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Behind the Scenes on Those Enormous Medicare Billing Numbers

| Thu Apr. 10, 2014 8:53 AM PDT

Yesterday's data dump of how much Medicare pays doctors has generated predictable outrage about the vast amounts some of the top doctors bill. Obviously there are a lot of reasons for high billing rates, but Paul Waldman points to an interesting one: the way Medicare reimburses doctors for pharmaceuticals is partly to blame. The #1 Medicare biller on the list, for example, was a Florida ophthalmologist who prescribes Lucentis for macular degeneration instead of the cheaper Avastin. Since Medicare pays doctors a percentage of the cost of the drugs they use, he got $120 for each dose he administered instead of one or two dollars. That adds up fast. (More on Avastin vs. Lucentis here.)

In the LA Times today, a Newport Beach oncologist who's also near the top of the Medicare billing list offers this defense:

For his part, Nguyen, 39, said his Medicare payout is misleading because all five physicians at his oncology practice bill under his name, and much of that money overall is reimbursement for expensive chemotherapy drugs on which he says doctors make little or no money. Other high-volume doctors voiced similar complaints about the data.

Anyway, Waldman wonders why we do this:

If nothing else, this story should point us to one policy change we could make pretty easily: get rid of that six percent fee and just give doctors a flat fee for writing prescriptions. Make it $5, or $10, or any number that makes sense. There's no reason in the world that the fee should be tied to the price of the drug; all that does is give doctors an incentive to prescribe the most expensive medication they can. That wouldn't solve all of Medicare's problems, but it would be a start. Of course, the pharmaceutical lobby would pull out all the stops trying to keep that six percent fee in place. But that's no reason not to try.

The backstory here is that Medicare used to set the reimbursement rate for "physician-administered drugs" based on an average wholesale price set by manufacturers. This price was routinely gamed, so Congress switched to reimbursing doctors based on an average sales price formula that's supposed to reflect the actual price physicians pay for the drugs. Then they tacked on an extra 6 percent in order to compensate for storage, handling and other administrative costs.

I don't know if 6 percent is the right number, but the theory here is reasonable. If you have to carry an inventory of expensive drugs, you have to finance that inventory, and the financing cost depends on the value of the inventory. More expensive drugs cost more to finance.

However, this does motivate doctors to prescribe more expensive drugs, a practice that pharmaceutical companies are happy to encourage. I don't know how broadly this is an actual problem, but it certainly is in the case of Avastin vs. Lucentis, where the cost differential is upwards of 100x for two drugs that are equally effective. And the problem here is that Medicare is flatly forbidden from approving certain drugs but not others. As long as Lucentis works, Medicare has to pay for it. That's great news for Genentech, but not so great for the taxpayers footing the bill.

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MAP: In 31 States, Daycare Is More Expensive Than College

| Thu Apr. 10, 2014 7:20 AM PDT

Last month, Shanesha Taylor, a homeless single mom in Phoenix, Arizona, was arrested for allegedly leaving her two children in her car while she went to a job interview. Taylor's story, and her tearful mug shot, have attracted national attention and an outpouring of donations. Debate the morals, but one thing is clear: child care is expensive. As the Washington Post reported Wednesday, infant daycare costs more than in-state college tuition in about two-thirds of the nation.

In 31 states, parents have to shell out more annually for infant child care than for a year of tuition and fees at a mid-priced state college, according to a report released last fall by Child Care Aware America, a national organization of child-care resource agencies. In New York, daycare for young children costs $8,000 more than in-state college tuition. Infant child care in Massachusetts, Maryland, Colorado, Wyoming, Alaska and Oregon also costs thousands of dollars more per year than a state college education. Check it out, via the Post. (In red states, daycare costs more):

The difference in the cost of daycare and higher education among states is due to variances in costs of living, differing state regulations, and disparities in state spending on higher education.

