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Secretary Price declares public health emergency in Puerto Rico and US Virgin Islands due to Hurricane Maria

HHS Gov News - September 19, 2017

Following President Trump’s emergency declarations for Puerto Rico and the U.S. Virgin Islands, Health and Human Services Secretary Tom Price, M.D., today declared a public health emergency in Puerto Rico and the U.S. Virgin Islands as Hurricane Maria approaches the U.S. territories. The declaration allowed the secretary to issue a waiver under section 1135 of the Social Security Act for these areas to enable the Centers for Medicare & Medicaid Services to take action that gives beneficiaries and their health care providers and suppliers greater flexibility in meeting emergency health needs.

“Hurricane Maria currently poses a significant threat to the public health and safety of those living in Puerto Rico and the U.S. Virgin Islands,” said Secretary Price, M.D. “In preparation, HHS is mobilizing assets and readying personnel and supplies to help those in the path of the storm. Declaring a public health emergency for Puerto Rico and the U.S. Virgin Islands will aid in the department’s response capabilities – particularly as it relates to ensuring that individuals and families in those territories with Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) maintain access to care.”

These actions and flexibilities are effective retroactively to September 16 for the U.S. Virgin Islands and to September 17 for Puerto Rico.

HHS is making preparations in advance to support Puerto Rico and the U.S. Virgin Islands in responding to Hurricane Maria. HHS has more than 120 personnel deployed in Puerto Rico, including staff from National Disaster Medical System personnel, an Incident Response Coordination Team from the Office of the Assistant Secretary for Preparedness and Response, and an environmental health team from the Centers for Disease Control and Prevention. The experts are ready to provide medical care and public health support as needed after Hurricane Maria makes landfall. Additional medical and public health teams are ready to be called in as needed.

The Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline is available to aid people in coping with the behavioral health effects of the storm and help people in impacted areas connect with local behavioral health professionals. Residents can call 1-800-985-5990 toll free or text TalkWithUs to 66746 to connect with a trained crisis counselor.

The Food and Drug Administration is actively sharing important information on food, medicine, and device safety in English and Spanish.

The Health Resources and Services Administration is monitoring twenty health center grantees, that operate more than 90 service delivery sites, where more than 350,000 patients in Puerto Rico received care in 2016.

HHS remains in regular contact with Puerto Rico and U.S. Virgin Islands health officials to maintain awareness of the local situation and stands ready to augment its support to the territory as the situation unfolds.

HHS is committed to meeting the medical and public health needs of communities across Puerto Rico and the U.S. Virgin Islands impacted by Hurricane Maria in the immediate aftermath of the storm and as affected areas recover. Information on health safety tips during and after the hurricane will be provided by the Office of the Assistance Secretary for Preparedness and Response and will be available at www.phe.gov/emergency

Critical updates will also be available at:

Readout of Secretary Price and ASPR’s Visit to Florida-Based Medical Support Teams

HHS Gov News - September 19, 2017

On Monday, HHS Secretary Tom Price, M.D., traveled to Florida as part of the Trump Administration’s government-wide efforts to provide relief to those affected by Hurricane Irma. Along with HHS Assistant Secretary for Preparedness and Response Robert Kadlec, M.D., Secretary Price visited the HHS National Disaster Medical System (NDMS) and U.S. Public Health Service Commissioned Corps teams that are serving as part of the federal response in Florida.

First, Secretary Price met with Florida Governor Rick Scott and local officials at the Marathon Emergency Operations Center to discuss the current state of the Florida Keys, as well as the recovery efforts on the ground. During the meeting, Secretary Price and Governor Scott discussed the cooperation between the state, local communities and HHS operations. Secretary Price highlighted the seamless coordination HHS has experienced working with the state of Florida. This cooperation is aided by President Trump’s early emergency declaration, which allowed HHS to prepare ahead of the storm.

