President Trump announced earlier today a new pharmacy cost reduction program, “American Patients First”. The program aims to provide new tools to Medicare to negotiate lower prices, stop limiting pharmacists from helping patients save money and speed up approval of over-the-counter medicines so that fewer will require prescriptions.
The plan has 4 components:
Increasing competition.
Easing negotiation.
Creating incentives to lower prices.
Lowering out-of-pocket spending on drugs.
“American Patients First” calls for reforms in Medicare Part D to allow plan sponsors to negotiate lower prices for high-cost drugs, including negotiation tools that may be available to private payers. The administration also plans to address incentives in Part D to push drug companies to lower prices.The plan includes a five-part plan to restructure the Part D program to reduce drug costs. The budget includes proposals to cap spending in Medicare Part B and move Part B coverage into Part D to facilitate better negotiation.
The Food and Drug Administration will begin acting quickly to bring more generics and biosimilars to the market to address competition issues, for example.
Another area of particular focus is using a US large buying group much as other countries have been doing traditionally. The U.S. pays for 70% of the profits of branded drugs among 35 leading countries because many have government-run health systems that pay one price for drugs, senior administration officials said. According to Trump the U.S. is essentially subsidizing the R&D costs for other countries.
Last Sundays 60 Minutes segement on how the Town of Rockford, Illinois can NOT meet its budgetery obligations due to crushing PBM influenced pricing. Example: In 2001 an infant drug cost $40/vile and now
$40,000/vile.
The Dept of Health and Human Services reiterated the agency’s focus on price transparency and said that was another crucial element of the drug pricing plan. The FDA, for example, is going to immediately begin
to examine ways to push drug companies to disclose prices in their advertising.Long awaited and a welcomed consumer policy.
Generics or Brands? This is not a new question and has been discussed. Our blog post “Generic Drugs vs. Brand Name – Are there any differences?” was covered in 2009. But since last decade most brand drug’s patents have fallen of a cliff. See popular Rx expirations below and infographic of “Major Drugs Going Off-patent in 2016.”
Lipitor
Seroquel
Crestor
Prevacid
Nexium
Zyprexa,
Plavix
Singulair
Lexapro
Enbrel
According to Vox article “Stop wasting money on brand-name drugs “On average, generics cost 80 to 85 percent less than name-brand medicines, according to the Food and Drug Administration (FDA). And buying unbranded drugs isn’t like opting for cheap toilet paper or no-name face cream: Less expensive here doesn’t necessarily mean lower quality.”
Many people have heard that switching to a generic medication will save them money. One of the questions we hear most often is, “How do generic medications compare to their brand name counterparts?” Knowing the facts about generics versus brand names can help make us all better consumers.
What’s the difference between generic and brand-name drugs?
Generic medicines are chemically equivalent to the original brand-name drugs and work just as well for nearly all patients. Many people are concerned that because generic drugs are often much cheaper than the brand-name versions, the quality and effectiveness have been compromised to make a less expensive product. The FDA requires that generic drugs be as safe and effective as the original brand name drugs. Generic drugs are copies of brand name drugs that have exactly the same dosage, intended use, effects, side effects, route of administration, risks, safety, and strength as the original drug. In other words, the pharmacological effects of generic medications are exactly the same as those of their brand name counterparts. It is important, however, to check with a Physician and have a conversation about alternatives since generic drugs may contain slightly different INACTIVE ingredients. These are things like binding materials, dyes, preservatives, and flavors.”
Another common myth is that generic drugs take longer to work. The FDA requires that generic drugs work as fast and as effectively as the original brand name products.
When a drug loses patent protection, often only one generic version is on sale for the first six months, so the price falls a little bit initially. Then, several other generic makers typically jump in, driving prices down dramatically.
What are the actual costs differences?
Last year, the average generic prescription cost $72, versus $198 for the average brand-name drug, according to consulting firm Wolters Kluwer Pharma Solutions. Those figures average all prescriptions, from short-term to 90-day ones.
Average copayments last year were $6 for generics, compared with $24 for brand-name drugs given preferred status by an insurer and $35 for non-preferred brands, according to IMS Health. Protonix, for severe heartburn, now costs just $16 a month for the generic, versus about $170 for the brand name. And of the top sellers that soon will have competition, Lipitor retails for about $150 a month, Plavix costs almost $200 a month and blood pressure drug Diovan costs about $125 a month. For those with drug coverage, their out-of-pocket costs for each of those drugs could drop below $10 a month.
