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Judge rules in favor of OCR and requires a Texas cancer center to pay $4.3 million in penalties for HIPAA violations

HHS Gov News - June 18, 2018

A U.S. Department of Health and Human Services Administrative Law Judge (ALJ) has ruled that The University of Texas MD Anderson Cancer Center (MD Anderson) violated the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules and granted summary judgment to the Office for Civil Rights (OCR) on all issues, requiring MD Anderson to pay $4,348,000 in civil money penalties to OCR. This is the second summary judgment victory in OCR’s history of HIPAA enforcement and the $4.3 million is the fourth largest amount ever awarded to OCR by an ALJ or secured in a settlement for HIPAA violations.

MD Anderson is both a degree-granting academic institution and a comprehensive cancer treatment and research center located at the Texas Medical Center in Houston. OCR investigated MD Anderson following three separate data breach reports in 2012 and 2013 involving the theft of an unencrypted laptop from the residence of an MD Anderson employee and the loss of two unencrypted universal serial bus (USB) thumb drives containing the unencrypted electronic protected health information (ePHI) of over 33,500 individuals. OCR’s investigation found that MD Anderson had written encryption policies going as far back as 2006 and that MD Anderson’s own risk analyses had found that the lack of device-level encryption posed a high risk to the security of ePHI. Despite the encryption policies and high risk findings, MD Anderson did not begin to adopt an enterprise-wide solution to implement encryption of ePHI until 2011 , and even then it failed to encrypt its inventory of electronic devices containing ePHI between March 24, 2011 and January 25, 2013. The ALJ agreed with OCR’s arguments and findings and upheld OCR’s penalties for each day of MD Anderson’s non-compliance with HIPAA and for each record of individuals breached.

“OCR is serious about protecting health information privacy and will pursue litigation, if necessary, to hold entities responsible for HIPAA violations,” said OCR Director Roger Severino. “We are pleased that the judge upheld our imposition of penalties because it underscores the risks entities take if they fail to implement effective safeguards, such as data encryption, when required to protect sensitive patient information.”

MD Anderson claimed that it was not obligated to encrypt its devices, and asserted that the ePHI at issue was for “research,” and thus was not subject to HIPAA’s nondisclosure requirements. MD Anderson further argued that HIPAA’s penalties were unreasonable. The ALJ rejected each of these arguments and stated that MD Anderson’s “dilatory conduct is shocking given the high risk to its patients resulting from the unauthorized disclosure of ePHI,” a risk that MD Anderson “not only recognized, but that it restated many times.”

The Notice of Proposed Determination and the ALJ’s opinion may be found on the OCR website at
https://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/mdanderson/index.html

Unwieldy Health Costs Often Stand Between Teachers And Fatter Paychecks

As teacher strikes flared this spring in more than half a dozen states, from West Virginia to Arizona, protesters bemoaned stagnant salaries, overcrowded classrooms and a lack of basic supplies like textbooks and computers.

But often missing from hand-scrawled placards and fiery speeches was an issue that has contributed greatly to the financial woes of America’s schools: skyrocketing health care costs.

Many teachers, like other public employees, have traditionally accepted a trade-off: In exchange for relatively low salaries, they could expect relatively generous benefits, including pensions and low- or no-cost health premiums.

But in an era of $100,000-a-year drugs and government budget cuts, school districts are struggling to find the money to keep up their end of the bargain, forced to take away from classroom funding and even modest, cost-of-living raises. Many cash-strapped school boards, cities and legislatures view health care benefits as an unpredictable budget-buster.

Meanwhile, teachers are being asked to fork over more of their paychecks to keep their health coverage, even as budget cuts have impelled them to use their own money for classroom supplies and to crowdsource money to buy computers.

In Jersey City, N.J., where health care expenses have gone up an average of 10 percent annually as district funding has remained flat, teachers staged a one-day strike in March to protest rising costs.

But with an underfunded school system and a $110 million health care bill that is expected to increase another 13 percent this year, teachers and officials accepted a mutually imperfect solution that included changes to their health care plan to end the strike and avoid cuts that would have gutted local schools.

“We’re talking about 300 teachers being laid off to be able to afford our health care bill,” said Sudhan Thomas, president of the Jersey City Public Schools’ board of education.

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While the teacher strikes have ebbed with the school year, deals brokered to end walkouts mostly offered temporary fixes, with no long-term solution in sight.

