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The key allegations in the John Carreyrou WSJ article of Oct 15, 2015 (1) on Theranos are aboutAlleged Clinical Laboratory Improvement Amendments (CLIA)-mandated proficiency tests (PTs) cheating (see extended quotes* from 1 at end of the answer).Alleged test protocol violations (allegedly inappropriately diluting test samples when they shouldn't) when using traditional machines (see extended quotes** from 1 at end of the answer).Why are these two the key allegations? Because they raise the most important and alarming suspicion about Theranos, namely, can we trust their test results? Less important issue is whether they were using their proprietary nanotainers to collect blood samples for the tests they offer as they claimed to have done.Cost, convenience, and test accuracy and reliability are the main elements to successfully challenge incumbents in the clinical blood diagnostics space. In the US, incumbents such as Quest and LabCorp already have accurate and reliable tests so a newcomer needs to prove they do too. Who cares about cost and convenience if test results are inaccurate? Certainly not me nor those dear to me.How could regulatory authorities assess if clinical testing labs generate accurate data? There are two steps.First, such labs need to be accredited. In the US, clinical labs that perform clinical laboratory testing on humans get accredited, i.e., CLIA-88, by the credentialing regulatory authority, Centers for Medicare and Medicaid Services (CMS), which falls under the United States Department of Health and Human Services.'Congress passed the Clinical Laboratory Improvement Amendments of 1988 to set criteria to improve the quality of clinical laboratory services. The goal of this law was to standardize laboratory testing across the United States in all sites conducting testing on human specimens for health assessment or for the diagnosis, prevention, or treatment of disease. Failure to comply with these requirements may result in sanctions by the Health Care Financing Administration (HCFA***), whose task is that of implementing CLIA-88' (2).*** in 2001, HCFA morphed into the current CMS.Second, once accredited, CLIA-certified clinical labs are required to enroll and participate in a Proficiency testing (PT) program administered by the CMS (3, 4).PT is conducted 3 times a year with 5 tests (analytes) per time.Test scores should be >80%, i.e., the results the lab generates in at least 4 of those 5 tests should meet previously established consensus acceptance criteria.Unsatisfactory test performance for a particular analyte on 2 consecutive PTs or for 2 out of 3 triggers sanctions against that lab.The regulations that oversee PT specify (5):'Section 353(d)(1)(E) of the Public Health Service Act requires the laboratory to “treat proficiency testing samples in the same manner as it treats materials derived from the human body referred to it for laboratory examinations or other procedures in the ordinary course of business, except that no proficiency testing sample shall be referred to another laboratory for analysis as prohibited under subsection (i)(4)”. Additionally, this requirement is emphasized in the CLIA regulations at §493.801(b). A laboratory is not to test PT samples on more than one instrument/method unless that is how they test patient specimens. Repeated analysis of PT samples is not appropriate unless patient specimens are similarly tested'.Mandatory PTs are the mechanism to ensure clinical lab tests are accurate (2):'Successful participation in a CLIA-88 approved proficiency testing program is mandated. Proficiency testing determines how well a laboratory’s results compare with those of other laboratories that use the same methodologies and can identify performance problems not recognized by internal mechanisms. Proficiency testing samples are tested along with the laboratory’s regular workload by staff who usually perform the testing using routine methods...Written procedures of the proper handling, analysis, review, and reporting of proficiency testing materials are required. There must be evidence of the identification and review of problems discovered through the use of this program and the documentation of corrective actions taken.When the laboratory uses different methodologies or instruments, or performs testing at multiple testing sites, a system has to be in place that evaluates and verifies the comparability between these test results...This must be documented biannually'.When a clinical testing lab uses, or claims to use, proprietary technologies it claims have no peers, as Theranos claims it does (see 6; the interview with Jonathan Krim at WSJ.D Live on Oct 21, 2015), they need to have a system in place to evaluate and verify comparability of their test results with standard tests. The key allegation pertaining to PT suggests either Theranos didn't or was trying to circumvent