Congress should move to slow spending in Medicare’s drug benefit by adopting a package of changes that could save billions of dollars, but that would also add costs for insurers and have mixed effects on enrollees, an independent advisory commission said Wednesday.

The Medicare Payment Advisory Commission warned in its June report to Congress that rising drug costs and other factors helped drive Medicare Part D spending up nearly 60 percent between 2007 and 2014.

MedPAC recommendations are considered influential, but don’t expect Congress to pursue those changes during an election year.

Still, the commission makes proposals it estimates could save at least $10 billion over five years, partly by encouraging more use of generic drugs and also by creating incentives for insurers to negotiate better prices from drugmakers.

The proposals would:

• Sharply reduce or even eliminate the copayments that about 12 million low-income Medicare enrollees pay for generic drugs — to encourage the use of the lower-cost medications.
• Create an annual out-of-pocket spending cap for higher-income enrollees that is similar to one already in place for low-income beneficiaries. After enrollees hit the cap, Medicare would cover 100 percent of the cost of their medications.
• Make it harder to reach that annual cap by not allowing a drug discount given by manufacturers to count toward the enrollees’ out-of-pocket maximum.
• Require insurers to pay 80 percent of drug costs, up from the current 15 percent, after patients hit the out-of-pocket maximum.

Patient groups like the idea of reducing generic copayments for low-income enrollees and setting an annual cap, yet they fear that the proposal would mean patients would remain in the coverage gap known as the “doughnut hole” for longer periods.

While in the doughnut hole, enrollees pay a higher percentage of drug costs. MedPAC estimates that its proposal would mean about half of beneficiaries whose drug spending is high enough to hit this gap would remain in it longer, paying about $1,000 more each as a result.

“We’re pleased that some of the recommendations would protect beneficiaries from the rising cost of medications … but we have concerns that fewer beneficiaries would benefit from the out-of-pocket maximum,” said Stacy Sanders, federal policy director for the Medicare Rights Center.

Some proposals have been rejected before, but the report could spark discussion under a new administration and Congress in 2017.

“Once MedPAC makes a recommendation, it gives it legitimacy,” Sanders said. “In future years, we could see the proposals as a starting point for some legislation.”

This year, the doughnut hole occurs after patients and their insurers combined have spent $3,310 on covered drugs. In the coverage gap, enrollees must pay a larger share of the cost of their drugs until catastrophic coverage kicks in. That happens when spending hits $4,850 and enrollees then pay 5 percent of the cost of their drugs.

While 5 percent isn’t much when a low-cost generic is taken, it can be substantial for expensive drugs, such as many used to treat hepatitis, cancer, multiple sclerosis and some forms of arthritis.

The Affordable Care Act gradually phases out the coverage gap by requiring drugmakers to give enrollees discounts. This year, the discount is 50 percent of the cost of the drug. Even though enrollees are not paying that discounted amount out of their own pockets, the ACA allowed the dollar value to count toward the $4,850 threshold for catastrophic coverage to begin. Since the ACA took effect, the number of Medicare Part D enrollees who reach the catastrophic coverage level has grown from 400,000 in 2010 to 700,000 by 2013, according to MedPAC. That shift costs Medicare and taxpayers more because the program pays 80 percent of the costs for drugs after enrollees go through the coverage gap.

Under the commission’s proposal, enrollees would no longer be allowed to count those drugmaker discounts toward the total, meaning it would take longer to hit the out-of-pocket cap. Indeed, about half of enrollees might not reach the threshold in a given year and not benefit from the 100 percent coverage, the report notes.

“For many people, this will actually increase spending,” said Caroline Pearson of consulting firm Avalere in Washington, D.C., which is in the process of analyzing the financial impacts of the MedPAC proposals. “While our results aren’t finalized yet, our generalized finding is that a small number of beneficiaries would save a lot of money … but a lot would spend more.”

Other elements of the proposal would affect insurers. MedPAC recommends insurers shoulder more of the cost of prescriptions after enrollees exit the doughnut hole. That would encourage insurers to try to keep enrollees from hitting the coverage gap’s upper limit by getting them to choose lower-cost drugs or by driving harder bargains with drugmakers, said Mark Miller, executive director of the commission.

“A good portion of that payment is because beneficiaries are either using more expensive drugs or the prices of their drugs are going up relatively aggressively,” said Miller. “We’re trying to say … you’re going to want to negotiate as tough prices as you can.”

