcare spending comes from a small percentage of people with multiple chronic conditions.

Vilfredo Pareto, an Italian civil engineer, economist and sociologist, termed the distribution of wealth, now known as the Pareto principle, as the “80/20 rule” – of which 20 percent of the population controls 80 percent of the wealth (some caveats apply, but you get the gist of this concept).

Let’s take a look at healthcare spending in our country. Most recently, the National Institute for Health Care Management (NIHCM) released a series of charts that provides a great deal of insight on how a few Americans can greatly impact overall healthcare spending. This insight, of course, is nothing new, yet the slides have been updated, using data from the 2014 Medical Expenditure Panel Survey.

The chart below provides a bird’s eye view of American’s spending distribution in 2014. In that year, the top 10 percent of healthcare spenders accounted for two-thirds of all spending. In healthcare, Pareto’s 80/20 rule might need to be adjusted to the “90/10 rule.” Digging deeper, the top five percent of spenders comprised half of all spending, while only one percent of spenders made up more than one-fifth of all spending.

In a country that spent roughly $3 trillion on healthcare in 2014, about $2 trillion was spent by 10 percent of all spenders and $600 billion was spent by just one percent of healthcare spenders. On the backside, the bottom 50 percent of spenders account for only three percent of spending – quite amazing, right?

In the chart below, the bottom 90 percent of the “Civilian Non-Institutionalized Population” paid $1,500 or less in out-of-pocket costs in 2014, while the top one percent of the distribution had out-of-pocket costs in excess of $6,100, and their mean spending burden was estimated to be nearly $11,000.

Over the past decade (2006-2015), spending for personal healthcare services increased by more than $2,400 per person – roughly a 40 percent increase. Higher spending was observed in all six sectors during this time, with hospital care leading the way:

  • Hospital Care48 percent
  • Home Health & Other LTC Facilities and Services41 percent
  • Physician and Clinical Services35 percent
  • Retail Prescription Drugs34 percent
  • Dental and Other Professional Services30 percent
  • Retail Durable Medical Equipment & Other Medical Products28 percent

Yes, prescription drug costs continue to attract a great deal of media air time concerning price inflation., But it’s hospitals, physician and clinical services and home health that grew more than retail prescriptions over this same time period.

The following chart illustrates the steady increase in per-capita spending for most types of services – such as hospital care, home health and other long-term care, and physician and clinical services. However, retail prescription drugs increased most rapidly from 2013 to 2015, warranting public scrutiny.

Aggregate national spending on personal healthcare services has risen by over 50 percent over the period 2006-2015. Public and private payers are spending more in total, in addition to patients personally paying more (out-of-pocket).

Despite more Americans having high-deductible health plans, other payers (e.g. Medicaid, Medicare and Private Insurance) continue to pay a higher share of the cost.

As health costs continue to increase, the share of total health spending by patient or family has actually decreased (see below).

What do these charts suggest? Healthcare continues to be highly concentrated (few spenders incur the most in claims), costs for all major types of care continue to increase more than we would like, and the spending of the public and private plans continue to outpace the out-of-pocket costs that individuals are required to pay. Finally, personal healthcare spending accounts for a greater portion of the median personal income (see below).

Despite the implications of the above data, recent House and Senate activity in Washington fails to address the source of the cost issue. Much of the ‘healthcare’ debate is about the individual insurance markets, including how to fund Medicaid. What we need is to have an honest, public debate about the relative costs and worth of healthcare – also known as ‘value.’ Currently, we reward volume, not value, in how we pay for the care we receive. The incentives and disincentives we use to ‘reward’ the players in healthcare determine both intentional and unintentional consequences. Because of this, our healthcare ‘system’ is merely performing as haphazardly designed. Let’s solve the individual market and move on.

Perhaps as we move forward, progress will be possible when politicians set aside ideology and focus on pragmatic solutions that put consumers first. That should be our collective hope.

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