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Urgent Care Sites Cater To Cancer Patients, Letting Them Check Some Worries At Door

On an afternoon a few weeks ago, Faithe Craig noticed that her temperature spiked to just above 100 degrees. For most people, the change might not be cause for alarm, but Craig is being treated for stage 3 breast cancer, and any temperature change could signal a serious problem.

She called her nurse at the hospital clinic where she gets care at the University of Texas Southwestern Medical Center in Dallas, who told her to come in immediately for cancer urgent-care services at the hospital’s hematology oncology clinic.

“I thought I’d be waiting there all night,” said Craig, 33. But the hospital had already lined up a blood draw before she arrived and then sent her directly to get X-rays.

Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

To contact Michelle with a question or comment, click here.

This KHN story can be republished for free (details).

Clinicians had details of her cancer care at their fingertips. “They already knew my story and knew everything about me,” she said. The blood work showed she had severe anemia, requiring a blood transfusion, pronto.

It’s been more than a year since the medical center began providing same-day urgent care services to cancer patients. It’s an effort to help them avoid the emergency department and hospital admissions, said Dr. Thomas Froehlich, medical director of the all the center’s cancer clinics.

Cancer treatment “clearly carries a lot of side effects and toxicity, and there are also complications of dealing with the cancer,” Froehlich said. “Many of these things, if you can intervene early, you keep patients at home and out of the hospital.”

UT Southwestern isn’t alone. A small but growing number of hospitals and oncology practices are incorporating urgent care aimed specifically at cancer patients, in which specialists are available for same-day appointments, often with extended hours, sometimes 24/7.

Keeping cancer patients out of the emergency department makes sense not only because many of them have compromised immune systems that put them at risk in a waiting room full of sick people, but to provide the most efficient and appropriate care.

Faithe Craig, who is being treated for stage 3 breast cancer, recently sought urgent care services at the University of Texas-Southwestern Medical Center in Dallas. (Courtesy of Faithe Craig)

“What we hear from cancer physicians and administrators is that in the emergency department not all emergency physicians and nurses feel equally confident in their ability to treat cancer patients,” said Lindsay Conway, managing director of research at the Advisory Board, a health care research and consulting firm. “So they may admit them when it’s not necessary.”

Severe pain, nausea, fever and dehydration are not uncommon side effects of traditional chemotherapy. Newer immunotherapy treatments that activate the immune system to fight cancer can cause serious and sudden reactions if the body instead attacks healthy organs and tissues.

It can be difficult for non-cancer specialists to evaluate what these symptoms mean. “Targeted therapies are wonderful, but if you don’t know the drug, you’re going to have a hard time managing the person,” said Dr. Barbara McAneny, CEO of New Mexico Oncology Hematology Consultants in Albuquerque, which operates three cancer centers in New Mexico that together provide same-day urgent care services for more than a dozen cancer patients daily.

Offering same-day services fits in with a broader shift in oncology toward patient-centered care, said Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society.

“There’s a general sense within the practice of oncology that we need to do a better job of managing pain and side effects, and we need to provide a higher level of care,” Lichtenfeld said.

The federal Centers for Medicare & Medicaid Services is encouraging these efforts through new payment and delivery models designed to reward quality cancer care, Lichtenfeld said. In addition, starting in 2020 hospitals may be penalized financially if patients who are receiving outpatient chemotherapy visit the emergency department or are admitted to the hospital, according to a final rule issued in November.

Avoiding the emergency department makes financial sense for patients and insurers, too.

Johns Hopkins Hospital opened a six-bed urgent care center next to its infusion center a couple of years ago. Of the patients who land there, about 80 percent are discharged home, at an average total hospital charge of $1,600, said Sharon Krumm, director of nursing at Johns Hopkins Kimmel Cancer Center. (The patient and the insurer would divvy up that charge based on the patient’s insurance coverage.) Only 20 percent of cancer patients who visit the hospital’s emergency department are discharged home. Those who are have an average total hospital charge of $2,300. The others face the ER charges plus the hefty cost of a hospital admission.

Rebecca Cohen has been a frequent visitor to the Johns Hopkins urgent care center. Diagnosed more than two years ago with stage 4 lung cancer, Cohen, 68, is receiving immunotherapy. She’s been treated or checked for dehydration, electrolyte abnormalities, low hemoglobin, low sodium, blood clots and infection, among other things.

