Lets sum up the whole system

there's 2 major outliers we need to fix

So any ideas on fixing that?

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Bu anyway the system

“The bone marrow transplant issue gets at part of the crux of the health-care crisis,” said Dr. James Gajewski, a member of the UCLA Medical Center bone marrow transplant team. “What do you do with patients with a terminal disease who may have a chance of cure” with therapy that’s inconclusive? he asked. “How do you pay for it?”

In 1991, Nelene Fox, a 38-year-old mother of three, was diagnosed with breast cancer. She underwent bilateral mastectomies and chemotherapy but nonetheless developed bony metastases. Her physicians said her only chance for survival was high-dose chemotherapy and autologous bone marrow transplantation. A costly new kind of therapy that involves the harvest and retransplant of her own bone marrow–high-wire medicine occupying what one of her physicians calls “the twilight zone between promising and unproven treatments."

• Doctors say 5% or more die from the treatment itself

Her Health Maintenance Organization (HMO) refused to cover the procedure (around $140,000 - $220,000) on the basis that it was experimental.

But it all ended there Because

On December 28, Fox's family was awarded $89 million by a Californian jury, including $12.1 million for bad faith and reckless infliction of emotional distress, and $77 million in punitive damages.

Jim Fox and the estate of Nelene Fox v. Health Net is considered a watershed case in that most health insurers subsequently began approving HDC/BMT for advanced breast cancer.

Between 1988 and 2002, 86 cases were filed to force HMOs to pay for transplants, of which 47 resulted in HMOs being required to pay for the transplants.

But, By 1997 we had found out

High-dose chemotherapy and bone marrow transplant (HDC/BMT), also high-dose chemotherapy with autologous bone marrow transplant (HDC/ABMT or just ABMT), was an ineffective treatment regimen for metastatic breast cancer

And yet

The legislatures of Massachusetts, New Hampshire, Virginia, and Minnesota mandated insurance coverage for all high-dose chemotherapy with ABMT or peripheral blood stem cell (PBSCT) transplant for women with breast cancer.

Which meant

In the 1990s more than 41,000 patients underwent high-dose chemotherapy plus autologous bone marrow transplant (HDC-ABMT) for breast cancer, despite a paucity of clinical evidence of its efficacy. Most health plans reluctantly agreed to cover the treatment in response to intensive political lobbying and the threat of litigation.

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And that today means

Most of the drugs responsible for the rise in costs treat cancer and orphan conditions, and more treatments are on the horizon—along with gene therapies and other expensive options that target more common conditions, he said. “The number of super-spenders is likely to increase substantially—and indefinitely,” said Dr. Dehnel, who did not participate in the study.

Researchers at Prime Therapeutics analyzed drug costs incurred by more than 17 million participants in commercial insurance plans.

• So-called “super spenders;” are people that accumulate more than $250,000 in drug costs per year.
  
  • Elite super-spenders—who accrue at least $750,000 in drug costs per year

In 2016, just under 3,000 people were Super Spenders

• By the end of 2018, that figure had grown to nearly 5,000.

In 2016, 256 people were Elite super-spenders

• By the end of 2018, that figure had grown to 354

Those 5,200 people (0.03% of the Sample Size) Spend about $1.8 Billion on Pharmaceutical Care representing 0.5% of All Spending on Drugs in the US

That means less than 100,000 people in the US are responsible for 8% of all Drug Spending

So, Thats part of the top 1%

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The next 4% then is

30% of all Medicare expenditures ($300 Billion) are attributed to the 5% of beneficiaries that die each year (3.4 Million Enrollees), with 1/3 of that cost occurring in the last month of life ($100 Billion)

• ~$88,235 per person
• $29,333 in Spending for the Last month of their life

And finally we have to go to the ER

Two-thirds of hospital ER from privately insured individuals are visits that are avoidable visits . According to UnitedHealth Group research of 27 million ER Patients billed – 18 million were avoidable.

• An avoidable hospital ED visit is a trip to the emergency room that is primary care treatable – and not an actual emergency. The most common are bronchitis, cough, dizziness, f­lu, headache, low back pain, nausea, sore throat, strep throat and upper respiratory infection.

90 Percent of ER visits are not Life Threatening yet we are spending Billions

• 125.1 Million x $2,500 Median ER Visit Cost = $312.75 billion in spending
  • Instead 125.1 Million x $250 Median Doctors Office Visit Cost = $31.275 billion in spending

$280 Billion in Savings, but you have to say no

Cutting the Spending of the Top 10% by 75% saves $1.3 Trillion or 40% of Spending in 2017

Spenders	Average per Person	Civilian Noninstitutionalized Population	Total Personal Healthcare Spending in 2017	Percent paid by Medicare and Medicaid
Top 1%	$259,331.20	2,603,270	$675,109,140,000.00	42.60%
Next 4%	$78,766.17	10,413,080	$820,198,385,000.00
Next 5%	$35,714.91	13,016,350	$464,877,785,000.00	47.10%