Richmond Community Hospital: Poster Child for Reforming 340B

By Dr. William S. Smith
and Chris Braunlich

Nonprofit hospitals in low-income neighborhoods should be the backbone of the American safety net system for low-income people who lack insurance. Instead, thanks to a federal program called 340B, many nonprofit hospitals have made maximizing revenue their primary goal, not providing charity care. Thanks to a New York Times investigation, Richmond Community Hospital has become the starkest example of a nonprofit hospital that exploits the 340B program while reducing medical services available to the distressed community surrounding the hospital.

The 340B program was created by Congress in 1992 and was intended to allow about 500 hospitals in low-income areas to purchase drugs at substantial discounts. It was thought that, with these discounts, nonprofit hospitals could provide more free care to the distressed communities where they were located.

However, the law was poorly written, and hospitals soon discovered that they could “arbitrage” these drug discounts into a profit center. How could they do this? In short, buy low and sell high. As The New York Times story explained, Richmond Community can buy a vial of the cancer drug Keytruda at a discounted price of $3,444, yet can bill the local Blue Cross health plan $25,425 for that same vial, for a profit of $22,000 on one patient’s prescription.

The Lown Institute, a nonpartisan think tank, calculated the “fair share deficit” of each state – the amount spent on charity and community investment minus the tax breaks received by the hospitals. Virginia ranked 34, with hospitals in the aggregate receiving $292 million more in tax breaks than the amount they spend on charity care.

This no doubt contributed to the growing profits of Virginia’s hospitals, most recently observed in a 2017 Thomas Jefferson Institute study.

These incentives caused Richmond Community to expand into wealthier neighborhoods so they could enroll more patients with good insurance coverage. After all, if Richmond Community gives Keytruda away for free, it will cost them $3,444, but if they prescribe it to a patient with insurance, they would profit by $22,000. The Times story describes how Richmond Community opened a cancer institute in a wealthier neighborhood in order to increase its revenues from the 340B program. “The Bon Secours Cancer Institute at St. Mary’s, for example, administers cancer drugs to patients in an office suite on the tree-lined campus of St. Mary’s Hospital.”

Richmond Community can expand into higher income neighborhoods because these satellite offices immediately become eligible for the 340B discounts that derive from the main hospital’s location in a low-income neighborhood. Congress wrote the law so poorly that they did not preclude satellite offices in wealthy zip codes from sharing the discounts.

The result has been that the number of contract pharmacies has skyrocketed as has the number of covered entities, far above just the number in low-income areas.

However, probably the worst aspect of the statute creating the 340B program is that it does not require hospitals to spend the 340B revenues on charity care for the local community. So, few policy makers know how much revenue hospitals get from the program and what they spend it on. As The New York Times explains the infirmities in the law: “Hospitals did not have to disclose how much money they made from sales of the discounted drugs. And they were not required to use the revenues to help the underserved patients who qualified them for the program in the first place.”

Therefore, the Congress and state governments can undertake a simple reform to help with this situation: disclosure. First, policy makers should develop a uniform definition of charity care.

For example, an unpaid bill from the wealthy patient does not count as charity care. Then, they should require that hospitals disclose how much revenue they secure from 340B and how much actual charity care they provide.

With this simple reform, policy makers and the public at large can know if nonprofit hospitals are living up to their mission.

William S. Smith, PhD, is Senior Fellow and Director of the Life Sciences Initiative at Pioneer Institute in Boston. He may be reached at Chris Braunlich is president of the Thomas Jefferson Institute for Public Policy. He may be reached at

This column was first published today by the Thomas Jefferson Institute for Public Policy, and has been republished here with permission.

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83 responses to “Richmond Community Hospital: Poster Child for Reforming 340B”

  1. LarrytheG Avatar

    Are these the same Conservatives that have opposed the ACA and the Medicaid Expansion and Medicare negotiating for drug prices?

    hard to understand Conservatives when it comes to health care. They say a bunch of things but in the end, they’re NOT in favor of helping people who need health care… just the opposite in fact even while they “question” what the definition of “charity” is.

    1. DJRippert Avatar

      Looks like the Congress which passed this half-assed law was Senate: majority Democrat, house: majority Democrat.

      It’s easy to understand the left / liberals/ progressives/ Democrats when it comes to healthcare (or anything else) … they are incompetent and insist that the answer to everything is more and bigger government using more and heavier regulation.

      1. LarrytheG Avatar

        It’s reason that seniors, veterans, and others who have the ACA and Medicaid expansion have health care they would not have if we let Conservatives do it.

        The law needs to be adjusted. Lots of laws that get passed by both Dems and GOP end up needing to be adjusted – it’s the nature of the beast whether it’s health care or any other laws.