such comparisons. Either is a form of PT cheating (1, see * below). Key questions are:For a given analyte, was Theranos testing both patient and PT samples on their proprietary systems or not?For a given analyte, was Theranos testing patient samples on their proprietary system but PT samples on another system?If the former, then those PT results should be comparable to standard PT results for the same analyte, i.e., Theranos should have developed a transparent system for regulators to assess such comparisons. OTOH, the latter would be a 'violation of the state and federal requirements' (1). This last bit brings us to the current conundrum regarding CLIA guidelines in general and to PTs in particular.Realizing that the 1988 CLIA guidelines lack substantial regulatory oversight of technologies that evolved in subsequent decades, the FDA published draft guidelines on October 3, 2014, noting (7),'In summary, the FDA has determined that the following attributes of modern LDTs [Laboratory Developed Tests], which are not attributes of the types of LDTs offered in 1976, create potential increased risk for patients in the absence of appropriate oversight. Many modern LDTs are:• manufactured with components that are not legally marketed for clinical use• offered beyond local populations and manufactured in high volume• used widely to screen for common diseases rather than rare diseases• used to direct critical treatment decisions (e.g., prediction of drug response)• highly complex (e.g., automated interpretation, multi-signal devices, use of non-transparent algorithms and/or complex software to generate device results)However, FDA recognizes that, as with all IVDs [In vitro Diagnostic Devices], there is a wide range of risks associated with the wide variety of LDTs. Thus, FDA believes that a risk-based approach to regulatory oversight of LDTs is appropriate and necessary to protect patient safety. A comprehensive framework that describes FDA’s enforcement policy for different classes and categories of LDTs will help provide clarity to LDT manufacturers and protect patients'.Tests performed using Theranos' proprietary technologies including Edison, i.e., LDT, fall into this grey area. As the Wired's Nick Stockton highlighted in his Oct 21, 2015 article, this grey area currently incompletely regulated by CLIA guidelines led to the FDA, 'increasing its oversight of lab developed tests' (8). These loopholes apply to Theranos' technology and the way they're used/could be used. By submitting their tests for approval by the FDA, Theranos is not so much going above and beyond the norm as they repeatedly claim but rather merely following the mandate of a rapidly evolving regulatory landscape that's finally trying to come to grips with the explosion in healthcare-related technological innovations over the past decade.The irony is that the FDA's increased focus on goings-on in this arena likely had originally nothing to do with concerns about Theranos, which is after all nothing but a traditional clinical lab and not biotech in the classical sense of the word. Rather, the FDA appears to have been extremely alarmed about the rise of DTC (Direct-to-Consumer) genomic tests. Witness their warning letters to Pathway Genomics in 2010 (9) and 2015 (10), and to 23andMe in 2013 (11). Two years later, 23andMe is coming out of the tunnel, having changed its research focus to drug discovery by partnering with Genentech (12).Yet, however the Theranos unraveling began, unravel it certainly has. In that regard, John Carreyrou's follow-up WSJ article of Oct 16, 2015, contained even more damaging information (13) since it alleges that FDA inspectors recently made an unannounced visit to Theranos' offices followed by an audit by CMS. 'Food and Drug Administration inspectors recently showed up unannounced at Theranos, the person familiar with the matter said... Since the inspection by FDA officials, Theranos has also been audited by the Centers for Medicare and Medicaid Services, the main regulatory overseer of clinical labs, according to people familiar with the matter.' (13). In the US medicine and healthcare space, an unannounced visit by FDA inspectors is as bad as it gets.