Dr. Kadlec provided additional details related to deployed assets and how his office, through its emPower initiative, quickly shared information with local first responders about Medicare beneficiaries whose lives depend on electrically powered medical equipment at home or on dialysis. Secretary Price underscored that, because of the President’s rapid action, HHS was able to lean in early to both prepare for, and respond to, the impact of Hurricane Irma by:

  • Deploying medical assets, including members of the Public Health Service, the NDMS, and mobile medical units;
  • Providing data and expertise to first responders and local officials;
  • Issuing waivers for Medicare, Medicaid, and CHIP to enable individuals to get the care they need; and
  • Supplying recovery assistance to address ongoing public health, healthcare, and human services issues that arise from an emergency.

Next, Secretary Price, Dr. Kadlec, and Governor Scott toured an NDMS temporary medical site set up in the parking lot behind Marathon City Hall. There they met with the NDMS teams comprised of medical professionals from Connecticut, Massachusetts, Maine, and New Hampshire who have treated nearly 200 patients over the past week. Secretary Price, Dr. Kadlec, and Governor Scott saw the NDMS team in action as members triaged and cared for patients and provided mental health support.

Secretary Price and Dr. Kadlec traveled to Florida International University (FIU) in Miami to visit a special needs shelter operated by the state and staffed in part by the Commissioned Corps. There, they met with FIU President Mark Rosenberg to learn how FIU has been serving its local community by housing medical responders, including the Commissioned Corps, and patients in need. The FIU shelter has accommodated people with chronic illness, those who require a caretaker, and those with unique mental health needs. Secretary Price and Dr. Kadlec toured the shelter and met with 25 patients who told them that the Commissioned Corps health professionals not only provided exceptional care, but also gave them hope for life after Hurricane Irma. 

HHS personnel have now cared for approximately 2,300 patients, equally split between the mainland and the islands. The Trump Administration and HHS remain committed to meeting the medical and public health needs of communities across the southeastern U.S., Puerto Rico, and the U.S. Virgin Islands impacted by Hurricane Irma. This visit will further support ongoing federal and state response and recover efforts.

Last-Ditch Effort By Republicans To Replace ACA: 5 Things You Need To Know

Kaiser Health News:HealthReform - September 19, 2017

Republican efforts in Congress to “repeal and replace” the federal Affordable Care Act are back from the dead. Again.

While the chances for this last-ditch measure appear iffy, many GOP senators are rallying around a proposal by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.), along with Sens. Dean Heller (R-Nev.) and Ron Johnson (R-Wis.)

They are racing the clock to round up the needed 50 votes — and there are 52 Senate Republicans.

An earlier attempt to replace the ACA this summer fell just one vote short when Sens. Susan Collins (R-Maine), Lisa Murkowski (R-Alaska) and John McCain (R-Ariz.) voted against it. The latest push is setting off a massive guessing game on Capitol Hill about where the GOP can pick up the needed vote.

Use Our ContentThis KHN story can be republished for free (details).

After Sept. 30, the end of the current fiscal year, Republicans would need 60 votes ­— which means eight Democrats — to pass any such legislation because special budget rules allowing approval with a simple majority will expire.

Unlike previous GOP repeal-and-replace packages that passed the House and nearly passed the Senate, the Graham-Cassidy proposal would leave in place most of the ACA taxes that generated funding to expand coverage for millions of Americans. The plan would simply give those funds as lump sums to each state. States could do almost whatever they please with them. And the Congressional Budget Office has yet to weigh in on the potential impact of the bill, although earlier estimates of similar provisions suggest premiums would go up and coverage down.

“If you believe repealing and replacing Obamacare is a good idea, this is your best and only chance to make it happen, because everything else has failed,” said Graham in unveiling the bill last week.