Proposed cuts to health benefits in West Virginia were also behind the first strike this year, shuttering the state’s public schools for nine days and inspiring similar protests in several states. When officials initially extended teachers a 1 percent pay raise, small in comparison to an imminent hike in their health insurance contributions, teachers rejected the offer.

“You really know you have arrived when you become a verb,” said David Haney, executive director of the West Virginia Education Association, whose wife is a teacher. “Don’t make me go West Virginia on you.”

A Pay Equation That Doesn’t Add Up

Teacher pay was below the national average of $59,660 in the six states that saw significant demonstrations this year — West Virginia, Oklahoma, Arizona, Kentucky, Colorado and North Carolina. But teachers are losing ground nationally.

The average teacher salary in the United States has decreased by 4 percent since 2009, adjusted for inflation, according to a report released in April by the National Education Association, an advocacy group for public school teachers. During that time, public schools have seen their revenue shrink, with federal funding dropping 19.5 percent, particularly after Congress’ across-the-board spending cuts known as budget sequestration took effect in 2013.

As funding has declined, the cost of health insurance has gone up. State and local governments paid 14.5 percent more last year to cover a primary, secondary or special education teacher and her or his family than they did in 2008, adjusted for inflation.

According to that data from the Bureau of Labor Statistics (BLS), in March 2017, family coverage for one teacher cost state and local governments an average of $1,010.85 per month.

Put another way, a 2015 report from the George W. Bush Institute’s Education Reform Initiative estimated that it cost about $550 per pupil to cover American teachers’ insurance expenses.

Educators have also felt the sting of growing health insurance costs, especially as officials have shifted some of the burden to them. Primary, secondary and special education teachers paid 25.4 percent more last year to insure themselves and their families than they did in 2008, according to BLS data adjusted for inflation.

Teachers paid an average of $585.71 per month — more than $7,000 annually — in premiums for family health insurance coverage in March 2017.

For early-career teachers, that price is especially unmanageable. In Pueblo, Colo. — where teachers secured raises and an additional $50 a month toward health insurance premiums after walking out in May — a new teacher makes $35,277, according to Suzanne Ethredge, president of the Pueblo Education Association.

And even where school systems offer teachers generous plans, with low deductibles and minimal premium contributions, the educators frequently have to pick up the costs for family members.

Many States, Common Themes

The standoff in West Virginia typified the strains in states grappling with rising benefit costs on budgets strained by tax cuts and the recession.

Teachers, like other West Virginia public employees, pay for insurance based on what they earn. For a plan that allows some choice of doctors and hospitals, that means $59 per month for someone making less than $20,000, but $164 per month for someone making more than $125,000.

Last fall, the Public Employees Insurance Agency floated the ideas of slashing the number of salary tiers used to calculate contributions, adding spouses’ salaries in those calculations and charging per person for family coverage rather than a flat fee.

The agency further announced that state employees would soon be required to use a wellness app called Go365, incurring penalties for failing to meet their health goals or for declining to use the system altogether.

So when state lawmakers proposed a mere 1 percent raise to an average salary of just $45,555, teachers pushed back. They refused to return to work until officials agreed to a 5 percent raise, scuttled the Go365 plan and delayed the health care hikes so a task force could review them.

In Oklahoma, the strikers publicly focused their complaints on operational costs like textbooks and salaries. They secured roughly an extra half a billion dollars, said Alicia Priest, president of the Oklahoma Education Association. “We got everything that we could out of legislators this year,” she said.

But Priest said health care costs remain a serious issue for school personnel. While the state covers teachers’ individual premiums, covering a spouse and children can cost an additional $1,200 per month, she said — a significant portion of a teacher’s starting salary.

She said that some teacher aides work only for the health insurance for their families — in some cases writing a check to the district to cover the difference between meager salaries and their premiums.

While the advent of summer break has calmed the protests, future strikes look likely, said Paul Reville, a professor at the Harvard Graduate School of Education and former Massachusetts secretary of education. The fact that most teachers negotiated at least some concessions proved the tactic effective enough, especially as health care costs continue to rise.

“The shoe is pinching,” he said, “and people are reacting.”