All patients are encouraged to discuss generic alternatives with their physicians prior to filling a prescription. The doctor and the patient should agree on the best course of treatment for any diagnosed medical condition.
Resource:
Discount Rx Card: www.bonusbenefit.com
Pharmacy and Rx Costs Look Up: http://www.rxpricequotes.com
In Time magazine’s March issue Bitter Pill: Why Medical Bills Are Killing Us Steven Brill gets to work on answering the ever elusive Why are Medical Costs So High? The 21,000 word article is longest article in Time Magazine history that can boiled down to simply there is no free marketplace in health care. We think everything in this country is a free market but is there a free market when one needs to got to an emergency room or a free market when one must take a cancer pill? According to Howard Dean the singular reason is to get away form the current fee for service system where providers get paid per procedure and not per patient.
Here’s an eye opener: “Insurance Companies are not really the problem they run pretty terribly. They process claims, a lot of us think they process claims and fairly consistently but they are increasingly at the mercy of hospitals which are consolidating buying a doctors practices. We should tax profits on so-called nonprofit hospitals and put that money back into the system. We should control all the prices for prescription drugs because if I have a monopoly a cancer wonder drug I can charge anything I want for them that’s obviously not a free market and it’s completely two different uses you see this article once you follow the money.”
Transcript of the video:
“This is not a free-market. You don’t get health care because you want it. You don’t wake up in the morning and gee I love to go down to the emergency room today. You enter that market and will you know nothing about the products of you being asked by no choice of those products. Hi I am Steve Brill I’ve got the cover story this week in TIME Magazine looking at the health care debate from a very different perspective. Everybody focuses on who should pay for the exorbitant cost of health care and that I decided to do was ask for more fundamental question which is why does health care cost so much.
I look behind the bills and trace the bills all the way back to who’s getting what money is making what profits and the results are really surprised one of the things I found that everybody in the healthcare industry knows about that that nobody else knows his something called the charge-master. The charge master is a internal listing each hospital of the thousands of different items that they charge and nobody could explain it to me. Indeed would be hard to explain for example why would you charge $77 for a box of gauze pads? You can buy for a dollar at the drugstore. why would you charge thousands of dollars for CAT scan it really isn’t cost you anything?
It’s emblematic if you will, of the irrationality of the higher healthcare system because no one can explain the cost no one tries to and the only people who are guaranteed surefire to pay to be asked to pay the charge-master prices are the poorest people who don’t have health insurance.
Real profit makers are way hospitals markup very expensive drugs that you get. If you have cancer to have pneumonia but they’re making thousands of dollars on these drugs and drug companies in turn making still more thousands of dollars.
Obamacare does very little to solve any of these problems and just probably why you got to Congress I’m it doesn’t do anything to control the prices of prescription drugs or medical devices CAT scan. In fact if anything it will increase the profitable the players in the market by making equal insurance and therefore more people are in the marketplace with the funds from insurance companies to buy all these products.
Insurance Companies are not really the problem they run pretty terribly. They process claims, a lot of us think they process claims and fairly consistently but they are increasingly at the mercy of hospitals which are consolidating buying a doctors practices. See Provider Consolidation Info-graph– “The proliferation of hospital mergers and hospitals’ appetite for buying doctors’ practices—in part to assure a steady stream of patients to fill hospital beds—could create local monopolies that raise prices without increasing efficiency. ‘Historically,’ says Deloitte’s Mr. Keckley, ‘hospital consolidation hasn’t reduced costs.’”
We should tax profits on so-called nonprofit hospitals and put that money back into the system. We should control all the prices for prescription drugs because if I have a monopoly a cancer wonder drug I can charge anything I want for them that’s obviously not a free market and it’s completely two different uses you see this article once you follow the money.”
The ACO (Accountable Care Organization) referenced in our post NYU Beth Israel Merger and ACOs are models encouraged in Obamacare in fact as examples of Provider capitated reimbursement that Howard Dean is in favor of. An ACOI cordiantes patient care and provide the full range of health care services for patients. The health reform law provides incentives for providers who join together to form such organizations and who agree to be accountable for the quality, cost, and overall care of Medicarebeneficiaries who are enrolled in the traditional fee-for-service program who are assigned to the ACO.