* From 1: 'Whether labs buy their testing instruments or develop them internally, all are required to prove to the federal Centers for Medicare and Medicaid Services that they can produce accurate results. The process is known as proficiency testing and is administered by accredited organizations that send samples to labs several times a year.Labs must test those samples and report back the results, which aren’t disclosed to the public. If a lab’s results are close to the average of those in a peer group, the lab receives a passing grade.In early 2014, Theranos split some of the proficiency-testing samples it got into two pieces, according to internal emails reviewed by the Journal. One was tested with Edison machines and the other with instruments from other companies.The two types of equipment gave different results when testing for vitamin D, two thyroid hormones and prostate cancer. The gap suggested to some employees that the Edison results were off, according to the internal emails and people familiar with the findings.Senior lab employees showed both sets of results to Sunny Balwani, Theranos’s president and chief operating officer. In an email, one employee said he had read “through the regulations more finely” and asked which results should be reported back to the test administrators and government.Mr. Balwani replied the next day, copying in Ms. Holmes. “I am extremely irritated and frustrated by folks with no legal background taking legal positions and interpretations on these matters,” he wrote. “This must stop.”He added that the “samples should have never run on Edisons to begin with.”Former employees say Mr. Balwani ordered lab personnel to stop using Edison machines on any of the proficiency-testing samples and report only the results from instruments bought from other companies...In March 2014, a Theranos employee using the alias Colin Ramirez alleged to New York state’s public-health lab that the company might have manipulated the proficiency-testing process.Stephanie Shulman, director of the public-health lab’s clinical-lab evaluation program, responded that the practices described by the anonymous employee would be a “violation of the state and federal requirements,” according to a copy of her email.What the employee described sounded like “a form of PT cheating,” Ms. Shulman added, using an abbreviation for proficiency testing. She referred the Theranos employee to the public-health lab’s investigations unit'.**From 1: 'In addition to the 15 tests run on the Edison system, Theranos did about 60 more on traditional machines using a special dilution method, the former senior employee says. The company often collected such a small amount of blood that it had to increase those samples’ volume to specifications required by those traditional machines, former employees say...For tests done with dilution, the process caused the concentration of substances in the blood being measured to fall below the machines’ approved range, three former employees say. Lab experts say the practice could increase the chance of erroneous results.Most labs dilute samples only in narrow circumstances, such as when trying to find out by how much a patient has overdosed on a drug, say lab experts.“Anytime you dilute a sample, you’re adulterating the sample and changing it in some fashion, and that introduces more potential for error,” says Timothy R. Hamill, vice chairman of the University of California, San Francisco’s department of laboratory medicine. Using dilution frequently is “poor laboratory practice.”'.BibliographyThe Wall Street Journal, John Carreyrou, Oct 15, 2015. Hot Startup Theranos Has Struggled With Its Blood-Test TechnologyFetsch, Patricia A., and Andrea Abati. "The clinical immunohistochemistry laboratory: regulations and troubleshooting guidelines." Immunocytochemical Methods and Protocols. Humana Press, 2010. 399-412.Page on gpo.govEhrmeyer, Sharon S., and Ronald H. Laessig. "Has compliance with CLIA requirements really improved quality in US clinical laboratories?." Clinica chimica acta 346.1 (2004): 37-43. Page on researchgate.netProficiency Testing ProgramsTheranos CEO Elizabeth Holmes Goes on Stage at WSJDLive 2015 — Live BlogPage on fda.govWired, Oct 20, 2015, Nick Stockton. Fixing the Laws That Let Theranos Hide Data Won’t Be EasyPage on fda.govPage on fda.gov 23andMe, Inc. 11/22/13Forbes, , Oct 14, 2015, Matthew Herper. 23andMe Wins A Second Life: New Business Plan Scores $115 Million From InvestorsThe Wall Street Journal, John Carreyrou, Oct 16, 2015. Hot Startup Theranos Dials Back Lab Tests at FDA’s BehestThanks for the A2A, Jay Wacker.

Health care costs affect the economy, the federal budget, and virtually every American family’s financial well-being. Health insurance enables children to excel at school, adults to work more productively, and Americans of all ages to live longer and healthier lives. The Affordable Care Act (ACA), has made substantial progress in addressing the uninsured Americans. Americans can now count on access to health coverage throughout their lives, and the federal government has an array of tools to bring the rise of health care costs under control.There are several companies which provide health insurance to the US citizens under the ACA, which in-turn promotes Medicaid and Medicare government programs. According to these programs and their respective market shares, the best positioned health insurers are:-UnitedHealth Group Inc.Humana Group Inc.Anthem Inc.These insurers have been working in developing a high-quality, affordable and accessible health care system.In this answer, I will be assessing the progress these companies have made towards