Before she started going to the cancer urgent care center, “you sat in the waiting room at the emergency room with people who had the most extraordinary diseases,” Cohen said. “Having stage 4 lung cancer, the thought of being exposed to pneumonia or bronchitis is more than scary.”

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Volunteers Help Ombudsmen Give Nursing Home Residents ‘A Voice’ In Their Care

Since retiring four years ago, Barbara Corprew has visited Paris, traveled to a North Carolina film festival and taken Pilates classes, focusing on — as she puts it — just “doing things for me.” Now the former Justice Department lawyer, who worked on white-collar crime cases, is devoting time to something completely different: She visits nursing homes every week.

Corprew is a volunteer in the District of Columbia’s Long-Term Care Ombudsman’s Office, a government-funded advocacy agency for nursing home and assisted-living residents.

Ombudsman’s offices, which operate under federal law in all 50 states, Washington, D.C., Puerto Rico and Guam, investigated 200,000 complaints in 2015, according to the Administration on Aging, a part of the Department of Health and Human Services.

Of those, almost 117,000 were reported to have been resolved in a way that satisfied the person who made the complaint, and about 30,000 were partially resolved. At the top of the list were problems concerning care, residents’ rights, physical environment, admissions and discharges, and abuse and neglect.

Barbara Corprew, a former Justice Department lawyer, says her service as a volunteer ombudsman was sparked in part by her experience acting as an advocate for her parents when they became ill. (Courtesy of Barbara Corprew)

The volunteers have permission to enter any nursing home, assisted-living or other long-term-care facility anytime, unannounced, talk to any resident and go wherever they want. They respond to issues raised by residents and their families and can bring up problems they discover. All complaints are handled confidentially, even kept from family members, unless residents allow the volunteer ombudsmen to reveal their identities.

“I know how important it is to find people who care and give good quality care,” said Corprew, who was an advocate for her parents when they became ill. Her mother was in and out of the hospital and a nursing home during her last years of life. So when she received a letter about the need for volunteer ombudsmen, the appeal hit home. “This was an opportunity to give back to the community and feel as if I was making a difference by representing people who didn’t have a voice.”

She is assigned to a nursing home in northwest Washington. She wears sturdy lace-up shoes for the trek through the hallways, knocking on doors to speak with residents in their rooms. She has handled problems involving call bells that don’t work or are out of reach, noisy roommates and procedures for bathing a resident.

Corprew distributes brochures about residents’ rights and how to contact the ombudsman, writing her name on the front. And she uses all five senses on her rounds: When coming across a chair that smelled of urine, she recalled, “the nose tells you a lot.”

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

Most ombudsman programs around the country depend on volunteers. After completing two days of classroom sessions and field training and passing a criminal background check, volunteer ombudsmen in Washington, D.C., spend about three hours a week at their assigned facilities and attend monthly update meetings for at least a year. Some stay in the program much longer. The Northern Virginia Long-Term Care Ombudsman Program includes people who have been volunteering for 17 years, including one woman who is almost 90, said coordinator Lisa Callahan.

Medical or legal experience is not required. Volunteers come from all kinds of backgrounds and careers, but they seem to have one thing in common: an abundance of compassion.

Gwendolyn Devore, another Washington volunteer, remembers a forlorn woman sitting in a hallway at the nursing home where her aunt lived. When she asked a staff member about the woman, the only reply was an angry look that unmistakably said, “It’s none of your business,” Devore recalled as she explained her interest in becoming a volunteer. “Now no one will be able to say it’s none of my business.”

Many nursing home residents have some degree of dementia or other disabilities that make it difficult for them to be their own advocates, while others don’t know whom to approach or how to seek help. Many don’t have relatives or friends nearby. An ombudsman can help fill that gap.

The volunteers are supervised by staff ombudsmen who can take over when a complaint can’t be resolved informally. Although ombudsmen cannot force facility management to follow state and federal laws, “we know the rules inside and out,” said Eileen Bennett, program director of the ombudsman program in Maryland’s Montgomery County. When persuasion fails, ombudsmen can call in reinforcements by reporting problems to state health inspectors, fire departments, police or other agencies that can compel action.

Unlike some programs, the district’s ombudsman’s office has its own staff attorney, Mary Ann Parker, whose tasks include representing residents who are being discharged but want to stay.  Under a new federal law, nursing home administrators must give ombudsmen copies of all involuntary discharge orders.