Here are five things to know about the latest GOP bill: 

1. It would repeal most of the structure of the ACA.

The Graham-Cassidy proposal would eliminate the federal insurance exchange, healthcare.gov, along with the subsidies and tax credits that help people with low and moderate incomes — and small businesses — pay for health insurance and associated health costs. It would eliminate penalties for individuals who fail to obtain health insurance and employers who fail to provide it.

It would eliminate the tax on medical devices. 

2. It would eliminate many of the popular insurance protections, including those for people with preexisting conditions, in the health law.

Under the proposal, states could “waive” rules in the law requiring insurers to provide a list of specific “essential health benefits” and mandating that premiums be the same for people regardless of their health status. That would once again expose people with preexisting health conditions to unaffordable or unavailable coverage. Republicans have consistently said they wanted to maintain these protections, which polls have shown to be popular among voters.

3. It would fundamentally restructure the Medicaid program.

Medicaid, the joint-federal health program for low-income people, currently covers more than 70 million Americans. The Graham-Cassidy proposal would end the program’s expansion under the ACA and cap funding overall, and it would redistribute the funds that had provided coverage for millions of new Medicaid enrollees. It seeks to equalize payments among states. States that did not expand Medicaid and were getting fewer federal dollars for the program would receive more money and states that did expand would see large cuts, according to the bill’s own sponsors. For example, Oklahoma would see an 88 percent increase from 2020 to 2026, while Massachusetts would see a 10 percent cut.

The proposal would also bar Planned Parenthood from getting any Medicaid funding for family planning and other reproductive health services for one year, the maximum allowed under budget rules governing this bill. 

4. It’s getting mixed reviews from the states.

Sponsors of the proposal hoped for significant support from the nation’s governors as a way to help push the bill through. But, so far, the governors who are publicly supporting the measure, including Scott Walker (R-Wis.) and Doug Ducey (R-Ariz.), are being offset by opponents including Chris Sununu (R-N.H.), John Kasich (R-Ohio) and Bill Walker (I-Alaska).

On Tuesday 10 governors — five Democrats, four Republicans and Walker — sent a letter to Senate leaders urging them to pursue a more bipartisan approach. “Only open, bipartisan approaches can achieve true, lasting reforms,” said the letter.

Bill sponsor Cassidy was even taken to task publicly by his own state’s health secretary. Dr. Rebekah Gee, who was appointed by Louisiana’s Democratic governor, wrote that the bill “uniquely and disproportionately hurts Louisiana due to our recent [Medicaid] expansion and high burden of extreme poverty.”

5. The measure would come to the Senate floor with the most truncated process imaginable.

The Senate is working on its Republican-only plans under a process called “budget reconciliation,” which limits floor debate to 20 hours and prohibits a filibuster. In fact, all the time for floor debate was used up in July, when Republicans failed to advance any of several proposed overhaul plans. Senate Majority Leader Mitch McConnell (R-Ky.) could bring the bill back up anytime, but senators would immediately proceed to votes. Specifically, the next order of business would be a process called “vote-a-rama,” where votes on the bill and amendments can continue, in theory, as long as senators can stay awake to call for them.

Several senators, most notably John McCain, who cast the deciding vote to stop the process in July, have called for “regular order,” in which the bill would first be considered in the relevant committee before coming to the floor. The Senate Finance Committee, which Democrats used to write most of the ACA, has scheduled a hearing for next week. But there is not enough time for full committee consideration and a vote before the end of next week.

Meanwhile, the Congressional Budget Office said in a statement Tuesday that it could come up with an analysis by next week that would determine whether the proposal meets the requirements to be considered under the reconciliation process. But it said that more complicated questions like how many people would lose insurance under the proposal or what would happen to insurance premiums could not be answered “for at least several weeks.”

That has outraged Democrats, who are united in opposition to the measure.

“I don’t know how any senator could go home to their constituents and explain why they voted for a major bill with major consequences to so many of their people without having specific answers about how it would impact their state,” said Senate Minority Leader Chuck Schumer (D-N.Y.) on the Senate floor Tuesday.