improving the US health care system and discuss how policy makers can build on that progress especially under the Trump administration.Medicare ProgramMedicare is a national social insurance program administered by the US federal government since 1966, currently using about 30–50 private insurance companies across the United States under contract for administration.UnitedHealth Group Inc. provides mainly three plans under the Medicare program.Medicare Part A (hospital)Medicare Part B (doctor and out-patient)Medicare Part C, a type of health plan ,also known as Medicare Advantage Plan. This plan combines the Medicare Part A and Medicare Part B, then provide additional benefits that contribute to improving your health and wellness.It also provides other Medicare Advantage plans which include prescription drug coverage (Medicare Part D). Enrollment in Medicare Part A and Medicare Part B is necessary to be eligible to enroll in this plan. It is necessary to continue paying your Medicare Part B premium to keep your coverage under this group-sponsored plan. UnitedHealth tries to offer coverage that is as good as Original Medicare. The government pays them a fixed fee for one’s care. UnitedHealth is required to handle the payments to doctors and hospitals.Humana Group offers the Medicare Savings Program (MSP) to Medicare beneficiaries whose income falls below $1,357 per month for single individuals and $1,823 per month for married couples.Humana offers several other plans under Medicare, one of which is the Humana Gold Choice plan. Humana Gold Choice is a Medicare Advantage private fee-for-service (PFFS) plan. Humana Gold Choice PFFS allows members to use any provider, such as a physician, hospital or any other Medicare provider in the US that agrees to treat the member after having the opportunity to review these terms and conditions of payment, as long as the provider is eligible to provide health care services under Medicare Part A and Part B or eligible to be paid by Humana Gold Choice PFFS for benefits that are not covered under Original Medicare.Anthem Inc. (Wellpoint Inc. Group) has been focusing on making sure that the needs of the people under the Medicare Program are addressed.Anthem has health plans that support those who are Medicare eligible by developing HMOs and PPOs specific to Medicare and providing Medicare Supplement plans to those who want them. They have been constantly working on expanding the tele-health options.Consumers’ costs concerns are addressed with Dual-Eligible Special Needs Plans (DSNPs) that are primarily $0 premium plans with $0 copays. They include dental and vision coverage and some even include coverage for over-the-counter drug costs. HMOs and PPOs specifically focused on accommodating the needs of the Medicare population are now available in targeted markets in 22 states. In specific markets in California and Texas, Anthem’s Medicare Select plans feature tight-knit provider collaboration. Also, convenient online doctor visits are available to most of Anthem’s affiliated Medicare Advantage plans through LiveHealth Online.Medicaid ProgramMedicaid in the United States is a social health care program for families and individuals with limited resources. Medicaid coverage is low cost or no cost to you. It is health care coverage for people with low incomes. Pregnant women, children, the elderly and people with a disability may qualify for the Medicaid Program.Medicaid Program discussed below is in reference with the state of Florida.UnitedHealth Group Inc. With growth in the Medicaid market, UnitedHealth took a vital step of launching a mobile app to better connect with people covered by the state-federal health insurance program.The new app called ‘Health4Me’ lets people in the state of Florida use their phones to more easily review their case history, track claims and find a doctor. The app also provides a digital health plan ID card, which has proved to be the most popular feature in early testing. It’s more about improving the way we share information than anything else when we decided to launch this for our Medicaid population.Expansion of Medicaid eligibility due to the federal health law has been a key factor in enrollment growth across the country, although some states have elected not to expand their programs. In 2014, about 5.1 million individuals were covered through Medicaid health plans at UnitedHealth and during the first half of 2015, the figure grew by 155,000.Humana Group has offered Medicaid services since 1970 in Florida. It is funded by both the state and federal governments and includes both capitated health plans as well as fee-for-service coverage. The Agency for Health Care Administration (AHCA) is responsible for administering the Medicaid program and to administer contracts, monitor Health Plan performance and provide oversight in all aspects of Health Plan operations. The state has sole authority for determining