        But Conservatives “other” approach is to vote against.

        There would be no Medicare, Medicaid, ACA or other healthcare if it were not for the Dems because Conservatives continue to insist that the “free market” will do it.

        1. DJRippert Avatar

          You understand that Medicaid, Medicaid expansion and most of the ACA are just extensions of a socialist approach., right Larry? There’s no government genius here – it’s just a transfer of wealth from one group of people to another.

          Like forgiving college debt doesn’t change the ever rising cost of tuition and doesn’t make college more affordable, the ACA didn’t reduce the cost of healthcare in the US. From 2010, when the Affordable Care Act was signed, through 2019, healthcare costs rose by 4.2% a year.

          Here we have an article about how an incompetent law, passed by a majority Democrat Congress 30 years ago, continues to be abused.

          30 years of incompetence here, Larry.

          Nobody doubts that the libtwits in America would be only too happy to implement policies which increase wealth transfers and make the US more socialist. What is astonishing is that the wokesters who demand more wealth transfers continue to insist that they are addressing the underlying problems. They are not.

          1. James McCarthy Avatar
            James McCarthy

            Ugh!! Silly critique of socialism and health care. “Transfer of wealth” in this paradigm includes SS and military appropriations to pay personnel. Such socialism is simply a function of society, not a conspiracy to empty the pockets of the wealthy. This type of woke conservatism contributes nothing to dialogue.

          2. DJRippert Avatar

            More silly walking. The article describes a botched federal plan to subsidize the cost of certain drugs for low income patients.

            How do you think that subsidy works? By magic? No, it works by taking money from one group of people and spending that money to benefit a different group of people.

            Now, that may have been an admirable goal. However, the government botched the law and ended up subsidizing the hospitals rather than their poor patients.

            What the hospitals did with that botched subsidy is anybody’s guess since the law never required the hospitals to account for their level of charitable care.

          3. James McCarthy Avatar
            James McCarthy

            Silly talking. The law needs revision because hospitals manipulated a weakness in pursuit of profit. No money is being taken from one group to subsidize another. The subsidy fails its purpose by distortion by hospitals to pad their bottom line. That includes not for profit hospitals.

          4. LarrytheG Avatar

            I don’t know about his particular case but a lot of hospitals provide services that have provide higher levels of reimbursement as well as services for the folks who can pay out of pocket for them – and from that, they use some of that profit to serve the community and individuals who don’t have insurance or wealth.

            It’s not easy to tell when that is going on or not but not all of this stuff is just for “profit” alone.

            Most hospitals do treat people who cannot pay.

            They have to eat what they cannot collect unless they have other ways to make up those losses.

          5. James McCarthy Avatar
            James McCarthy

            The issue here is a practice employed to make profit in one area to bolster losses or pad the bottom line. It’s one way to absorb losses. In this case the proportions are grotesque.

          6. LarrytheG Avatar

            I just don’t what the standard is or how much of their “take” needs to go to charity and what happens to the “excess”: that is left over. We need to know all the pieces and parts to really have a good understanding IMO.

          7. James McCarthy Avatar
            James McCarthy

            Charity care costs are driven by the same codes as all other care. The net to patient is minus insurance coverage. Insurance income over costs must cover charity care and fund the institution’s bottom line for capital and personnel mostly. The care cost in this article is the manufacturer’s drug prices.

          8. LarrytheG Avatar

            Right. If they use their “profits” to pay for charity care … do we know how much their “take” is and how much they provide in charity care?

          9. James McCarthy Avatar
            James McCarthy

            As the article argues, no one knows a la Don Rumsfeld. What is known is that patients and carriers pay the piper. And it ain’t socialism.

          10. LarrytheG Avatar

            right. So why does the program need to be “reformed” if it actually is working and that money actually does go back into charity care?

          11. DJRippert Avatar

            How do you think the hospitals get to buy those drugs for 70% off what everybody else pays? Even if the discount is forced on the pharma companies those companies will just increase the price to those prescribers who pay full boat to make up the difference. That will be factored into health insurance costs for those not eligible for the discounted drugs. Which creates a wealth transfer from those who are not subsidized to those who are subsidized.

            There is no free lunch.

            Every time the government subsidizes anything it os done with money provided by those who are not receiving the subsidy.

          12. James McCarthy Avatar
            James McCarthy

            Because individuals in health care are not buyers but secondary consumers. If drug mfgrs are discounting to hospitals, it’s because there are no other purchasers. You’re not getting the drug cited in this article at CVS! If there is a wealth transfer, it is from the wealthy drug mfgr to the wealthy hospital. No end recipient benefits from the bargain. Sophmoric silly attempts to critique socialism are pure propaganda and irrelevant.