MedPAC says the proposals are needed because rising drug prices and other factors helped drive spending in the program to $73 billion in 2014, and more high-cost drugs will hit the market soon. Without action, the rising costs could drive up program costs and probably premiums for enrollees, MedPAC said.

When MedPAC adopted its recommendations unanimously this spring, they drew mixed reviews and many comments from the drug industry, consumer groups and insurers. All the groups found elements they liked in the plans and parts they opposed.

Little change was seen in the final version released to Congress.

“PhRMA remains concerned about the sweeping recommendations MedPAC approved in April and opposes changes to Medicare Part D that taken together could harm beneficiaries by eroding coverage and protections for many of the most vulnerable enrollees in the program,” said Allyson Funk, spokeswoman for the drug industry’s trade group PhRMA.

Kaiser Health News is a service of the nonprofit Kaiser Family Foundation. Neither one is affiliated with the health insurer Kaiser Permanente.

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Summer camp and mosquitoes go together like chicken and waffles, particularly in the South. But Zika virus may raise the stakes in the age-old struggle of campers versus pests. The mosquito species capable of carrying Zika can be found in much of the southern United States.

Anxious parents need not panic; no Zika-infected mosquitoes have been identified in the country. Nonetheless, Tisha Bolger, board president of the American Camp Association, says camp administrators are particularly interested in what they can do to prevent mosquito bites this summer.

The CDC has not released guidelines specific to summer camps for Zika prevention, but camp managers should follow general prevention guidelines, CDC spokesman Benjamin Haynes tells Shots. Many of those suggestions, such as wearing long-sleeved shirts and long pants and staying inside air conditioned buildings with windows, seem a tad unrealistic for kids having fun outdoors.

“If you’ve got a kid in summer camp,” says mosquito biologist Todd Livdahl of Clark University, “they’re wearing shorts or they’re wearing swimsuits when they’re outside.” And unless you’re sending your child to summer camp at the Four Seasons, air-conditioned cabins may also be in short supply.

Another tip in the CDC guidelines suggests treating clothing and gear with permethrin, a chemical that kills insects and can cause skin rashes in humans. “I don’t see most parents deciding that’s an OK thing to do,” says Livdahl of coating clothes with the chemical. “Most people have never heard of this approach.”

Don’t lock your children indoors for a summer of video games just yet. First, some perspective.

There’s still no evidence that Aedes aegypti mosquitoes carrying Zika have reached the U.S.

As of June 8, all 691 recorded cases in the country have been linked to international travel or sexual transmission. What’s more, the most serious of Zika’s known side effects – abormally small heads, or microcephaly, in infants – only appears to affect babies whose mothers became infected while pregnant.

That said, campers aren’t totally out of the woods.

If the culprit mosquitoes do spread to the southern U.S., as CDC scientists have suggested they might, some campers infected with Zika could suffer fever, joint pain, and in rare cases get sick enough to require hospitalization. In a much smaller set of cases, Zika may be linked to a neurological disorder called Guillain-Barré syndrome, which can cause muscle weakness and paralysis. (The CDC is investigating the connection between Zika and this syndrome.)

Finally, because scientists still don’t know how long Zika can stay in someone’s system, it’s possible that summer mosquito bites could someday cause the virus to be spread later by sexually active teens.

“I guess we’re just stressing applying bug repellant more,” says camp director Alyson Gondek of Camp Woodmont in Cloudland, Ga. She says the camp has not invested in mosquito netting for each of the camp’s beds, another recommendation from the CDC. And she’s not planning on netting larger areas either.

“It would be nice to have a huge dome over our property,” Gondek says, but “we’d have to net an entire 170 acres.”

Managers from other southeastern camps reported a similar approach, namely, business as usual, with extra bug spray. And several said that they hoped a drier spring would cut back on insects.

“I’m out a lot, and they all love to eat on me,” says Mark Magee, executive director of Twin Lakes camp in Florence, Miss. “And I haven’t been chosen this summer to be eaten yet.”

Summer camps have few weapons in their arsenals to combat a potential mosquito invasion, but they may be spared in the battle with Zika, at least this season. That means administrators can focus on other staples of the camp experience: sports, s’mores and sunburn.