Statement by HHS Deputy Secretary Hargan on Unaccompanied Alien Children Facilities

HHS Gov News - June 17, 2018

Health and Human Services Deputy Secretary Eric Hargan issued the following statement regarding the upcoming Congressional tours of the Unaccompanied Alien Children facilities:

"We look forward to having several members of Congress tour HHS – funded Unaccompanied Alien Children (UAC) facilities in Texas and California today and tomorrow. Congress gave HHS the responsibility to care for these children and teenagers, and we take this legal mandate very seriously. It is our hope that as members tour the facilities they will see the facilities for what they are intended to provide: safe and healthy environments for children and teenagers to reside until such time as they can be released to an appropriate sponsor, while their immigration cases are adjudicated."

"Unfortunately, the need for these facilities has grown over the last decade, in large part because of the flaws in our immigration system that draw many immigrants to try to cross our borders illegally. As a result, temporary shelters have been necessary to ensure that HHS is able to meet its responsibility, by law, to provide shelter for UAC referred to our care by the U.S. Department of Homeland Security (DHS). As was done in the previous administration in the summer of 2014 at Lackland Air Force Base and again in January and February of 2016 at Holloman Air Force Base, HHS has established a semi-permanent shelter in Tornillo, Texas. These semi-permanent structures have ventilation and cooling to ensure appropriate temperature, and teenagers at Tornillo range in age from 13-17. No UAC under the age of 13 are placed at semi-permanent facilities such as Tornillo."

"Their age and the hazardous journey they take, make unaccompanied alien children vulnerable to human trafficking, exploitation and abuse. This is why we insist on proper processes for elected officials and media tours of our facilities and why we do not permit outside cameras inside facilities or interviews with children in our care. Disregarding those processes puts the children and teens in our care at real risk."

"It is unfortunate that there are still some who fail to understand the role of HHS in caring for these children and teenagers. We need fewer media stunts and more real solutions. We welcome additional elected officials to visit these facilities, and it is my sincere hope that after their visit, Members of Congress heed the call of the Trump Administration to close dangerous loopholes in U.S. immigration laws that are the root cause of this issue. Until these laws are fixed, the American taxpayer is paying the bill for costly programs that can only temporarily try to address the consequences of our broken immigration system."

Please see below for footage of the UAC facilities in Brownsville, TX and San Diego, CA:

Brownsville: https://youtu.be/WyRu1PiPYIc

San Diego: https://youtu.be/mHWKjUtbYtc

Photos of Casa Padre Shelter, Brownsville, TX:

Photos of Casa San Diego, San Diego, CA:

SAMHSA announces $930 million funding opportunity to combat the opioid crisis

HHS Gov News - June 15, 2018

The Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the Department of Health and Human Services (HHS), is now accepting applications for $930 million in State Opioid Response Grants. SAMHSA will distribute funds to states and territories in support of their ongoing efforts to provide prevention, treatment and recovery support services to individuals with opioid use disorder.

The State Opioid Response Grants aim to address the opioid crisis by increasing access to evidence-based medication-assisted treatment, reducing unmet treatment need and reducing opioid-related overdose deaths. “This large new grant program reflects President Trump’s deep commitment to fighting the opioid crisis, and will provide extra support for the hardest-hit states,” said HHS Secretary Alex Azar. “It demonstrates the emphasis we place on expanding access to treatment that works, especially medication-assisted treatment with appropriate social supports.”

The grants will be awarded to the states and territories using a formula specified in the funding announcement. Fifteen percent of the total funds will be set aside to provide extra support to states that have been hardest hit by the crisis. States and territories will use the grants to design plans and conduct activities across the spectrum of prevention, treatment, and recovery.

These prevention, treatment, and recovery activities represent a comprehensive response to the opioid crisis and include action at the federal, state and local levels. “The State Opioid Response Grants were designed to meet the specific needs of communities within each state and territory,” explained Assistant Secretary for Mental Health and Substance Use Dr. Elinore F. McCance-Katz. “The grants will expand capacity to provide much needed evidence-based care to people who haven’t yet been reached.”

Under President Trump, in April 2017, HHS unveiled a new five-point Opioid Strategy. The Strategy prioritizes efforts in five areas: 1) Improving access to prevention, treatment and recovery support services, including medication-assisted treatment; 2) Promoting the targeted availability and distribution of overdose-reversing drugs; 3) Strengthening public health data reporting and collection; 4) Supporting cutting-edge research on addiction and pain and 5) Advancing the practice of pain management. Over fiscal years 2017 and 2018, HHS will invest over $4 billion in opioid-specific funding, including funds to state and local governments as well as tribal, public, and nonprofit organizations to support treatment and recovery services, target availability of overdose-reversing drugs, train first responders and more.

