Health care special interests v. Biden

Organized medicine, staffing agencies, nursing homes mobilize to fight change

Lobbyists for some of health care’s most powerful special interests are looking to derail several of the policy initiatives unveiled by the Biden administration last week.

The move with the most immediate consequences is the American Medical Association’s opposition to the president’s plan to turn retail pharmacies into one-stop COVID-19 test-and-treat facilities. AMA president Gerald Harmon branded the move “extremely risky” in a statement released late Friday.

“Leaving prescribing decisions this complex in the hands of people without knowledge of a patient’s medical history is dangerous in practice and precedent,” he said. “We urge patients who test positive for COVID-19 to contact their physician to discuss treatment options.”

That delay could have serious consequences for patients who do not have immediate access to a physician or are fearful they may have to pay out-of-pocket if they go to an emergency room or urgent care facility to obtain the new anti-viral drugs, which the president promised to provide for free.

In December the Food and Drug Administration authorized emergency use of Pfizer’s Paxlovid to treat COVID-19. The oral drug’s label stressed the medication must be administered within five days of the onset of symptoms. Many people who buy and use same-day tests at pharmacies are already experiencing symptoms and may have had them for several days.

The AMA’s main excuse for denying pharmacists the right to issue immediate prescriptions was Paxlovid’s long list of potential drug interactions with other medications. It also noted that molnupiravir, the Merck-Ridgeback oral medication that also received emergency use authorization in December (but is less effective than Paxlovid), is not authorized for children under 18 and should not be used by women who are pregnant or breastfeeding.

To me, the doctor guild’s stance is inexplicable. Aren’t these pharmacists trained professionals? How hard would it be for them to inquire about a person’s other medications, age or relevant health issues before issuing a prescription?

This wouldn’t even be an issue if the U.S. had an integrated electronic health record system where every person’s medical records were uploaded to a privacy-protected national database. If such a thing existed, it could be programmed to send up red flags when a newly prescribed medication to fight COVID-19 would interact with one of the other medications the patient in front of the pharmacist was already taking.

But rather than working to ensure that patients have immediate access to antivirals, the AMA stormed the ramparts to maintain strict physician control over the prescribing process. The glassblowing guild in medieval Venice would approve.

Price gouging for temp nurses

Meanwhile, the American Staffing Association is fighting efforts in a handful of states to limit the fast-rising fees that its member companies are charging nursing homes and hospitals for temporary nurse placements. Demand for temps has grown tremendously over the past two years as COVID-related early retirements, resignations and burnout decimated the nation’s nursing corps.

Staffing companies are charging rates that are as much as 40% higher than pre-pandemic levels, with only a fraction of the excess winding up in nurses’ paychecks. Profits at AMN Healthcare Services, the nation’s largest medical personnel temp agency, rose 364% last year to $327 million after pandemic-driven demand increased total revenue by 66% to $4 billion.

A bipartisan group in Congress has called on the White House to investigate anti-competitive practices in the staffing industry. You can read more about that here.

The Biden administration’s proposed nursing home reforms steered clear of the staffing agency debate. But it did propose a a federal minimum staffing requirement and stepped-up enforcement at facilities that accounted for 20% of the 1 million COVID deaths during the pandemic. That, of course, would require nursing homes hire more nurses, which in turn would provide another boost in demand for the temp agency services.

The nursing home industry, whose operators are mostly for-profit firms, is opposing any new requirements. “We would love to hire more nurses and nurse aides to support the increasing needs of our residents,” said Mark Parkinson, CEO of the American Health Care Association said. “However, we cannot meet additional staffing requirements when we can’t find people to fill the open positions nor when we don’t have the resources to compete against other employers.”

With more than 60% of nursing home residents covered by Medicaid, the rates paid by the state-based agencies that run the program is certainly an issue. But the structure of the industry should also be on the table, as this interesting report by researchers at American University shows.

For-profit versus not-for-profit

Nearly two-thirds of the nation’s 15,000 nursing homes are operated by for-profit entities. Many inflate their costs by paying exorbitant rates to owners of their real estate, which has often been sold to real estate investment trusts owned by affiliated entities. Compared to non-profit homes, the for-profits also pay higher fees for management, cleaning and other services, which are often provided by firms owned by the same people who own the nursing homes.

“For-profit homes, which are motivated to keep costs low and profits high, tend to be understaffed and, on average, provide lower-quality care compared with public and nonprofit homes,” the American University researchers noted. “In contrast, nonprofit and public homes tend to put higher emphasis on patient-centered care and reinvest their profits into better physical spaces, equipment and responsiveness to clients’ needs.”

The White House might want to look into that, too.