Child care costs have jumped over the past couple decades. In 1985, the average weekly cost of daycare in the US was $87 in 2013 dollars. In 2010, child care cost $148 a week. That may help explain why more moms are choosing to stay at home today than at any point during the past 20 years. According to a Pew Research report released Tuesday, the share of stay-at-home mothers rose from a low of 23 percent in 1999 to 29 percent in 2012.

Second Look: Greece May Be Recovering, But Only Barely

| Thu Apr. 10, 2014 7:16 AM PDT

Yesterday I linked to a Hugo Dixon column arguing that Greece is, improbably, starting to recover. Ryan Cooper points to Greece's stubbornly high unemployment rate and begs to differ:

With unemployment still over 27 percent, I'd say let's hold off on talk of a recovery.

Indeed, I rather fear this could be the worst of all worlds. Moving off the Euro would have been awful, but at least held the prospect of returning to growth and full employment within a couple years (from a much lower base). By contrast, the bank Natixis recently estimated that, given very generous assumptions, it will take Spain (which is in similarly dire straits) 25 years to return to 2007-era employment. A nation can do a great deal of catch-up growth in that time.

Realistically, I'd guess this means that Spain, Greece, Italy, Portugal, Ireland, etc., will never recover fully, and instead we're witnessing the birth of a crummy, tattered Franco-German empire with a permanently depressed periphery.

Fair enough. I think it's worth pointing toward signs of progress, but it's certainly true that the eurozone's can-kicking response to its financial crisis has had the effect of enormously protracting the misery of the mostly southern debtor countries. Recovery may be starting, but even if it is, it's going to be a very, very long time before Greece is actually in anything approaching decent shape.

We're Still at War: Photo of the Day for April 10, 2014

Thu Apr. 10, 2014 7:00 AM PDT

Solders assigned to Troop C, 1st Squadron, 33rd Cavalry Regiment, 3rd Brigade Combat Team “Rakkasans,” 101st Airborne Division (Air Assault), fire 60mm mortars during a live-fire exercise March 23. The exercise consisted of infantry, artillery and aircraft coming together as one to destroy targets on the range. (Photo by Sgt. Brian Smith-Dutton 3rd BCT Public Affairs)

Democratic Donors Are Gearing Up for Clinton in 2016

| Thu Apr. 10, 2014 6:36 AM PDT

Democratic donors are apparently warming to the idea of a Hillary Clinton presidential run. On Thursday, Ready for Hillary, a super PAC that aims to encourage Clinton to enter the 2016 race, released its fundraising numbers for the first quarter of 2014. Between January and March, it pulled in more than $1.7 million.

In the realm of super PACs, $1.7 million might not seem like much—compared to the massive sums the Koch brothers regularly dump into campaigns, it's a pittance. But it's an impressive haul given Ready for Hillary's self-imposed limitations. The group started off as a small-scale operation, just two Clinton superfans agitating for their hero to make another run at the White House. Ready for Hillary capped donation at $25,000 to maintain little-guy cred, a restriction its founders have maintained even as major Democratic donors like George Soros have joined their cause. That $1.7 million was cobbled together from 32,000 donations, 22,000 of them from new donors, and 98 percent of them for less than $100. Nearly 10,000 contributions were for the group's suggested amount: $20.16.

The group's funds are coming in at a faster clip with each reporting deadline. Ready for Hillary raised $1.2 million in the first half of 2013 and more than $4 million last year total. The midterm elections are still seven months away, but a growing number of Democrats are already opening up their wallets for 2016.

What's the point of raising all that money when Clinton isn't even a candidate yet? List-building. Ready for Hillary has no intention of running TV advertisements—that responsibility has fallen to Priorities USA, the super PAC that bolstered President Obama's 2012 reelection campaign but has retooled to support Clinton's presumed candidacy. Instead, Ready for Hillary is building a network of field staff and running online ads to collect the names and contact information of diehard Clinton supporters. Once Clinton makes her candidacy official—presumably sometime early next spring—Ready for Hillary will sell or lease its list to the official campaign, giving Clinton a leg up on any primary challengers. She'll launch her campaign with a national database of her most likely donors and volunteers. At the group's current pace, Ready for Hillary should have ample information to offer: It now boasts 1.7 million Facebook fans and, with the latest report, more than 55,000 donors.