eligibility for Medicaid and whether Medicaid recipients are required to enroll in, may volunteer to enroll in, may not enroll in a Medicaid health plan or are subject to annual enrollment. The 2011 Florida Legislature passed House Bill 7107 to establish the Florida Medicaid program as a statewide, integrated managed care program for all covered services. This program is referred to as the Statewide Medicaid Managed Care (SMMC). In addition, Humana has the responsibility to ensure providers’ submission of encounter data is accepted by the Florida Medicaid Management Information System and/or the State’s encounter data warehouse.The Florida Managed Medical Assistance (FMMA) program focuses on four key objectives in order to support successful implementation:Preserving continuity of care.Requiring sufficient and accurate networks under contract and taking patients, allowing for an informed choice of plans for recipients and the ability to make appointments.Paying providers fully and promptly to preclude provider cash flow or payroll issues, and to give providers ample opportunity to learn and understand the plan’s prior authorization procedures.Coordinating with the Choice Counseling Call Center and website operated by the Agency’s contracted enrollment broker.Anthem Inc. has been investing significant time and resources to understand and serve the nearly 5.9 million plan members in state-sponsored programs across the country. While focusing on the needs of individual consumers, our plans are seeking out new and better ways to improve health outcomes with high-quality, cost-efficient programs that help society more broadly.Florida ranks first in the nation in the number of newly diagnosed HIV infections and second in the number of pediatric HIV cases reported. Clear Health Alliance, an HIV/AIDS Medicaid specialty plan offered by Simply Healthcare Plans, is addressing the special needs of those living with HIV/AIDS in Florida by offering bundled services tailored to their treatment requirements. Anthem is equipping consumers with the knowledge and support to better manage their health.Commercial Business ModelsUnitedHealth Group Inc.The UnitedHealth Group is a leading diversified health and well-being company that provides health benefits and health services through UnitedHealth and Optum business segments. UnitedHealth provides health benefits services to individual consumers, governments, and employers of all sizes. Optum offers health services to diverse stakeholder groups that include individuals, employers, governments, healthcare providers, payers, and life sciences companies.UnitedHealth Group Business Model EvolutionThe chart shown below is a one year stock market analysis till January 2017.The Insurance Company saw an enormous rise in the revenues and made a large operating profit.Humana Group Inc.Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. As of 2014 Humana has had over 13 million customers in the U.S. reported a 2013 revenue of US$41.3 billion and has had over 52,000 employees. It has been the third largest health insurance in the nation.Following is the Financial Highlights of Humana Inc. The results have been extremely supreme over the years!Stock market of Humana Inc. over the last year:Anthem Inc.Anthem Inc. is an American health insurance company founded in the 1940s, prior to 2014 known as WellPoint, Inc. It is the largest for-profit managed health care company in the Blue Cross and Blue Shield Association. It was formed when Anthem Insurance Company acquired WellPoint Health Networks, Inc. with the combined company adopting the name WellPoint, Inc. trading on the NYSE for the combined company began under the WLP symbol on December 1, 2004. On December 3, 2014, WellPoint changed its corporate name to Anthem Inc, and its NYSE ticker changed from WLP to ANTM.Financial Highlights of Anthem Inc. for the past years:Financial and Membership Highlights:(The information presented below is as reported in Anthem’s 2015 Annual Report.)Data Sources:How UnitedHealth Group Makes Money? - Revenues & ProfitsUnitedHealthcare launches Medicaid AppHumana Medicare and Medicaid InformationAnthem, Inc | Investor Relations | Annual ReportsAnthem Annual ReportMedicaid - WikipediaMedicare - WikipediaImage SourcesUnitedHealth Group Incorporated (UNH) Stock ChartGoogleGoogle Images2015 Annual Review UHC