In Stark Contrast To ACA Plans, Premiums For Job-Based Coverage Show Modest Rise

Kaiser Health News:HealthReform - September 19, 2017

Family health insurance premiums rose an average 3 percent this year for people getting coverage through the workplace, the sixth consecutive year of small increases, according to a study released Tuesday.

The average total cost of family premiums was $18,764 for 2017, according to a survey of employers by the Kaiser Family Foundation and the Health Research & Educational Trust. That cost is generally divided between the employer and workers. (Kaiser Health News is an editorially independent program of the foundation.)

While overall premium increases remain modest, workers are picking up a greater portion of the tab — this year $5,714 for family coverage, about a third of total cost.

Employer-provided coverage for a single person rose on average 4 percent, to $6,690. Those individuals pay $1,213 on average.

Use Our ContentThis KHN story can be republished for free (details).

Still, the employer market looks remarkably stable compared to the price increases seen in the Affordable Care Act’s insurance marketplaces for people who buy their own coverage. Premiums on those plans spiked on average about 20 percent this year, and many insurers dropped out because of financial concerns.

For all the media attention and political wrangling over the  Obamacare exchanges, their share of the market is relatively small. They provide coverage to 10 million Americans while 151 million Americans get health insurance through their employer.

The continued slow rise of employer health premiums identified in the Kaiser survey surprised some analysts who have expected the trend to end as the economy picked up steam, leading to a jump in use of health services and health costs.

Drew Altman, CEO of the Kaiser Family Foundation, said it’s “health care’s greatest mystery” why health insurance costs have continued their slow pace even as the economy has picked up the past few years. “We can’t explain it.”

Another unexpected result was that workers’ deductibles — the health bills that workers must pay before their insurance coverage kicks in — remained stable this year at $1,221. Since 2010, as companies sought to keep premiums in check, deductibles have nearly doubled. Higher deductibles can limit premium increases because costs are shifted to workers and it gives them greater incentive to cut spending.

“Increasing deductibles has been a main strategy of employers to keep premiums down and we will have to watch if this plateauing is a one time thing … or if this portends a sharper increase in premiums in future years,” said Altman. “It could be deductibles are reaching their natural limit or could be the tighter labor market” that’s causing employers to back off, he added.

Meanwhile, a second employer survey released Monday by Mercer, a benefits consulting firm, suggests a modest increase in health costs coming next year, too. Employers said they expect their health costs to increase by an average 4.3 percent in 2018, according to the survey.

To deal with higher medical costs — notably big increases in the prices of prescription drugs — employers are using multiple strategies, including continuing to shift more costs to workers and paying doctors and hospitals based on the value of the services rather than just quantity of services.

Jeff Levin-Scherz, a health policy expert with benefits consultant Willis Towers Watson, said there is a limit on how much employers can shift costs to their workers, particularly in a tight labor market. “Single-digit increases doesn’t mean health care costs are no longer a concern for employers,” he said.

The 19th annual Kaiser survey also found that the proportion of employers offering health coverage remained stable last year at 53 percent. But the numbers have fallen over the past two decades.

The survey highlights that the amount workers pay can vary dramatically by employer size. Workers in small firms — those with fewer than 200 employees — pay on average $1,550 more annually for family premiums than those at large firms. The gap occurs because small firms are much more likely than large ones to contribute the same dollar amount toward a worker’s health benefits whether they’re enrolled in individual or family coverage.

More than one-third of workers at small employers pay at least half the total premium, compared with 8 percent at large employers.

That’s the case at Gale Nurseries in Gwynedd Valley, Pa., where health insurance costs rose 7.5 percent this year. Its 25 workers are paying nearly half the cost of the premium — at least $45 a week for those who choose the base coverage plan offered through Aetna. Employees also have deductibles ranging from $1,000 to $2,500.

A decade ago, the nursery paid the full cost of the premium.