The fee-for-service system has evidentially driven costs by incentivizing volumes of added procedures. The ACO model is built on par excellence hospitals such as Mayo Clinic where there is team of providers are financially incentivized for patient care coordination outcomes and high quality of care. The ACO’s payment would be tied to achieving goals that improve health care and save money. Members of the ACO would divvy up that payment. Today’s payment system, investments in providing better care are doubly penalized. If a hospital hires a nurse to follow up with patients after they are discharged in order to reduce readmissions — for example, to help patients with diabetes improve blood sugar control — it must pay for the nurse, which is typically not reimbursed by insurance companies or Medicare, and it loses revenue by preventing the readmission.
Congress included ACOs in the health care law as a way to rein in Medicare spending. That federal program pays for health care for people 65 and older and the disabled. The federal government estimates ACOs could save the Medicare program up to $940 million over four years. Medicare recently began testing this system with 32 pilot ACOs in 18 states, including one in the New York City area – Bronx Accountable Healthcare Network.
Some have pointed to ACO Model just as a pro-merger supporting argument with the FTC. These significant mergers create market dominance and therefore limit competition and drive up health care dollars. And yet Hospitals operate on thin profit margins and cannot afford to lose market share therein lies is the conundrum.
Note: At time of this article MVP and Hudson Valley Health Plans announced a merger –Hudson Health Plans joins MVP. Hudson Health Plan, the Medicaid managed care organization based in Tarrytown, will join the MVP Health Care group of companies, the two nonprofit health plans jointly announced today.
“Size and diversity of offerings are important for health plans in the new world of the health insurance marketplaces. A 55-year-old person would like to join a health plan that can continue to cover him when he turns 65. Likewise, if someone is no longer eligible for Medicaid, she might prefer to buy a commercial product from that same insurer. Together, MVP and Hudson now can cover people through all of life’s stages and changing needs.
In the coming months, Millennium Medical Solutions Inc will host seminars and will share information you’ll need to know as the countdown continues to October 1st. Please contact us for immediate information on how to implement these initiatives for your group-specific needs at info@medicalsolutionscorp.com or Call (855) 667-4621.
Anti Mandatory Mail Order Victory. A little noticed NYS Healthcare Law has gone under the radar amidst fast changes in Affordable Care Act tumult. AMMO – Anti-Mandatory Mail Order passed late Dec 2011 effective for groups renewing after Jan 11, 2012. A significant signal by Governor Cuomo to stand up to the billion dollar industry no doubt.
According to trade group Pharmacists United for Truth the PBM (pharmaceutical benefits managemnt) claim that mandatory mail order lowers costs proves otherwisee. Plan sponsors are routinely charged far more than retail price in mandatory mail order plans, and their lack of transparency keeps plan sponsors to detecting the unreasonable prices.
After spending a good part of a day in early March helping a NYS client faced with mandatory mail order I learned of this change. For certain medications the insurer limits retail pharmacy coverage. While the incentivisation of 90 day supply at 2 copays was attractive this has now declined to 2.5 copay. With few exceptions such as specialty pharmaceuticals retail pharmacists are given the same advantages and evening the playing field.
The National Community Pharmacists Association’s blog post below offers a helpful FAQ. Additionally with the steady decline of the local independent pharmacist a quality of personalized care has been eroded. The price paid in patient compliance and safety has received little attention. Independent Pharmacists have been the canary in the mine for fellow small businesses competing with large copra big box chain stores. At least now NYS is finally listening.
Community pharmacists in New York scored a significant win for their patients, communities and pharmacy choice in late 2011 with the enactment of the Anti-Mandatory Mail Order or AMMO with overwhelming, bipartisan backing. What lessons might the campaign in support of the AMMO law hold for community pharmacists across the country?
To find out, NCPA recently asked one of the legislation’s staunchest supporters and advocates to share his observations on the effort to enact the AMMO law. Craig Burridge, M.S., is Executive Director of the Pharmacists Society of the State of New York (PSSNY). Mr. Burridge credits PSSNY members as most instrumental to enacting AMMO over the fierce opposition of mandatory mail order proponents, principally large pharmacy benefit managers (PBMs). He notes people including Ray Macioci, Charles Catalano, Vinny Chiffy and literally hundreds of pharmacy owners helped win a hard fought battle by gathering tens of thousands of signatures on petitions from their patients and coordinating tens of thousands of phone calls, emails and letters.