Ombudsmen also differ in their responsibilities. In addition to investigating and trying to resolve complaints, the district’s ombudsmen can help families choose a nursing home or assisted-living center, although they don’t make recommendations. District staff ombudsmen will also field complaints from people who receive Medicaid-funded health care in their own homes, as do Virginia’s ombudsmen. Maryland’s staff ombudsmen do not.

Some volunteers occasionally drop out after discovering that spending time in a nursing home wasn’t what they expected. But the experience has made Corprew only more committed.

“We all need people to care for us when we can’t care for ourselves,” she said. “I may be in this same situation … and hopefully there will be other people who will care about me and will come see me and will be my advocate.”

KHN’s coverage of aging and long-term care issues is supported by The SCAN Foundation.

Exodus By Puerto Rican Medical Students Deepens Island’s Doctor Drain

CAGUAS, Puerto Rico — Myladis Reyes, 26, fell in love with medicine by accident. She was a sophomore at the University of Puerto Rico studying chemistry seven years ago when she visited her aunt, a clinic internist, in New Jersey and witnessed the difference she made with patients.

“She was always smiling. She always made little jokes,” Reyes said. “I just saw that and I thought, what better way to help?”

The experience showed Reyes a new way to harness her interest in science and directly improve people’s lives. But after a fierce struggle to get into medical school, she foresees challenges in finding hands-on medical training — known as a residency — in Puerto Rico. And because of poor job prospects on the island afterward, she expects her career to steer her far from home.

Studying medicine is a popular option among young Puerto Ricans. Acceptance rates at the commonwealth’s four medical schools are low and competition runs high. For example, Ponce Health Sciences University received 1,200 applications for its medicine program in the 2015-16 academic year. It accepted 180. Last spring, the Association of American Medical Colleges reported the island’s schools graduated a combined 277 medical students.

This KHN story also ran in USA Today. It can be republished for free (details).

But many of those graduates are leaving the island for better work opportunities, despite Puerto Rico’s growing and urgent health needs.

In the Residency Match announced in March — where students learn where they will continue training — about half of students matched to the mainland, based on figures provided by officials at Puerto Rico’s four medical schools.

That exodus is particularly alarming because the commonwealth’s health care infrastructure is suffering from a shortage of trained physicians.

Physicians opt out of Puerto Rico for many reasons: Nearly 4 in 10 people in the commonwealth are insured through Medicaid managed-care programs, but payments for doctors and hospitals are a third less than the average payments by Medicaid managed-care organizations on the mainland. Most Medicare patients also use the private alternative — Medicare Advantage plans — but their reimbursements are well below mainland rates too.

The low payments are compounded by a $70 billion debt crisis in Puerto Rico. Last summer, Congress established an oversight board charged with saving the island’s economy. Its fiscal plan released in March calls for more cuts to provider reimbursements and fewer benefits for Medicaid enrollees, adding pressure to an economic recession that has helped drive thousands of physicians off the island.

To cauterize the bleeding, Gov. Ricardo Rosselló signed into law a measure that lowers physicians’ income taxes to 4 percent if they complete 180 hours of medically related community service or compensated care to Medicaid patients.

For medical students Reyes and Rafael Cardona, the uncertainty presents a large risk in deciding where to seek their medical residency and become licensed physicians.

As they near the end of their academic training and weigh their options, both are struggling to find a reason to stay.

A Tenacious Drive

Myladis Reyes, 26, has a clerkship at HIMA San Pablo Hospital in Caguas, Puerto Rico. While curricula in Puerto Rican medical schools resemble those of programs on the mainland, students like Reyes are taught in Spanish and English, making them enticing candidates for residencies overseas. (Carmen Heredia Rodriguez/KHN)

It took Reyes four rejections, two schools and a master’s degree to secure her place in med school.

As she finished her undergraduate program in biomedical sciences, Reyes submitted her application to each of the medical schools on the island. Her scores and GPA were lower than average, but she figured her personality during interviews could make up the difference.

She was turned down by each one.

Although the rejection was devastating, Reyes’ mother encouraged her to keep trying.

“She was like, ‘If you want it, you’ll find a way to get it,’” Reyes said.

She threw herself into a master’s program in health administration and finished with a 4.0 GPA. She raised her score on the standardized medical school application test by three points and volunteered at a Veterans Affairs hospital in the emergency room.