For more information on how to apply, see https://www.samhsa.gov/grants/grant-announcements/ti-18-015.

HHS makes $350 million available to fight the opioid crisis in community health centers nationwide

HHS Gov News - June 15, 2018

Today, the Department of Health and Human Services (HHS) announced the availability of $350 million in new funding to expand access to substance use disorder and mental health services at community health centers across the nation.  These funds will support health centers in implementing and advancing evidence-based strategies, including expanded medication-assisted treatment (MAT) services, and are expected to be awarded in September of this year by HHS’s Health Resources and Services Administration (HRSA).

“Local communities have played a vital role in combating our country’s opioid crisis,” said HHS Secretary Alex Azar. “The contributions of HRSA-funded health centers in particular have been invaluable. These new grants, provided by the government funding bill President Trump signed earlier this year, will allow centers to expand their important work providing high quality substance abuse and mental health services.”

The Expanding Access to Quality Substance Use Disorder and Mental Health Services funding opportunity supports HHS’s Five-Point Opioid Strategy, launched in 2017 to empower local communities on the frontlines to combat the crisis. These funds will make a significant impact in furthering community-driven efforts to reduce opioid use and increase access to mental health services.

Primary care settings, like the community health centers supported by HRSA’s Health Center Program, have increasingly become a gateway to integrated care for individuals with substance use disorder (SUD) and primary care needs. HRSA support enables community health centers to enhance access to primary care-based SUD services, including MAT services, as well as pain management and other prevention services. In 2017 alone, nearly 65,000 health center patients received MAT.

“HRSA’s recent investments in substance use disorder and mental health services have significantly increased the capacity of health centers to provide critical care to their communities,” said HRSA Administrator Dr. George Sigounas. “For example, the number of health center clinicians providing MAT increased by 75% between 2016 and 2017, from 1,700 to nearly 3,000 in 2017. This is just one way that health centers are in a unique position to make a significant impact in combatting the opioid crisis, and this new funding will further that impact.”

The Expanding Access to Quality Substance Use Disorder and Mental Health Services funding opportunity invests in personnel and one-time infrastructure enhancements to enable health centers to address immediate barriers they have faced to implementing or expanding SUD and mental health services. It also builds on the $200 million investment made last year to 1,178 community health centers across the US to increase access to SUD and mental health services.

HRSA’s Health Center Program provides grant funding to community-based health centers in underserved areas. Nearly 1,400 community health centers operate more than 11,000 sites, providing care to nearly 26 million people across the nation, in every state, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Pacific Basin.

Throughout the country, community health centers employ more than 200,000 people, and with this new funding opportunity, they will be able to increase personnel to help expand access to SUD and mental health services.

Applications for the Expanding Access to Quality Substance Use Disorder and Mental Health Services award are due July 16, 2018.

For more information about the SUD-MH funding opportunity, visit: https://bphc.hrsa.gov/programopportunities/fundingopportunities/sud-mh

For additional information on how HRSA is addressing the Opioid Crisis, visit HRSA’s Opioid Crisis Webpage

To learn more about HRSA’s Health Center Program, visit: http://bphc.hrsa.gov/about

To find a health center in your area, visit: http://findahealthcenter.hrsa.gov

HHS Secretary Azar Meets with Health Insurance Leaders

HHS Gov News - June 15, 2018

On Thursday, June 14, Secretary Alex Azar met with representatives from America's Health Insurance Plans and a number of health insurance companies.

Secretary Azar shared the Trump Administration's agenda for a future of health insurance, based on promoting competition and placing the patient at the center. He also discussed ways to help the nearly 28 million Americans left out by the Affordable Care Act, including ways to lower premiums and promote transparency and value throughout the system.

The Secretary also addressed ways to lower the price of drugs for American patients and promote universal access to coverage through private-sector competition. He reiterated that the President and HHS are doing everything they can to ensure that the American people not only receive healthcare coverage but quality care and treatment as well.

Participants included representatives from Aflac U.S., AHIP, AvMed, Healthfirst, Independent Health, InnovaCare, Kaiser Foundation Health Plan, L.A. Care Health Plan, Neighborhood Health Plan of Rhode Island, Physicians Mutual Insurance Company and Hospitals, Santa Fe HealthCare, Sentara Health Plans, Trustmark Companies, Tufts Health Plan, and WellCare Health Plans.