What follows is a Q&A with Mr. Burridge, in hopes that his advice would benefit patients and independent community pharmacists in other states advocating for patient choice.
NCPA: When it comes to the forced or mandated use of mail order pharmacies, many of the concerns expressed by patients and the community pharmacists who care for them are not new and have, in fact, been voiced for a number of years. What made 2011 different in New York?
Mr. Burridge: In New York, consumers by the tens of thousands signed petitions at their local pharmacy against mandatory mail order. Patients wrote dozens of letters to the editor of many regional newspapers telling about their horror stories with mail order. Finally, pharmacy owners had had enough of losing their patients to self-dealing PBMs. Tens of thousands of phone calls to the Governor’s Office and to Legislators were made by pharmacy owners, their staffs and their patients in support of passage of the no mandatory mail order bill.
NCPA: One obstacle to ensuring patient choice of pharmacy is the myth of mail order savings. This persists in some minds despite what appears to be rampant mail order waste and studies demonstrating how health plan sponsors that incent or require the use of mail order can end up paying more for drugs. Did you encounter such misperceptions and, if so, what did you do to alter or overcome them?
Mr. Burridge: We did in New York. The PBMs came at us with ads stating that costs would go up and that it was a ‘prescription drug tax’ or that it would ‘prohibit mail order.’ We responded with evidence that exposed the ‘spreads’ being used at mail for generics and the fact that the legislation requires participating pharmacies to agree to the same reimbursement and the same co-pays.
NCPA: The health care benefits of a patient’s face-to-face consultation with a community pharmacist and the preference of most patients for going to a local pharmacy are both well-established. But how did you chronicle and reinforce the economic and tax benefits of buying local when it comes to pharmacies?
Mr. Burridge: According to national data (IMS Health) for 2009, the last year we had data before introducing legislation, 22.8 percent of the national drug spend was for mail order prescriptions. Using New York’s percentage of total drug spend (11 percent), we removed hospital expenditures and Medicaid (which had less than one percent mail order) and came up with a mail order drug spend in NY in access of $5.8 billion annually. New York State has no major mail order facilities so this represents thousands of lost pharmacy jobs.
NCPA: Like PSSNY, NCPA continually stresses to its members the importance of grassroots activism, whether it is at the federal or state levels or with local employers and leaders. Did you find that your memberships became more engaged than usual in 2011 and, if so, what did you do to encourage their further involvement?
Mr. Burridge: It helped to have the PBM industry fly in colleagues from around the country and host their own Lobby Day. They told legislators that New York’s pharmacies could survive on acute medications only. This only caused yet another round of thousands of phone calls from our pharmacists, their staffs and patients. Our grass roots turned into a raging grass fire. Livelihoods were at stake and our opponents showed their hand. They wanted ALL maintenance medications going to their wholly-owned out-of-state mail order facilities. Our legislators saw that too.
NCPA: What surprised you the most about your 2011 campaign against mandatory mail order?
Mr. Burridge: I’ve been doing this too long to be surprised. We expected the worst from our opponents and they did not disappoint us.
NCPA: What were some of your opponents’ most challenging arguments and how did you address them?
Mr. Burridge: That depends if you consider outright lies as a challenge. Their ads said that it was a “Prescription Tax” or, when that flopped, they said our bill “would prohibit mail order.” These were easily swept aside and only upset legislators who felt the PBM industry was accusing them of passing a tax on prescription drugs.
NCPA: Do you have any other words of wisdom that you would like to share with concerned patients or your colleagues in community pharmacy?
Mr. Burridge: Choosing one’s pharmacy should be a basic right. If the playing field is level, it only makes sense to buy local. Watch out for PBMs calling all maintenance medications so-called ‘specialty drugs’ as a way of getting around no mandatory mail order laws. We’ll have a lot more to say on that in the near future.
With access to MDs expected to be reduced as has been felt in Massachusetts, an early adapter of universalized health care, the elevated roles of supporting medical providers such as Nurses, Physician Assistants and Pharmacists will be significant.
I agree with this article and the notion that public policy strategies should include and incorporate the value of pharmacy, and certainly should not jeopardize the viability or accessibility of pharmacies. Pharmacist-provided care can improve outcomes for patients with chronic disease, and reduce costs. In sited studies thefailure of patients to take medications as prescribed costs over $150 Billion/year.