          13. LarrytheG Avatar

            this is true. the point is “we” do pay so if we are, then why not in the most efficient way possible – as opposed to demonizing the program and the hospitals that use it for their “profits”.

            We make the point that it’s “shocking” that non-profit hospitals can make a “profit”.

            Where do those profits go? If they roll back into their programs and services is that like profits going to shareholders?

          14. LarrytheG Avatar

            Health Care done like every other developed country on the planet – that leads to longer lifespans and higher productivity, etc.

            No different than public roads and public education.

            There are “incompetent” laws done by both Dems and GOP but they are in the minority of all laws that we do.

            You guys have an inherently destructive approach to governance IMO.

          15. DJRippert Avatar

            Having been to Ukraine and done business in Ukraine, I’ll make a prediction right now …

            If there is an accounting of where US aid to Ukraine really went – there will be billions upon billions of dollars lost to Ukrainian corruption.

            Read the book Bailout, written by Neil Barofsky (a liberal Democrat). He chronicles the gross incompetence and culpable negligence of the Obama Administration in administering the bailouts from The Great Recession.

            Yes, I am inherently destructive when it comes to bigger and bigger government.

            Our government is corrupt and incompetent.

            More government = more corruption and more incompetence.

          16. how_it_works Avatar

            “Our government is corrupt and incompetent.”

            But some, perhaps some commenters on this blog, benefit from that corruption and incompetence.

          17. James McCarthy Avatar
            James McCarthy

            Caramba!! A corrupt and incompetent government, too big to succeed. Yes, let’s destroy it. Nutz!!

          18. LarrytheG Avatar

            that’s the conservative theme song!

          19. LarrytheG Avatar

            in terms of “aid” to Ukraine and Afghanistan, and other countries – yes… it’s the nature of the beast no matter Dem or GOP.

            GOvt is corrupt and incompetent, yes, at times but it’s also the opposite so folks who look at one side and want to destroy are destructive,

            You travel on public roads every day I bet. Yes, there is waste and even corruption with regard to transportation – but it’s also a well-functioning system for most people most of the time.

            Ya’ll are just inclined to destroy sometimes by your willful myopia.

          20. James McCarthy Avatar
            James McCarthy

            The roads per se are corrupt along with foreign aid. The ACA is corrupt and must be destroyed. Hospitals are corrupt. Vote Bannon and Fuentes in 2024.

    2. James McCarthy Avatar
      James McCarthy

      There is no free market in which health insurance can thrive. Insurers will not insure the sick and the old. Social responsibility for health care is neither socialism nor a transfer of wealth.

      1. LarrytheG Avatar

        yes and most Conservatives who say that are either bat-crap crazy and live in LA LA Land or they know they’re lying but it’s what they do to please their base.

  2. f/k/a_tmtfairfax Avatar

    So, why not rewrite the law to eliminate the loophole?

    Of course, we must ignore the decades of illegal immigration that has kept compensation for those citizens and non-citizens authorized to work here and who have little education or lesser skills lower than they would otherwise be. If we didn’t have open borders, more people would be paid more and maybe have better benefits.

    The small restaurant chain where my son is a manager was losing good workers because they had no health insurance plan. To attract and retain good workers, the owners had to offer health insurance.

    1. LarrytheG Avatar

      I think they should but again point out that a few laws do need to be re-written or even repealed. That does not mean that governance is an evil by a long shot.

      And you KNOW the problem with immigration. It’s Conservatives refusal to require E-Verify.

      We don’t have “open borders” in my view. What we have is a law that says if someone gets into the country, that we will determine if they qualify for asylum. We do not have enough judges and courts and administrative resources to process them quickly enough – IMO.

      on small business health insurance. It’s a problem but less so than it used to be now that we do have the ACA as well as the Medicaid Expansion.

      Many, many of us would not have health insurance at all if it were not for the Govt requiring that insurance companies cover us in employer plans that also say that the premiums have to be the same for each class – i.e. self-only, family, etc regardless of the actual health status of those covered.

    2. James McCarthy Avatar
      James McCarthy

      Not exactly a loophole but more akin to a manipulation in pursuit of profit to run end around a worthy purpose. Still, the law requires amendment.

      1. f/k/a_tmtfairfax Avatar

        That ought to be the argument. If a law is not working the way it was intended, it should be modified to address the problem or repealed.

        1. LarrytheG Avatar

          We need to know how much of that “profit” goes for charity care.

          If a hospital is in a poor neighborhood and a LOT or most of the drug “profits’ goes to provide those services, does that mean the law IS working as intended?