With more experience on her résumé and stronger scores, Reyes again applied to three medical schools, submitted more letters of recommendation and visited her preferred university multiple times to make sure they received her submission.

“I literally put [on the application], ‘If I don’t get in this time, don’t think that you won’t hear from me again next year,’” Reyes said.

Several months later, Reyes received a letter from her top choice school: Central Caribbean. She was in.

A Change In Direction

Rafael Cardona, 27, is a third-year medical student at Central Caribbean University, located in Bayamon, Puerto Rico. He wants to specialize in otolaryngology — focused on disorders of the ears, nose and throat — but the island has only one residency program for 10 people in that field. (Carmen Heredia Rodriguez/KHN)

Reyes’ classmate Cardona, 27, had nearly graduated with an electrical engineering degree before realizing he wanted to study medicine.

“I knew that if I wanted to do it, maybe I could,” Cardona said.

He began tailoring his electives toward biology and chemistry classes and picked up several more credits over the summer. The switch ultimately cost him an extra 12 months in college — taking him six years to earn his bachelor’s degree in 2014.

As both Reyes and Cardona fought for a place in medical school, scores of physicians were departing Puerto Rico. From 2009 to 2014, Puerto Rico’s total number of physicians decreased by nearly 2,400, according to the legislation that Rosselló signed in February. In 2014, 365 left. In the same year, only 278 residents completed their training. The following year, 500 doctors left the island, leaving behind only 293 new physicians to fill their void.

The exodus is partly fueled by financial incentives. Doctors working in the mainland earn two to three times more in wages than their colleagues in Puerto Rico. General and family practitioners here earned an average of $82,710 in May 2016. In contrast, the same doctors working in Oklahoma, the state with the lowest average earnings in the nation, earned $155,420.

Now in their third year of medical school, Reyes and Cardona are getting some hands-on experience through clerkships, where students spend several weeks at a hospital working with patients and physicians.

A stint in each specialty culminates in a shelf exam, where students are tested on what they learned in the field. This means the students’ lives revolve around practicing medicine by day and studying by night. Both Reyes and Cardona are up by 5:30 a.m. to be at the hospital by 7. They leave in the afternoon and head back to campus to study until about 11 p.m.

To Go Or Stay?

Reyes and Cardona have already begun to think about their future in medicine and how they will handle their residency applications for next year. They pay attention to the migration of Puerto Rican doctors and both intend to follow suit.

Cardona plans to leave Puerto Rico and go to New York. He wants to specialize in otolaryngology — a specialty focused on the ears, nose and throat — but Puerto Rico maintains only one program in the field. He is hoping to travel to the states next year to make some connections to residencies there. Ideally, Cardona said, he could return to Puerto Rico and re-establish roots.

“It would be really good if I could train in the United States, and if I could get a really good job in Puerto Rico,” he said.

Reyes said she intends to pursue a residency in the northeastern United States. The move means leaving behind her mother but a better salary to pay her student debt — totaling roughly $200,000 as of this year. With those bills, Reyes said, she cannot afford subpar pay.

“I have a debt to pay. And it’s pretty steep,” Reyes said. “I need to find someone that’s going to pay me” better than the residencies in Puerto Rico.

HHS Secretary Tom Price, M.D. Praises FDA Delay of Menu Labeling Regulations

HHS Gov News - May 01, 2017

Health and Human Services Secretary Tom Price, M.D., issued the following statement on the Food and Drug Administration’s actions to delay the implementation of its proposed Menu Labeling Rule until May 7, 2018:

"The FDA has made the right decision to delay a rule that would have essentially dictated how every food service establishment in America with more than 20 locations — restaurants, grocery stores, movie theaters, and more — writes and displays their menus.

"HHS believes strongly in promoting sound nutrition through public health efforts. Tackling childhood obesity is one of our top three stated clinical priorities. We should do this by helping families gain the information they need to make their own choices. Imposing burdensome rules that leave business managers and owners worried about harsh potential penalties and less able to serve their customers is unwise and unhelpful.

"Under President Trump, our department will focus on promoting public health in ways that work for American consumers. Toward that end, the FDA is asking for feedback about how to make the Menu Labeling Rule more flexible and less burdensome while still providing useful information to consumers. We look forward to working with all involved to find the right balance."