 

Meet the Artists Behind the Giant Poster Targeting Drone Pilots

| Wed Apr. 9, 2014 2:21 PM PDT
Two weeks ago, artists unfurled this giant poster of a drone-strike survivor in a field in northwest Pakistan.

On the night of August 23, 2010, an American drone destroyed a home in Danda Darpakhel, a village in North Waziristan, Pakistan. The strike was meant to target a Haqqani network compound, but also killed Bismillah Khan, his wife, and two of their sons, aged 8 and 10 years old. The family's two young sons and daughter, whose names and ages are unknown, survived.

Now Khan's daughter's face has become part of the first-ever art installation aimed at an audience watching from the sky: American drone pilots.  Two weeks ago, artists spread out a large poster of the girl in Khyber Pakhtunkwwa, the Pakistani province that neighbors North Waziristan. The image on the sprawling poster comes from a photo (below) taken by Pakistani photographer Noor Behram a few hours after the strike on the girl's home. 

The artists call their project #NotABugSplat, a reference to "bug splat," drone-pilot lingo for kills.

A girl and her two brothers after surviving a drone strike in August 2010  Noor Behram/ Reprieve

The artist collective, which includes artists from France, Pakistan, and the United States, set up the poster with the help of the British charity Reprieve  and a Pakistani NGO, the Foundation for Fundamental Rights. They hope that the poster will make drone operators empathize with the people who live under their gaze. "We were considering whether to put words in the poster, but decided against it, since the photograph already speaks a thousand words," one of the members of the collective, who asked to remain anonymous, told Mother Jones, "Her eyes say everything."

When the artists arrived in Khyber Pakhtunkhwa, they were greeted by "warm, welcoming" villagers, who helped them unfold the gigantic image. The 90-foot by 60-foot poster took an hour and a half to unfurl. At ground level it looked like a bunch of pixels. But once the villagers saw a photo of the image taken by the artists' own remote-controlled mini-drone, they were ecstatic. 

Unfolding the image #NotABugSplat
Villagers with the poster #NotABugSplat.com
The poster as seen from the artists' own drone #NotABugSplat

To get a sense of the scale of the poster, it helps to look at the road winding besides it, dotted by miniscule people who are "about the size of bugs", says one of the artists.

The strike that killed most of the girl's family also destroyed or badly damaged five other houses, killing at least nine civilians who were part of a community of Afghan refugees that had been there for two decades. The girl and her brothers were taken in by family members on the other side of the Pakistan-Afghanistan border.

More than 100 days have passed since the last American drone strike in Pakistan. The #NotABugSplat artists hope there they won't have to make any more such posters. "But if the need is there, we will do more," says the collective.

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Most Senators Overseeing the Comcast-Time Warner Deal Have Taken Money From Both

| Wed Apr. 9, 2014 1:35 PM PDT

Today the Senate Judiciary Committee heard testimony from Comcast and Time Warner executives about their extraordinarily controversial merger proposal. A recent poll found that 52 percent of respondents believed mergers like it lead to reduced competition and poorer service for consumers. 

At today's hearing, a number of the senators expressed concern about the deal which, if approved, would result in a single company serving slightly less than 30 percent of the US paid television market and up to 40 percent of American broadband subscribers. Chairman Leahy (D-Vt.) started the proceedings, saying that "thousands of Americans have flooded the FCC [Federal Communications Commission] in recent weeks with comments supporting the restoration of open-internet rules. Their voices on this issue should be heard."