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People who die in the hospital undergo more intense tests and procedures than those who die anywhere else.

An analysis by Arcadia Healthcare Solutions also shows that spending on people who die in a hospital is about seven times that on people who die at home.

The work confirms with hard data what most doctors and policymakers already know: Hospital deaths are more expensive and intrusive than deaths at home, in hospice care, or even in nursing homes.

“This intensity of services in the hospital shows a lot of suffering that is not probably in the end going to offer people more quality of life and may not offer them more quantity of life either,” says Dr. Richard Parker, chief medical officer at Arcadia.

Arcadia analyzed all the Medicaid claims data for a private Medicaid insurance company in one Western state and detailed how many billable medical procedures each patient received and where. Patients in hospitals were billed for far more medical interventions in the last days of their lives than people who died in other settings. The company declined to name the state or company.

The study showed that 42 percent of patients died at home at a cost of about $4,760 for their last month of life, while 40 percent died in a hospital at a cost of $32,379. Dying in a nursing home was the second most expensive locale, inpatient hospice was third and an emergency room was fourth.

“In the end, everyone died. They all died,” Parker tells Shots. “If we look at this retroactively, retrospectively — and we could go back and ask people — I bet most of them would say I’d rather be home with my family.”

Parker says the cost of hospital deaths paid for by Medicare or private insurance are likely even higher because they pay doctors and hospitals more for their services.

Many studies have shown that people, when asked, say they’d prefer to die at home rather than in a hospital. However, those wishes aren’t always realized if a person hasn’t given clear instructions to a doctor or family member.

Parker says hospitals are designed to cure people who are ill rather than to allow people to die peacefully.

“The culture of American medicine today and for the last several decades is to keep treating patients regardless of the quality of life,” he says. “A lot of physicians have been reluctant to admit that the patient’s life is coming to an end.”

The picture is more complicated than the data show, says Dr. Lachlan Forrow, a professor of medicine and medical ethics at Harvard University.

Many patients move from home to hospice to hospitals and back during the last 30 days of life. And some may end up in the hospital because their pain or symptoms weren’t adequately controlled at home.

Still, he says, hospitals are just not good at caring for dying people.

“We do lots of very expensive things in hospitals to people in the last part of life who would rather be home, and we do those in part because in the hospital they get paid for,” he says.

It’s the only way to justify keeping in a hospital the people who need around the clock nursing care but can’t get it at home.

“If we really tried to make sure people at home could have what they needed at home, we could take better care of them, with less medical system-caused suffering, at lower cost, sometimes much lower cost,” he says.

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Zac Talbott sees the irony of running an opioid treatment program from a former doctor’s office.

“The funny thing is, a lot of patients are like, ‘This is where I first started getting prescribed pain pills,’ ” Talbott says.

Now, the Tennessee native says those same patients are coming to his clinic in Chatsworth, Ga., a small city about a half-hour south of the Tennessee border, to fight their addiction to those very pills.

Outpatient clinics like the one Talbott co-owns dispense drugs like methadone and buprenorphine, which are legal synthetic opioids that block cravings and withdrawal symptoms. Federal health officials say this medication-assisted treatment, coupled with counseling, is the best way to treat an addiction to prescription painkillers or heroin. Patients are required to show up a set-number of times a week — the number of visits determined by how long they’ve been receiving treatment — to take their medicine in front of a nurse.

Talbott’s clinic, Counseling Solutions, started treating patients in February, but he says it’s already treating 150 people in a space that’s fit for about 200. There’s such a need in this part of the state, Talbott says, he’s already making expansion plans.

More than 1,200 people died of an overdose in Georgia in 2014, according to the Centers for Disease Control and Prevention, with opioid drugs frequently implicated in those deaths. That’s a 10 percent increase over the previous year. So Talbott is outraged that Georgia has put a one-year moratorium on issuing licenses to clinics that use medicine to treat people addicted to heroin or painkillers.

“We’re in the middle of an opioid addiction and overdose epidemic,” Talbott says. “You just think about that for a minute.”

Too Many Clinics?

The reason for the moratorium, according to state Sen. Jeff Mullis, a Republican, is the state needs to figure out why so many opioid treatment programs have opened in Georgia. Mullis sponsored the legislation — which has since been signed into law — that created the freeze on new clinics. The law also required that a committee be established to look into Mullis’ question.