Pharmacy can help mitigate these costs, and foster better health. With a community pharmacy, on average, within about two miles of every American home, pharmacies present amazing potential.
The President earlier today has signed The Health Care and Education Affordability Reconciliation Act of 2010, a historic health care reform that’s been 14 months in the making. This is after Sunday’s Congressional passage by the slim margins of 219-212.
The Bill for the most part follows the President’s version of the Reform Health Bill which tweaked measures such as elimination of Nebraska’s politically wrangled special Medicaid deal, delays on Cadillac Tax enactment and the establishment of a new Health Insurance Rate Authority to give guidance and oversight to states and monitor insurance market behavior. “If a rate increase is unreasonable and unjustified, health insurers must lower premiums, provide rebates, or take other actions to make premiums affordable.” The 21% Medicare cuts to providers were rescinded.
Children under 19 with certain pre-existing conditions could not be barred from coverage.
Dependent children will be allowed to continue coverage on their parents’ plans until age 26 as long as they are not eligible for coverage from an employer. Previously, this applied only to full-time students usually up to the age of 23. Dependents previously dropped because they no longer met the old coverage requirements can be picked up by parents’ plans. At least some insurers will be charging adult children the full rate for an individual rather than including them in the family or employee and child rate. This may or may not be beneficial depending on the situation.
Subsidies for Medicare Advantage will be cut but the so called donut hole under the Medicare Drug Plan would be closed. Seniors getting a prescription drug benefit under Medicare will get $250 later this year under the reconciliation bill. And starting this year, Medicare beneficiaries can get some free preventive services like routine cancer screenings.
The bill creates a temporary pool for “high risk” uninsured. That is, individuals who currently have no coverage due to a pre-existing condition, and who have been uninsured for at least six months, would qualify for coverage under a government plan until the other provisions regulating coverage for pre-existing conditions kick in.
There will be no lifetime limits on coverage paid out under insurance plans.
Certain tax credits will also go into effect for small businesses.
Long Term Changes:
Some medical devices will be newly taxed. Same with drug makers.
Beginning in 2013, income over $200,000 for individuals and $250,000 a year for couples would be hit with a 2.35 percent Medicare payroll tax instead of the existing 1.45 percent rate. Those upper incomes would also see 3.8 percent more in taxes on unearned income such as stock dividends and interest income above the thresholds.
By 2013, employers will have to redesign their flexible spending accounts to impose a $2,500 annual limit on contributions. There is no limit now, though employers typically impose limits between $4,000 and $5,000.
In 2014, citizens will be required to have acceptable coverage or pay a penalty of $95, $325 in 2015, $695 (or up to 2.5 percent of income) in 2016. Families will pay half the amount for children, up to a cap of $2,250 per family. After 2016, penalties are indexed to Consumer Price Index.
in 2014, a new affordability test will kick in that could result in employers facing assessments unless they redesign their plans. If the premium paid by an employee exceeds 9.5% of their income and the employee uses federal health insurance premium subsidies to purchase coverage through new state health insurance exchanges, the employer would have to pay an assessment of $3,000 for that employee.
In 2014, employers with at least 50 employees that do not offer coverage will pay a tax of $2,000 for each employee without coverage. However, in determining the assessment, an employer’s first 30 employees would be excluded from the calculation. Taking the case of an employer with 100 employees that did not offer coverage, for example, its assessment would be 70 times $2,000.
So-called Cadillac health plans would also get dinged. Employer-sponsored plans worth $10,200 for individuals and $27,500 for families would be hit with a 40% excise tax starting in 2018.
Individual Mandate:
All individuals will be required to have health insurance, with some exceptions, beginning in 2014. Those who do not have coverage will be required to pay a yearly financial penalty of the greater of $695 per person (up to a maximum of $2,085 per family), or 2.5% of household income, which will be phased-in from 2014-2016. Exceptions will be given for financial hardship and religious objections; and to American Indians; people who have been uninsured for less than three months; if the lowest cost health plan exceeds 8% of income; and if the individual has income below the poverty level ($10,830 for an individual and $22,050 for a family of four in 2009).