Common error inherent in the term; healthcare isn’t “free”. What you’re asking for is taxpayer-funded, government-administered healthcare, which, ideally, would be rendered with no expectation of direct payment by the patient at or after time of service.Can it be paid for without hindering the economy? Of course it can. All you would do is transition all existing private healthcare plans to an agency of the government; same terms, at least for now, but the government collects all premiums and pays all claims.We have this for our senior citizens, in the form of Medicare. Medicare works much like any other U.S. medical insurance program in that there are premiums and copays payable by the beneficiaries of the plans, and then the plan pays the amount beyond the copay/coinsurance that is billed by the provider.However, it has two fundamental differences. First, anyone with an employment arrangement that the government knows about is paying the bulk of the costs of this plan, in the form of a 2.9% payroll tax, theoretically split half-and-half between your employer and you. So, if you make the US medin income of about $60k a year at 35 years old, you personally are paying $870 for a healthcare plan you legally cannot participate in, and your employer is paying another $870 toward that plan to have you on the payroll, which you will never see even in your gross pay. Unless you’re an independent contractor paid by 1099, basically considered self-employed, in which case you are responsible for both employer and employee portions of the tax ($1740 total). Multiply that by about 265 million working-age adults, and that’s on the order of about $460 billion annually that the seniors actually getting this insurance aren’t paying in premiums, because employers and working-age adults are paying this money but not getting the insurance. That’s something no other insurer on the planet besides the U.S. Government could ever get away with. Imagine having Blue Cross/Blue Shield as your health insurance, and then Cigna or Humana comes and tells your employer “hey, we need 3% of your total employee gross pay to be sent to us to help defray the costs of our own plan for another employer”. You’d tell them to pound sand. But the U.S. government has the power to tax. And it does.Why does the government need so much money to run this program? Because under Federal law, the Department of Health and Human Services which oversees the Medicare program has statute limits on its power to negotiate the “allowable amount” that providers can charge for drugs, devices and equipment. Perhaps you’ve seen the ads on TV, or gotten a robocall, from a company claiming they can get you some medical device like a motor scooter, knee brace or oxygen concentrator at no cost to you if you’re over 65 and eligible for Medicare. These companies aren’t doing it out of the goodness of their hearts; they’re doing this because they can bill Medicare on your behalf at a ridiculous markup over the actual cost of goods sold. These are literally legal insurance scams, legal because the government must pay the quoted price for any covered medical device properly prescribed and procured for a Medicare patient. They can’t choose the lowest bidder, they can’t make you get competing bids, and they definitely can’t examine the provider’s cost structure and insist on cost plus a reasonable markup. They pay the firm’s asking price, because they can do no other. The same applies for prescription drugs under Part D plans; these are privately offered, but pretty much every Medicare patient has a Part D supplemental plan. Yet the government is forbidden to negotiate drug prices on behalf of all Part D subscribers; the insurance companies offering Part D plans must negotiate on behalf of their subset of Medicare patients, a much smaller pool of people that usually have other choices for plans, making the insurer the weak link in negotiations.Much the same happens in the world of private medical insurance, which 85% of U.S. working-age residents have through their employer. Each “group”, generally representing all employees of one company in one state, negotiates with their insurer on premiums and plan features, then insurers negotiate for allowable amounts chargeable by doctors, hospitals and other providers that are “in-network”. Being a network provider has advantages in referrals and compensation for services rendered, the flip side being that providers are limited in the price they can charge for various services.This leads to the basic problem; the provider networks, especially manufacturers, have better negotiating power than any one insurer, because they’re providing healthcare across a very broad geographic area with people covered by dozens of insurers. Insurers, by antitrust law, cannot collude cooperatively to fix prices. So the providers get to set the tone of the negotiations for their products and services, and they do so by demanding ridiculously inflated prices. Unlike in any other debate, the insurer cannot easily just walk away from Merck’s entire product line or from Baylor Scott and White’s hospital system, because its customers have an “inelastic demand” for Merck’s drugs or Baylor’s medical facilities.Simply put, it’s hard to set a price on not dying.As a result, about $500 billion of the U.S.’s annual total healthcare spending is to pay costs for drugs, devices and services in excess of the industrialized world’s average prices for these things, literally “because we