          I don’t think you can just look at how much “profit” they make and not see how they are spending it. If it is for some high dollar administrators, then there IS a problem. If it gets plowed back into services for those who cannot pay, maybe not so much.

          But we are SO suspicious these days in general. Anything the govt does is “suspect” especially if it involves subsidies and such.

          It just seems to me that the mindset of many conservatives these days is that the govt is “bad” and needs to be “investigated” for possible wrongdoing – even when the data to show that is just not there.

  3. Nancy Naive Avatar
    Nancy Naive

    The only thing American patients are less informed about than the information in the “informed consent” is the cost and whether it’s covered in their insurance policy.

    1. LarrytheG Avatar

      The average person has almost no clue about the actual terms of their coverage – until they use it a lot.

      1. Nancy Naive Avatar
        Nancy Naive

        And the only way is hours on the phone with an insurance agent who knows even less.

        In England, you talk only to the doctors.

        1. LarrytheG Avatar

          And the ones that DO find out and KNOW, there is no guarantee that the insurance companies won’t then change coverage year to year in concert with how their payouts are going.

          Medicare still has a 20% co-pay and bankruptcies due to medical debt are still

  4. Nancy Naive Avatar
    Nancy Naive

    You can get better healthcare in 20 other countries BUT you can’t pay more for it.

    1. LarrytheG Avatar

      wonder if that is because bigger govt is corrupt and incompetent?

  5. Nancy Naive Avatar
    Nancy Naive

    A little OT. I just watched “48 Hours”, a cop show, and this guy gets shot and killed. One guy turns himself in, confesses and IDs the other shooter. The police find the other guy hiding out and arrest him.

    They’re both charged with 1st degree manslaughter, plead guilty and sentenced. One gets 8 years, and the other gets 10.

    Guess which one got 8 years?

    1. how_it_works Avatar

      Usually the one that “squeals” first gets the lighter sentence. Usually.

      1. Nancy Naive Avatar
        Nancy Naive

        Nah, it was the white guy they had to chase. The black guy got 10. Texas.

        1. how_it_works Avatar

          Did either of them have any priors?

          1. Nancy Naive Avatar
            Nancy Naive

            In Texas? Everyone does. I’m sure there was a reason beyond the obvious.

  6. Nancy Naive Avatar
    Nancy Naive

    The Brits do it better.

    It’s not a VMI exam. You can copy from the smarter kids.

  7. Dick Hall-Sizemore Avatar
    Dick Hall-Sizemore

    The state also benefits from the 340B program. For example, there are several serious medical conditions which affect prison inmates for which the drugs are very expensive. HIV and, more widespread and expensive, Hepatitis C. By having these inmates treated by MCV physicians in “clinics” (usually telehealth), the Dept of Corrections is able to take advantage of VCU Hospital’s 340B eligibilty and save millions on the cost of the medications.

  8. LarrytheG Avatar

    I was looking at this map:

    and wondering how many hospitals can exist in such close proximity and stay solvent. VCU is about a mile away. Bon Secours looks like they
    have 7 hospitals in Richmond.

    How many hospitals can operate financially in a place like Richmond? Perhaps there are too many for the population and some will need to close?

    I also wonder that the percent of charity cases is for the Bon Secours Richmond Community Hospital is and how much “profit” they are making.

    If they are providing a LOT of charity care, they may well need a LOT of subsidy from that program to pay for it.

    The NYT article looked at the corporate Bon Secours which includes many other hospitals not in lower income locales – like the Bon Secours St. Mary’s Hospital in the west end.

    It’s not easy to determine what the actual situation is or what Bon Secours is doing but it well could be that they have a high percentage of charity cases and the hospital is actually selling drugs at a profit to higher income folks in order to subsidize the community hospital.

    I don’t know but the article seems to be focusing on the fact that the Bon Secours hospital system is big and profitable as opposed to looking more closely at the finances of this specific hospital and really focusing more on the 304B program and what they feel is abuse of it to make a “profit”.

    I’m a bit of a skeptic at this point in part because it’s a conservative group with a bit of an agenda about govt and subsidies.

    1. how_it_works Avatar

      “wondering how many hospitals can exist in such close proximity and stay solvent”

      Population density probably helps. It would be interesting to know what the population within 1-2-3 miles of those hospitals is.

      (If you’ve ever looked at a brochure for a commercial retail property, they almost always give the population within a 1 mile, 5 mile, and 10 mile radius–this is important information for many businesses in deciding where to locate)

      1. LarrytheG Avatar

        yes. And these are things we do not know and seldom addressed in commentaries asking hospitals what they are doing with their “profits”.

  9. How is the reduced price of $3,444 under 340B set? Is this mfgrs cost, below mfgrs cost, etc. Also, what is the normal hospital cost from the mfgr?