Postcard From D.C. Courthouse: Medicaid Work Requirements And Manafort

It’s probably safe to say that the scrum of reporters — noses and lenses pressed up to the glass doors of the E. Barrett Prettyman Federal Courthouse in Washington, D.C., — were not there to cover a hearing regarding Kentucky’s work requirements for some Medicaid recipients.

No, the news satellite trucks parked outside and long queue of spectators stacked up against the building where there to catch a glimpse of Paul Manafort, President Donald Trump’s former campaign chairman, who was appearing that same morning before another judge in another federal courtroom.

But while the hearing for the Stewart v. Azar case might not have generated as much buzz as Manafort’s, it has the potential to impact many more people. Kentucky itself says as many as 95,000 enrollees would likely lose coverage.

Judge James E. Boasberg acknowledged that he wasn’t presiding over the flashiest case in the courthouse.

“I guess the Paul Manafort overflow room was full so you decided to come in here,” he said.

Even so, Boasberg’s courtroom was packed, with about 65 people inside and a few others waiting outside.

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People started to line up for entry more than 90 minutes before the hearing’s 11 a.m. start. They huddled in the cream-colored hallway near its marble pillars to discuss health policy — and the Manafort scene. By 10:30 a.m., a security guard arrived on the scene to shush the assembled crowd, complaining that she could hear their chatter from “every level” of the courthouse.

Who knew Medicaid wonks were such a rowdy bunch?

There was a lot at stake, though. The case’s outcome could reverberate across the country and help determine how much authority the Trump administration has to unilaterally change Medicaid.

Medicaid is the federal-state health insurance program for low-income and disabled people. Kentucky expanded Medicaid under the Affordable Care Act, but got approval from the Trump administration this year to require healthy adults who gained that coverage to prove that they are working, volunteering or taking care of family members for at least 80 hours each month.

Three advocacy organizations sued the federal government on behalf of 15 Kentucky Medicaid recipients who said they would lose their coverage if the work requirements, and some other aspects of Kentucky’s plan, were implemented.

The crux of the argument boiled down to this: What is the purpose of Medicaid?

Ian Heath Gershengorn, the attorney arguing on behalf of the Medicaid recipients, said the Kentucky plan went too far. Instead of tweaking some things to make Medicaid better or allow it to serve more people, he argued that Kentucky was fundamentally turning it away from a program designed to improve medical access.

The main goal of the Medicaid statute, according to Boasberg, was to furnish “medical assistance” to people. How then could stripping coverage from 95,000 individuals fit that definition, he asked.

Justice Department attorney Ethan Davis said people who lost their coverage because of the work requirement would find it in the private or employer-sponsored market. Plus, the secretary of Health and Human Services had interpreted Kentucky’s plan to be consistent with Medicaid’s, he added.

Davis also said if Kentucky’s work requirements were struck down, it would discourage other states from expanding their Medicaid programs.

Boasberg said he would try to have a decision by the end of June. Kentucky’s work requirements are scheduled to go into effect July 1.

As Medicaid Costs Soar, States Try A New Approach

Kaiser Health News:States - June 15, 2018

MINNEAPOLIS — Sandy Dowland has been to the emergency room 10 times in the past year and was hospitalized during four of those visits. She has had a toe amputated and suffers from uncontrolled diabetes, high blood pressure, major depression, obesity and back pain.

But her health is not high on the 41-year-old woman’s priority list.

“I have a lot going on,” said the unemployed mother of five who lives in a homeless shelter. She said it’s a struggle just to get herself and children through each day.

Her health bills are covered by Medicaid, the state-federal health insurance program for the poor. That’s a relief for her, she said. But state officials say Medicaid is busting Minnesota’s budget, particularly with patients like Dowland and its system of paying hospitals for each admission, ER visit and outpatient test.

To ease that financial strain, Minnesota is at the forefront of a growing number of states testing a Medicaid payment system. It rewards hospitals and physician groups holding down costs by keeping enrollees healthy.

Under this arrangement, those health care providers are asked to do more than just treat medical issues such as diabetes and heart disease. They are called on to address the underlying social issues — such as homelessness, lack of transportation and poor nutrition — that can cause and exacerbate health problems.

It’s why North Memorial arranged for a community health worker and paramedic to meet Dowland on a recent weekday at a day care center for homeless families. They advised her on how to take her insulin, prodded her to use a patch to quit smoking and helped her apply for Social Security disability payments and food stamps.