But Leahy and most of his colleagues have already "heard" from both Comcast and Time Warner—in the form of generous campaign contributions. Out of the committee's 18 members, 15 have accepted donations from at least one of the two media giants since the 2010 election cycle; 12 have received money from both. The average contribution over that time: $16,285. Democrats were the biggest recipients, taking an average of $18,531 from the two cable and internet giants, nearly twice as much as their Republican counterparts. Here's the breakdown: 

Senator Comcast Time Warner
Chris Coons (D-Del.) $57,200 $10,200
Chuck Schumer (D-N.Y.) $41,600 $21,300
Orin Hatch (R-Utah) $36,750 $6,000
Amy Klobuchar (D-Minn.) $28,373 $23,575
Patrick Leahy (D-Vt.) $22,500 $62,650
Sheldon Whitehouse (D-R.I.) $21,831 $20,275
Dick Durbin (D-Ill.) $20,600 $0
Richard Blumenthal (D-Conn.) $17,000 $2,333
Al Franken (D-Minn.) $14,750 $11,600
Chuck Grassley (R-Iowa) $13,000 $4,000
Diane Feinstein (D-Calif.) $12,025 $25,780
Mazie Hirono (D-Hawaii) $8,500 $5,000
Ted Cruz (R-Texas) $7,500 $0
John Cornyn (R-Texas) $6,000 $3,500
Lindsey Graham (R-S.C.) $0 $3,000
Jeff Flake (R-Ariz.) $0 $0
Mike Lee (R-Utah) $0 $0
Jeff Sessions (R-Ala.) $0 $0

Source: Center for Responsive Politics

Update: What Do Critics Mean Who Say Obamacare "Isn't Liberal Enough"?

| Wed Apr. 9, 2014 11:38 AM PDT

I periodically drone on about the laziness of polls that ask a simple approve/disapprove question about Obamacare. The problem is that a lot of people say they disapprove because Obamacare isn't liberal enough. These are folks don't necessarily disapprove of the concept of national healthcare in general or Obamacare in particular, and shouldn't really be counted among right-wing opponents of the law.

A couple of weeks ago, a Kaiser poll gave us a slightly deeper glimpse into all this. They asked the disapprovers why they disapproved, and it was clear that some of them had lefty criticisms of the law, not conservative criticisms. But the evidence was still a bit fuzzy.

Today, Mark Blumenthal goes further. In a recent HuffPo poll, about 9 percent of the respondents said they opposed Obamacare because it wasn't liberal enough. Then, in a follow-up question, they were asked, "In your own words, what do you mean when you say the health care law is not liberal enough?"

The results are on the right. There's still some ambiguity here, but I'd classify several of the responses as likely left-wing criticisms. Adding up the percentages, I get 6 + 4 + 15 + 4 + 4 + 3 = 36 percent. That's a little less than half of those who had a response.

So, very roughly speaking, in future polls I'd guess that about half of the "not liberal enough" folks are basically supporters of Obamacare but want the law to go further. It might even be more than that, but it remains hard to parse the motivations behind all of these responses with precision. Is "too complex" a liberal or conservative criticism? How about "lack of choice"? Hard to say.

In any case, this adds some context to the whole debate about Obamacare critics who say it's "not liberal enough." It's also an object lesson against assuming too much ideological coherence from survey respondents. A larger survey with a bigger sample size and a little more structure to the questions would be welcome.

WATCH: GOP Lawmaker Compares Getting Abortion to Buying a Car and Picking Carpeting

| Wed Apr. 9, 2014 11:12 AM PDT

A bill is making its way through the Missouri House of Representatives that would require women seeking abortions to undergo mandatory ultrasounds and increase the waiting period for an abortion from 24 to 72 hours—measures that are necessary, in the words of the bill's sponsor, because women should have as much information about pregnancy as he seeks out when he's shopping for a car or picking out carpeting for his house.