  10. William O'Keefe Avatar
    William O’Keefe

    It’s amazing how Larry and a few others can divert a discussion from a specific subject to one that is tangential. In this case, the 340B program to health insurance and evil conservatives who are heartless.
    The New York Times article and coverage by the RTD raised some important questions but failed to cover one very important point. What does Bon Secours do with the profits from drugs purchased at a discount and sold at higher prices reimbursed by health insurance. If it is used to cover services to the underserved in Richmond then the program is working as it was supposed to. If on the other hand, those profits are being used for other purposes, then the program is being gamed.
    340b was designed to create cross subsidies that are intended to cover costs for medical treatment of low income and underserved people in a community. If services and treatments to low income and underserved residents in the Richmond community have increased as its 340B revenue has increased, then it has a defensible case. If that is not the case, then Bon Secours deserves the criticism and any penalties that it gets.
    When laws are written, they create incentives for those who are covered by them. Those incentives include both compliance and exploitation. The book Bootleggers and Baptists by Bruce Yandle demonstrates that clearly.
    As for all the commentary on health insurance, much of it is uninformed and ill informed because it does not reflect an understanding of incentives, market distorting regulations, or how the best health care systems in other countries actually work.

    1. LarrytheG Avatar

      the most relevant thing you say here Bill is ” but failed to cover one very important point. What does Bon Secours do with the profits from drugs purchased at a discount and sold at higher prices reimbursed by health insurance. ” of which I have the SAME question and I think we need to know the answer to that before we conclude that the hospital is abusing the program.

      It’s in a poor section of town and I’d not be surprised that it has a high percent of charity cases.

      Beyond this , the basic argument seems to be that the program _might_ be abused because we don’t know what they do with their “profits”. Do they use them for charity or something else?

      So you seem to think the same and no I did not call them evil – had the same observation!

      The health insurance issue goes to how Conservatives in general have reacted to providing health care and health insurance in general – not something they have a reputation of supporting at all so why think they’d be much different for cross-subsides for drugs?

      Their basic perspective seems to be that such arrangements are not so good to start with and especially so if they can be abused or are abused – as opposed to supporting the basic premise of the law and then advocating making it stronger with more transparency and safeguarding abuse.

      In Conservatives world, these things are not good things to start with and from that point on, they want to point out the flaws and downsides that prove “once again” that such an approach to providing health care is fundamentally wrong – i.e. the govt providing the “wrong” incentives and messing up the potential for a “market” to “work”…. etc, etc…

      I’ve just never really seen a cogent approach from Conservatives on any of this. Their basic belief seems to be that govt should not be doing any of this and that if the govt stayed out of it the “market” would provide the services.

      As far as other countries health care, typically in my observations, Conservatives in this country OPPOSE what other countries are doing , consider it socialism , and say the “free market” is how it should work instead. IOW, we’d not have Medicare, Medicaid, the ACA if Conservatives had their way – we’d have health insurance that did not have the wrong incentives and “market distorting” regulation. Yep, Repeal and replace with… never got a cogent proposal… just the standard right wing blather – “repeal”.

      1. William O'Keefe Avatar
        William O’Keefe

        There have been a lot of proposals from the conservative community. You are just focusing on those from politicians.

        1. LarrytheG Avatar

          Yes, there are “proposals”, I agree. But they’re mostly pie-in-the-sky libertarianism type stuff.

          No country on the face of the planet does health care like these “proposals” save for some 3rd world countries where only the rich get quality health care.

          Every other developed country on the planet delivers health care in ways that Conservatives fundamentally oppose. They call it socialism.


          1. Socialized medicine is the cure for what ails you – if you can wait long enough.
            Britain is often given as an example of what good single payer looks like.

            It would be nice if this link was the exception, but it’s easy to find lots like it if you want the truth.


            NHS patient’s 812 days on a waiting list as delays ‘spiral out of control’: Average wait for a routine operation is two weeks longer than a year ago

            The average wait at NHS hospitals is two weeks longer than this time last year
            This is despite health service rules stating they should be treated in 18 weeks
            Patients are routinely waiting more than a year for relatively simple procedures
            One person in Derby waited two years and three months to have their tonsils out

          2. LarrytheG Avatar

            The wait times are real and that’s how they do triage and prioritize.

            All OECD countries do some version of it and so do we.

            The proof is in the pudding:


            but you guys can’t seem to deal with the truth and reality. Govt sponsored health care , despite the wait times, produces the highest life expectancies in the world and the US is not among the best – we’re more like some developing countries.

          3. Medicine seems to be a death cult to you. Kill them in the womb or later with triage and prioritization. What’s next – a gulag for political enemies?