“It’s crazy — we keep paying more and getting less,” said comptroller Candy Koons.

At the Westport (Conn.) Weston Family YMCA, health insurance premiums rose about 7 percent this year, leaving its 50 full-time employees to pay a $156 premium for individual coverage.

“It’s not problematic, but it’s one of our bigger costs associated with payroll,” said Joe Query, the human resources director.

As Care Shifts From Hospital To Home, Guarding Against Infection Falls To Families

Kaiser Health News:Marketplace - September 19, 2017

Jaycee Gray, 18, of Mapleton, Iowa, spent four days in the hospital in July after getting a bloodstream infection in her central line, which she uses to treat her rare blood cancer. Her mother, Angela Cooper, said that learning to clean the central line was “very nerve-wracking.” (Courtesy of Jaycee Gray)

Angela Cooper arrived home from work to discover her daughter’s temperature had spiked to 102 degrees — a sign that the teenager, who has cancer, had a potentially deadly bloodstream infection. As Cooper rushed her daughter to the hospital, her mind raced: Had she done something to cause the infection?

Cooper, who works at a Chevy dealership in Iowa, has no medical background. She is one of thousands of parents who perform a daunting medical task at home — caring for a child’s catheter, called a central line, that is inserted in the arm or torso to make it easier to draw blood or administer drugs.

Central lines, standard for children with cancer, lead directly to a large vein near the heart. They allow patients with cancer and other conditions to leave the hospital and receive antibiotics, liquid nutrition or chemotherapy at home. But families must perform daily maintenance that, if done incorrectly, can lead to blood clots, infections and even death.

As more medical care shifts from hospital to home, families take on more complex, risky medical tasks for their loved ones.

But hospitals have not done enough to help these families, said Dr. Amy Billett, director of quality and safety at the cancer and blood disorders center at Dana-Farber Cancer Institute/Boston Children’s Hospital.

This KHN story also ran in The Washington Post. It can be republished for free (details).

“The patient safety movement has almost fully focused all of its energy and efforts on what happens in the hospital,” she said. That’s partly because the federal government does not require anyone to monitor infections patients get at home.

Even at the well-resourced, Harvard-affiliated cancer center, parents told Billett in a survey that they did not get enough training and did not have full confidence in their ability to care for their child at home.

The center was overwhelming parents by waiting until the last minute to inundate them with instructions — some of them contradictory — on what to do at home, Billett said.

An external central line, which ends outside the body, must be cleaned every day. Caregivers have to scrub the hub at the end of the line for 15 seconds, then flush it with a syringe full of saline or anticoagulant.

If caregivers don’t scrub properly, they can flush bacteria into the tube, and — whoosh — the bacteria enter a major vein close to the heart, Billett said. One father, noting that the hub looked dirty, scrubbed it with a pencil eraser, sending three types of bacteria into his child’s bloodstream, she said.

Learning the cleaning steps was “very nerve-wracking,” recalled Cooper, whose 18-year-old daughter, Jaycee Gray, has had a central line since April to receive treatment for anaplastic large-cell lymphoma, a rare type of blood cancer.

“You can scrub and scrub and scrub, and it doesn’t feel like it’s clean enough,” she said. Parents must keep track of other rules, too, like covering up the central line before the child gets in the shower and changing the dressing if it gets dirty or wet.

Monitoring Infection Cases At Home

Bloodstream infections associated with central lines lead to thousands of deaths each year inside hospitals, costing billions of dollars, according to the Centers for Disease Control and Prevention. Research has also shown these infections are largely preventable: Hospitals have slashed infection rates when staff follow the CDC’s standardized safety steps.

But researchers recently discovered that more kids with central lines are getting bloodstream infections at home. In a three-year study of children with cancer and blood disorders at 15 hospitals, 716 such infections took place outside the hospital, compared with 397 inpatient infections. This is partly because children with central lines spend much less time in hospitals than not.