Premium subsidies will be provided to families with incomes between 100-400% of the poverty level (or $22,050 to $88,200 for a family of four in 2009) to help them purchase insurance through the Exchanges. These subsidies will be offered on a sliding scale basis and will limit the cost of the premium to between 2% of income for those between 100-133% of the poverty level to 9.8% of income for those between 300- 400% of the poverty level.
Employer Requirements: There is no employer mandate but employers with more than 50 employees will be assessed a fee of $2000 per full-time employee (excluding the first 30 employees from the assessment)
Employers that offer coverage will be required to provide a free choice voucher to employees with incomes below 400% of the poverty level if their share of the premium cost is between 8-9.8% of income and who choose to enroll in a plan in an Exchange. Employers that offer a free choice voucher will not be subject to the above penalty.
Large employers (more than 200 employees) that offer coverage will be required to automatically enroll employees into the employer’s lowest cost premium plan if the employee does not sign up for employer coverage or does not opt out of coverage.
No employer may impose a waiting period that exceeds 90 days
Small Business Tax Credit
Provides a two year tax credit to small businesses (less than 25 employees) with aver annual wages of less than $40,000 that purchase health insurance with the tax credit.
For tax years 2010 to 2013, the tax credit would be up to 35% of the employer’s contribution toward the employee’s health insurance premium if the employer contributes at least 50% of the total premium cost.
For tax years 2014 and later, for eligible businesses that purchase through the Exchanges, the tax credit would be up to 50% of the employer’s contribution toward the employee’s premium if the employer contributes at least 50% of the employee’s total premium cost.
The full credit will be available to employers with 10 or few employees and average annual wages of $25,000 and less, the credit phases out as firm size and wages increase.
American Health Benefit Exchanges
States will create the American Health Benefits Exchanges where individuals can purchase insurance and separate exchanges for small employers to purchase insurance. These new marketplaces will provide consumers with information to enable them to choose among plans. Premium and cost-sharing subsidies will be available to make coverage more affordable.
subsidies will only be available to those without other coverage or whose share of the premium for coverage offered by an employer exceeds 9.8% of their income. Small businesses with up to 100 employees can purchase coverage through the Exchange.
the Office of Personnel Management, which administers the Federal Employees Health Benefit Program, will contract with private insurers to offer at least two multi-state plans in each Exchange, including at least one offered by a non-profit entity. In addition, funds will be made available to establish non-profit, member-run health insurance CO-OPs in each state
Plans in the Exchanges will be required to offer benefits that meet a minimum set of standards. Insurers will offer four levels of coverage that vary based on premiums, out-of-pocket costs, and benefits beyond the minimum required plus a catastrophic coverage plan.
Premium subsidies will be provided to families with incomes between 100-400% of the poverty level (or $22,050 to $88,200 for a family of four in 2009) to help them purchase insurance through the Exchanges. These subsidies will be offered on a sliding scale basis and will limit the cost of the premium to between 2% of income for those between 100-133% of the poverty level to 9.8% of income for those between 300- 400% of the poverty level.
Cost-sharing subsidies will also be available to people with incomes between 100-200% of the poverty level to limit out-of-pocket spending.
Broker Role – HHS Secretary is required to “establish procedures under which a State may allow agents and brokers to enroll individuals” in Exchanges.
Beginning in 2014, the legislation allows states the option of merging the individual and small group markets within the Exchanges.
A more comprehensive chart is available through NAHU (National Association of health Underwriters).
Several states have already challenged this law as an over extension of Federal powers. Additionally, the requirement of mandating an individual to buy insurance is not so clear.
Many additional questions will arise such as:
-How will plans with Federal minimum standards reconcile with progressive states like NY that have numerous state mandates already? -Afterall, a Healthy NY plan can operate commercially without mandates that an ordinary group plan must comply with? -What happens to community rated states like NY? -Will they drop this rating methodology altogether? -Since there will be no longer pre-existing conditions is it just cheaper for an individual to just withdraw pay the penalty and then hop in when in need of coverage?
Lastly and importantly, the bending of the cost curve is weak. There is language, however, on attacking fraud & billing abuses as well successful Pharmaceutical concession for Medicare Part D. But Rome was not built in a day and this lays the foundation for a path of extending coverage to as many people as possible. Heavy topics such as Tort Reform, exorbitant malpractice insurance, federal medical reimbursements cuts must wait for another day.