          4. LarrytheG Avatar

            what? Simple and true data seems to be an anathema to you folks. You want to believe something and you don’t seem to care if it is true or not as long as it “fits” what you want to believe.

            The USA has the most expensive health care in the world and among the worst in life expectancy for developed countries.

            One might think fiscal conservatives would want to know why and deal with it instead of just living in their own little make-believe world.

            BTW – We “kill” more born babies than much the rest of the developed world also:

          5. You can pick all the cherries you want to, but you haven’t proven that all the ills you claim are due to inadequate health care and not due to other causes.

          6. LarrytheG Avatar

            Not trying to prove much other than the countries with the longest life expectancies seem to all provide govt sponsored health care.

          7. Correlation is NOT causation.
            STATS 101

          8. LarrytheG Avatar

            the data is petty overwhelming when you compare this country with other countries on both life expectancy and infant deaths.

            And to portray this country as having shorter wait times when some of our people can’t even get adequate insurance nor afford their care, die from lack of is nothing short of blind eye.

            Here’s and example of Conservatives “approach” to health care – to deny it – by Don McEachin who just died from cancer:


          9. There’s a macabre humor when someone who supports abortion on demand then claims to care about infant mortality.

            For your claim to be true, you have to rule out any other cause(s) for the higher death rates. You haven’t done that. You have not presented any evidence whatever that lifestyle, diet, etc. is not the cause for the difference.

            Your sole argument, which you demonstrate again with the McEachin reference, is: Larry is good and superior to the evil Republicans.

          10. LarrytheG Avatar

            Maybe but do you actually know my position on abortion and if you don’t why would you say you do?

            I don’t have to “prove” anything , just point to the data on a worldwide basis.

            Do you really think the US is unique with regard to things like diet, lifestyle, to the point where it causes our lower life expectancies compared to most all other developed countries?

            Do you think diet and lifestyle affects infant mortality – again on a world wide basis compared to most other developed countries?

            You misunderstand totally what “good” and “superior” is or not IMO and you demonstrate it well here and it seems to be a trait with some conservatives. Ya’ll are not able to change even when it’s clear it’s needed.

          11. Excellent! Thank you for proving my point. There is no link between the data you presented and the claim you made, and you refuse to provide one.

            As I said earlier: Correlation is NOT causation.

            What conservative trait are you referring to and can you explain what good and superior mean?

          12. LarrytheG Avatar

            of course. and especially if one really does not want to know why to start with and instead just makes bogus excuses like “diet” and “lifestyle” that involves millions of people on a worldwide basis.

          13. LMAO! Bogus!

            Here’s an article about why a Japanese diet leads to a longer life and comparison to the typical US diet.


            Here’s another one on the same topic.


            If you really try, I bet you could find a lot more – hint: Google

            It’s not bogus, Larry – it’s science.
            Correlation is NOT causation.
            Anything is possible until you rule it out with facts.

          14. Correlation is NOT causation.
            STATS 101

          15. Triage:

            A disabled veteran in Canada
            has slammed her government for offering to euthanize her when she grew frustrated at delays in having a wheelchair lift installed in her home.

            Retired Army Corporal Christine Gauthier, a former Paralympian, testified in Parliament on Thursday that a Veterans Affairs Canada (VAC) caseworker made the assisted suicide offer.

            After years of frustrating delays in getting the home lift, Gauthier says the caseworker told her: ‘Madam, if you are really so desperate, we can give you medical assistance in dying now.’

          16. LarrytheG Avatar

            yep, the anecdotal things are interesting…

          17. All your claims are just anecdotes and opinions until you prove them.

          18. LarrytheG Avatar

            I’ve provide you with REAL DATA not anecdotal.

            I can give you a lot more if you can’t reconcile the truth.

          19. William O'Keefe Avatar
            William O’Keefe

            You make assertions that suppose that you have reviewed all of the literature on health care improvements by “conservative”. I doubt that is the case. I don’t know how you can assert that “Every other developed country on the planet delivers health care in ways that Conservatives fundamentally oppose.” The best systems are generally in Europe by countries that combine public and private insurance. In some countries cost control is In the form of health care rationing.
            Here is a paper that describes a system that has been adopted by some providers. It was designed by Alain Einthoven who is/was one of the leading health care economists in the country.–-Revisiting-Enthovens-Principles_WP07.pdf
            If you check the vast majority of health insurance is provided by private employers who have to comply with government regulations that create distortions and make insurance more expensive because there is not competition among providers.

          20. LarrytheG Avatar

            Well, no I have not reviewed “all” at all!

            Thanks for the link.

            You know of course “managed care” is a lot of what we do also , right?