These hospitals belong to a national collaborative of 20 pediatric cancer centers, organized through the Children’s Hospital Association, that aims to keep kids out of the hospital by training families, visiting nurses and clinic staff on handling central lines.

At one of the hospitals, Johns Hopkins in Baltimore, researchers discovered that patients as young as 8 were cleaning their own central lines at home, even though the hospital had designed its training materials for adults.

Cooper said that when her daughter developed the fever July, she immediately started wondering if she was to blame: “It’s really hard,” she said. “I don’t want to put her in the hospital.”

When doctors confirmed that Jaycee had a bloodstream infection, Cooper asked them what caused it. Days later, after interviews and tests, no one knew for sure.

Jaycee was transferred to Children’s Hospital & Medical Center in Omaha, Neb., one of the other hospitals in the collaborative, where nurse Amanda Willits works with families to identify the likely causes of infections and practice safe techniques. Willits said the bacteria probably came through the skin, but there’s no sign Cooper is to blame, and Cooper demonstrated her line-care technique perfectly.

Jaycee spent four days in an isolated room at the hospital, two hours away from home. Doctors warned her that if the bacteria had colonized the plastic of her central line, she might have to go through surgery to have it removed and replaced.

As it turned out, Jaycee didn’t need surgery; she recovered with antibiotics. But about four times out of 10, children who get these infections do need their lines surgically removed, according to research by pediatric oncologist Dr. Chris Wong Quiles at Dana-Farber/Boston Children’s.

Looking at 61 patients there, Wong Quiles tackled basic questions that researchers don’t have national data on: When patients get these infections at home, what happens to them, what does it cost and how often do they die?

Wong Quiles found that in 15 percent of cases, children ended up in the intensive care unit. Four children died. Their median hospital stay was six days, and their median age was 3.

These episodes also cost a lot. Wong Quiles found that median hospital charges were $37,000 per infection. That’s not counting professional fees from hospital staff; the cost of going home with antibiotics and possibly nursing care; or the cost to families from losing days of work to be at the hospital with their kids.

Dan and Megan Kelley care for daughter Bridget, 8, who has leukemia, at home in Quincy, Mass. When Bridget was discharged from the hospital after treatment, it “felt like bringing a newborn baby home,” Megan Kelley says. (Melissa Bailey/Kaiser Health News)

Bringing In A Checklist Engineer

In Boston, Billett and Wong Quiles have enlisted extra staff and resources to try to help parents. The hospital hired a “checklist engineer” to clean up inconsistent messaging and created family-focused videos, flip charts and pocket-size brochures about handling central lines.

Now, patients and families start learning central line care five to 10 days before discharge, instead of just one or two days, Billett said. Parents first practice on a dummy called Chester Chest, then demonstrate their skills on their child.

Even after this training, bringing a child with cancer out of the hospital still felt scary, said Megan Kelley, whose 8-year-old daughter, Bridget, is being treated there for leukemia.

“It felt like bringing a newborn baby home — we’ve never done this before,” said Kelley, who lives in Quincy, Mass., with her husband, Dan, and their three daughters.

Bridget and her family have managed to avoid infection since she was first discharged last December.

Along the way, the family got support and was spot-checked: The hospital keeps track of who was trained and that person’s skill level, and sends a nurse home to see how the caregiver handles the line.

This approach to patient safety — helping families at home through standardized learning tools, hands-on training and tracking skill development — could have broad applications for caregivers of patients young and old, Billett said.

Some early work at Johns Hopkins has shown success: The hospital found a dramatic reduction in outpatient bloodstream infection rates after it trained families, home health nurses and clinic staff.

These infections “can exact such a harsh toll on some of our most vulnerable patients,” said Dr. Michael Rinke, who led that research and now works at Montefiore Medical Center in New York. “Preventing even one of these can help a kid have an important out-of-hospital time, and have an important being-a-kid experience.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

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