Republican Rep. Chuck Gatschenberger made the comparison between cars and pregnancy while taking questions on the bill before the Committee on Children, Families, and Persons with Disabilities. In his remarks, captured on video, Gatschenberger noted that he has many sisters and daughters who put ultrasound images of their children on the fridge. An off-camera committee member then asked him, "Do you not trust your sisters to make their decisions for themselves?"

Gatschenberger replied:

"Well, yesterday, I went over to the car lot over here. I was just going to get a key made for a vehicle. And I was looking around because I'm considering maybe buying a new vehicle. Even when I buy a new vehicle—this is my experience, again—I don't go right in there and say I want to buy that vehicle, and then, you know, you leave with it. I have to look at it, get information about it, maybe drive it, you know, a lot of different things. Check prices. There's lots of things that I do, putting into a decision. Whether that's a car, whether that's a house, whether that's any major decision that I put in my life. Even carpeting. You know, I was just considering getting some carpeting or wood in my house. And that process probably took, you know, a month, because of just seeing all the aspects of it."

In a later exchange between Gatschenberger and Rep. Stacey Newman, a Democrat on the committee, Newman called his remarks "offensive to every woman in this room." Gatschenberger replied to her that he wasn't comparing reproductive health decisions to buying a car—and then went on to compare reproductive health decisions to buying a car.

Here's part of the exchange:

Newman:  Your original premise, that a woman who is receiving any type of care with her pregnancy, regardless of what decisions are involved, is somehow similar to purchasing a key for an automobile—

Gatschenberger: If you were listening to my explanation, it had nothing to do [with] that…In making a decision—not making a life-changing decision—but making a decision to buy a car, I put research in there to find out what to do.

Newman: Do you believe that buying a car is in any way related to any type of pregnancy decision?

Gatschenberger: Did I say that?

Newman: That's what I'm asking you.

Gatschenberger: I did not say that. I'm saying my decision to accomplish something is, I get the input in it. And that's what this bill does, is give more information for people.

Newman: So you're assuming that women who are under care…for their pregnancy, need additional information that they're not already receiving?

Gatschenberger: I'm just saying they have the opportunity, it increases the opportunity. If you want to know what this bill does, [it] increases the opportunity.

See the whole video here:

Can Anyone Win the 2016 Republican Nomination?

| Wed Apr. 9, 2014 9:41 AM PDT

Ben Smith pours cold water on the idea of Jeb Bush running for president:

The notion that Jeb Bush is going to be the Republican presidential nominee is a fantasy nourished by the people who used to run the Republican Party. Bush has been out of a game that changed radically during the 12 years(!) since he last ran for office. He missed the transformation of his brother from Republican savior to squish; the rise of the tea party; the molding of his peer Mitt Romney into a movement conservative; and the ascendancy of a new generation of politicians — Marco Rubio, Paul Ryan, Scott Walker, Ted Cruz, among them — who have been fully shaped by and trained in that new dynamic. Those men occasionally, carefully, respectfully break with the movement. Scorning today’s Republican Party is, by contrast, the core of Jeb’s political identity.

There's more, and Smith makes a good case without even bothering to mention Bush fatigue.

But I have to say that I'm mystified right now. In 2012, from the very start, I thought Mitt Romney would win the nomination. Basically, the whole contest boiled down to Mitt and the Seven Dwarves, and eventually I figured Mitt would stomp each dwarf and then, battered and bruised, win the nomination.

But this time around, it's just dwarves. Like Smith, I have a hard time seeing Jeb Bush making a serious run. Chris Christie still seems terminally damaged by Bridgegate, though I suppose that's still up in the air depending on what future investigations reveal. Beyond that, I guess Scott Walker is still a possibility—though, in the immortal words of Ann Widdecombe, it's always seemed as if there's a bit of the night about him. And Paul Ryan, of course, though it sure doesn't seem like he's seriously interested in running.

Beyond that, it's just the usual clown show of nutballs and C-list wannabes. You can make a great case for why none of them can possibly win. And yet, someone has to win. It's a mystery.