            And agree about the regulation. THe biggest one by far is that employer-provided cannot turn down any employee no matter their health status. Neither can Medicare nor Medicaid nor the ACA.

            You take away that rulel and let health insurance companies sell it like auto insurance or fire insurance is sold – using risk underwriting and you can cut costs dramatically because the most expensive folks won’t get insurance.


            I just think Conservatives have no real approach to it.

            They don’t like what we have and they point out all the things wrong with it but they don’t really have viable counter proposals.

            They’re fundamentally opposed to programs that subsidize like the one that is the subject of this blog post.

            Part of the opposition is because of a lack of transparency but beyond that the basic concept of selling high dollar drugs to one set of customers and channeling the profit to pay for others who can’t pay – is not something most conservatives agree with fundamentally as a concept much less as something the government enables and incentivizes.

            I say that even as drug manufacturers do the same thing. They claim they have to make big profits on some drugs in order to pay for research for other drugs and because Europe won’t let them sell it at a high profit.

            The same Conservatives opposed Medicare negotiating for drug prices even though the VA is allowed to.

          21. William O'Keefe Avatar
            William O’Keefe

            The sad fact is that health care reform to lower cost and increase efficiency isn’t going to happen for the same reason that social security reform isn’t going to happen. Both democrats and republicans can use both as wedge issues. If health insurance could be sold like auto insurance, we’d be better off as long as there was high risk pooling for the otherwise uninsured.

          22. LarrytheG Avatar

            I appreciate and respect your comment and view.

            You don’t believe it but I share some of your views in general but we disagree on specifics.

            High Risk pools won’t help seniors and many, including middle class, would end up in poverty if they did not have Medicare. A simple thing even like a colonoscopy would wipe out their savings.

            Ditto for the working poor and worse, if they get a health condition like diabetes , a high-risk pool would not help them with costs that would exceed their earnings.

            Social Security is entirely funded from FICA taxes, UNLIKE Medicare (Part B, not A), and Medicaid which is entirely general fund (except for premiums and co-pays).

            The problem with Social Security is the same problem with ANY annuity – including things like teacher pensions when demographics change over time, e.g. less younger workers, older workers living longer, etc. Social Security pays you no matter how long you live, if you live longer than what you paid in, it loses. If a whole bunch of seniors live longer than expected, it faces shortfalls for everyone.

            Private annuities make these adjustments all the time. What you or the Teachers pensions might pay for an annuity 10 years ago is not the same as it costs now.

            SS just needs to be able to make similar adjustments but I do agree with you, both sides demonize the “cuts”.

          23. William O'Keefe Avatar
            William O’Keefe

            It all depends on how the system is designed and the extent of government regulation which can’t be zero. Check out the health care systems in the Netherlands and Switzerland. As for SS, the FICA taxes are going to be increasingly inadequate as the number of retirees grow. When SS first started there were over 40 workers for each retiree; now it’s down to something like 2 or 3. In addition, there is the trust fund which is projected to run out of funds in a little over a decade. Change or reform is needed and has been for some time. See this article–

          24. LarrytheG Avatar

            I will take a closer look at the Netherlands and Switzerland and comment,

            The Trust Fund that IS going broke was fully funded initially with FICA taxes, not a penny of general fund.

            Other agencies borrowed from it and paid it back with general funds but the original fund was built entirely with FICA taxes.

            It looks like we still have many millions of wage-earners and salaried paying FICA taxes and it’s not just for Social Security, it’s also for Medicare (Part A).

            So the question is how to fix it whereas some on the right are saying “no”, we need to privatize it.

            So the debate is not just about fixing it but some want to get rid of it.

            that’s a much bigger debate.

            Before Social Security – a substantial percentage of seniors lived in poverty because they had no pension and could not save enough for their retirement, still true for low paid workers, Unless there is a forced savings program, taxpayers will end up paying for seniors who end up poor (like we do now except many more).

            Do we reform SS or junk it?

          25. LarrytheG Avatar

            THanks for the link and yes, the fool article is correct from what I read.

            Here’s one thing I found on the Dutch system:

            “The average cost to a Dutch citizen for health insurance is about 1,400 euros, or $1,615, annually. People with lower incomes get additional government assistance to reduce their payments. The government also collects contributions from employers to help fund the insurance scheme and covers the cost for children; revenues are spread among the insurers based on the health status of their customers. Public financing covers about 75 percent of the system’s costs; the insurers have also generally operated as nonprofits.