can, because you’ll pay it anyway”. That’s about 15% of total U.S. healthcare spending; imagine getting 15% of your current insurance premiums back onto your paycheck. I dunno about you, but that’s grocery money for me and my family. This $500 billion is more than all other reasons we spend more than other countries combined, including higher medical payroll, defensive medicine, billing system inefficiency, “Americans are sicker” etc…… with one exception. End-of-life care. The United States spends nearly 4 times as much per capita keeping the very oldest among us alive, healthy and active as the next biggest spender, Germany:Again, this comes down to “it’s hard to put a price on not dying”, allowing providers of “heroic” end-of-life treatments to charge whatever they like “because we can”. There’s an emotional component to providing care for the elderly; they’re our parents and grandparents, they raised us, they provided for us, got us where we are today. Of course we are going to do whatever we can to provide for their health and comfort in their old age, and to keep them around as long as their bodies keep working (and often after they’re not).This is why the Republican fearmongering of “death panels” under an expansion of government control over healthcare in the U.S. was so effective in limiting the power the government got under ObamaCare; the idea that the choice of how to care for your elderly parents would be taken away from you in the name of cost control scared the bejeezus out of the Baby Boomer generation, whose parents are on the right side of this graph and who are facing the foothills of this uphill climb in spending themselves (and who, not coincidentally, wield considerable power among both parties in Congress). Nobody wants to spend the last years of their lives in a gussied-up hospital complex being cared for by the lowest bidder, especially if the overall goal behind your sacrifice is to get as many others as possible into that facility who otherwise wouldn’t be able to afford it.So, we’ve basically got two problems to solve: providers are the 800-pound gorillas in U.S. healthcare cost negotiations, because they’re providing all of a particular drug or device to the entire market with very few available substitutes, and no one entity in the U.S. has the power to sit on the other side and represent all U.S. healthcare consumers (which is all 325 million of us); and, we love Nana and Pop-Pop too much not to do everything we possibly can to keep them with us as long as possible, long after these treatments are doing more harm than good.Solutions? Well, for the first problem, a single-payer program would give one entity the power to deal face-to-face with providers. This has those providers scared shitless, because the U.S. is pretty much the world’s last cash cow to pad their profit margins. The U.S. is almost literally subsidizing the drug and device prices all the other countries are negotiating; “The Brits want a 20% price reduction on Valium? Sure, fine, give it to them, we’ll just push up the price in the U.S. market to make up the difference on the bottom line”. If the U.S. goes single payer, with the muzzle taken off the government’s price-negotiating ability, that chops down the money tree; the U.S. will be looking at the prices everyone else gets and will demand nothing less.That’s going to hurt drug and device companies, and boy do they ever know it. That’s why the pharmaceutical advocacy lobby, aka “Big Pharma”, spent just shy of a billion dollars on political activity in the 2016 election cycle. $1 billion to protect $500 billion? Sounds like a pretty good business investment. And it’s working; politicians even on the Democrat side are very hesitant to propose or support anything Big Pharma can use to put their picture alongside footage of elderly people with their families and tell the nation “this politician wants your parents to hurry up and die already”.That also hurts other countries; the National Health in the UK will very likely not get the prices it currently does for Valium and fake hips, because all the providers of benzos and artificial joints will be feeling the squeeze in the US and will be looking to bid up the prices everywhere else to stay in the black. So far, we haven’t seen too much concern about that (the ability of the National Health to do business at all post-Brexit is the bigger deal right now), but that may change if and when the details of a single-payer healthcare system empowered to negotiate become widely known.As for getting our country to know when to let their parents go? That’s a far more personal thing, and it’s not something a PSA campaign is going to change hearts and minds about. Quite the contrary, that’s exactly the ammunition Big Pharma needs, a government-sponsored ad campaign encouraging hospice over life-extending treatments. Hope is a really powerful motivator, and it sells a lot of pills and pokes.