            The benefits are designed to encourage cost-efficient use of medical care by patients. Dutch patients can visit a primary care doctor for free. For a visit to the hospital, they will need to pay toward their deductible. The annual deductible is today capped at €385 ($429), although people can choose to pay a lower monthly premium in exchange for a higher deductible — up to €885 ($980). That is still well below the typical deductible in America (more than $1,600 on average for workers on their employer’s plan, and many people have a higher deductible than that).”

          26. LarrytheG Avatar

            here’s Switzerland:

            ” In Switzerland, people with modest means may struggle to pay for basic health coverage for two simple reasons: insurance premiums are not adjusted to income, and they have doubled in price since 1996, while salaries have risen by just one-fifth. It comes as no surprise, then, that just over a quarter of the population needed government assistanceExternal link to pay their premiums in 2014.

            The state offers subsidies to ensure that everyone can afford basic health insurance, which is compulsory in Switzerland. Eligibility criteria is set by each canton. For households obtaining such assistance, insurance premiums account for 12% of disposable income, double the national average. Families, young adults and the elderly are the main subsidy recipients.”

            I’m not opposed to systems like the Netherlands and Switzerland which in some respects sound like our ACA where there is a market and it does cost money but there are subsidies for those on the lower income AND there are caps for out of pocket so that if someone has very high medical expenses it does not bankrupt them.

            If you took the ACA and also made it an option to those who have employer-provided so they could chose, many would likely switch in no small part because ACA health insurance is “portable” and employer-provided is not,

            you switch jobs and you switch insurance and if the new job has different insurance and provides different coverage, you may not take that job.

            So if we had PORTABLE health insurance – LIKE the Netherlands and Switzerland have, I’d support it!

        2. LarrytheG Avatar

          Hey Bill – focus on the issue, the discussion, the merits of it rather than the person.

          You can call any argument or point I make “garbage” and I can debate you on it but naming me as part of your reply just personalizes the discussion for no good or valid reason.

  11. Paul Sweet Avatar
    Paul Sweet

    “Richmond Community can buy a vial of the cancer drug Keytruda at a discounted price of $3,444, yet can bill the local Blue Cross health plan $25,425 for that same vial, for a profit of $22,000 on one patient’s prescription.”

    Blue Cross (or other insurance) isn’t likely to pay the full $25,425 that they are billed. Most medical bills I get show a substantial reduction on what medical insurance pays. When I had my knees replaced several years ago the hospital I was in for 10 days of rehab billed a little over $300K, but insurance slashed it to about $30K .

    1. LarrytheG Avatar

      Yes. Same here (different health issues). And on mine, it seems to be keyed to the Medicare reimbursement amount.

  12. LarrytheG Avatar

    More from RTD on the story:

    It’s clear money is going from Richmond Community to Ohio but other Richmond area Bon Secours are also sending money to Ohio and it’s said to be reimbursement for centralized/back office services – like computer systems and supply chain products.

    It’s also clear that Community Hospital is closing down services so it’s no longer a full service hospital serving a poor section of town. Bon Secours is saying that Community Hospital is not self-supporting and needs to be subsidized and they are doing it but also using the 340B program also – which when you get right down to it is doing what the drug companies are doing – making huge profits on drugs – from people who have the money or insurance for it.

    The big drug companies claim their profits are going back into their research to produce newer drugs which would not be possible if they did not make those profits.

    Bon Secours is claiming they use their profits to provide services to people who can’t pay. I’m not as bothered if community hospital doesn’t provide all services as long as people needing those services can get them at other hospitals which are not far away – some as close as a mile.

    So the irony here is that Conservatives complain about “regulations”, and here they are arguing for more and they
    argue about subsidies that go for health care but they oppose health care to the poor and working poor by opposed Medicaid and Medicaid expansion.

    So the Dems come up with these programs like 340b to “help” the hospitals pay for charity care – and yep, some of
    those “profits” might be “leaking” to the mother corporation for “reimbursements”.

    At the end of the day, the 340B program exists because “we”, the govt does not provide enough or adequate care to the poor and we expect the hospitals to do that but eat the costs.

    So what’s the answer?

    Well, conservatives hate the basic concept of the 340B program but they also hate the concept of the govt providing free health care to the poor so they are not exactly covering themselves in glory on the issue.

    They oppose comprehensive health care for the poor so the Dems create “shadow” laws to “help” that then turn out to have “loophole” issues of which the media and Conservatives rail about to be fixed. So Congress tightens up the regs with more regs and the hospitals then try to figure out other ways to get their costs covered, including going back to the Dems to create more shadow legislation – all the while the Conservatives still staunchly opposed to the basic concept of the govt providing charity care to the poor

    All of this stuff like the 340B program would go away if the govt said they would cover any/all of Community Hospitals charity care costs – up front – not through programs like the 340B.

    Guess who won’t agree to do that?

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