“This is nice to have someone who I can talk to about everything in my life and give me access to the community resources I need,” said Dowland, who added that she puts off her own health needs in order to care for her children and look for housing and a job. “I appreciate the help because, at the clinic, the doctor doesn’t have time for this.”

North Memorial is among 21 health systems in Minnesota participating in this new model of care, called accountable care organizations. ACOs get to share in money they save Medicaid by keeping spending under a budget and by reaching quality targets, such as averting hospital-acquired infections and controlling patients’ blood pressure and asthma.

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The shift toward ACOs is occurring with Medicare and employer-sponsored insurance, too. But for Medicaid programs, it presents unique challenges. Medicaid enrollees, by definition, are low-income. Many have little experience navigating health systems and large numbers are homeless or dealing with mental health problems, conditions that can lead to difficulties in encouraging healthy behaviors.

“The goal [of ACOs] is really exciting to make health systems more responsive to what people need to be healthy,” said Ann Hwang, director of the center for consumer engagement and health innovation at Community Catalyst, a Boston-based consumer advocacy group. “But the jury is still out as to whether they are really moving the needle in addressing social services such as transportation, housing and food insecurity — the things we know affect people’s ability to be healthy.”

Nationwide, a dozen states are experimenting with Medicaid ACOs and 10 more are making plans for them.

About half of Minnesota’s 1 million Medicaid recipients are in ACOs, which officials said saved the state $213 million since 2013. Hospitals and doctors received $70 million of that.

In addition to North Memorial, other participating health systems include the Mayo Clinic and Hennepin Healthcare, the state’s largest safety-net provider based in Minneapolis.

‘Going To Where The Patient Is’

For giant health systems that for years have competed by adding the latest technology or building sleek facilities, the ACOs are a huge shift. In effect, the ACOs push hospitals to address patients’ problems before they end up in the ER or operating rooms.

“We are learning to have to do a better job of going to where the patient is … as we now realize we are responsible for the patient when they are engaged with us and when they are not here,” said Robert Stroebel, who helps leads the ACO effort at Mayo Clinic.

So far, the model isn’t proving to be a panacea.

In six states using ACOs, a March federal study in found, Medicaid enrollees received more primary care services — such as doctor visits — but the program did not reduce hospital visits in most states or lower costs.

“Changing provider and beneficiary behavior may take more time than the few years this report covers,” concluded the study.

Minnesota’s experience demonstrates the challenges of changing to a new Medicaid payment system. In 2016, the latest year for which data are available, only six of the 16 ACOs were eligible to share in cost savings.

But Marie Zimmerman, Minnesota’s Medicaid director, noted the state’s program has seen a 7 percent cut in ER visits and a 14 percent reduction in hospital stays in areas where health providers participate in an ACO.

“Medicaid is 20 percent of Minnesota’s population, and we have to care about getting the best deal and the long-term fiscal ability of the program and not cutting eligibility and provider rates and benefits to show sustainability,” she said.

At Hennepin Healthcare in Minneapolis, Dr. Allison Wert examines Medicaid enrollee Rachel Rowell, who participates in the ACO.(Phil Galewitz/KHN)

Struggle To Change Behaviors

The switch to ACOs accelerated efforts by hospitals and physician groups to attack so-called social determinants of health, such as the lack of stable housing and poor nutrition. But providers still struggle to change patients’ behaviors, particularly helping those with addiction and mental health problems, according to interviews with officials at several ACOs.

Doctors, nurses and social workers at Hennepin dealt with that head-on during a recent routine review of their patients. When they came to a 58-year old man suffering from alcoholism, anxiety and heart problems and living in a homeless shelter, they noted how they couldn’t get him into a primary care clinic and saw him only during frequent hospital admissions.

“Best we can hope for him is if we can facilitate a safe ending,” said Dr. Rachel Silva, a Hennepin internist, acknowledging that despite their best intentions, health providers likely would not be able to prevent his early death.

Even with teams of nurses, social workers and community health workers, Hennepin officials say they struggle to keep up with many Medicaid enrollees who have addiction problems, and many patients still go to the ER out of habit or convenience rather than the organization’s primary care clinics, which are as close as across the street.

Yet, there are success stories, too. The Mayo Clinic has started a community health worker program to help at-risk patients connect to social services such as housing and transportation.

Nancy Zein, 47, a Medicaid recipient who uses the Mayo Clinic, said having weekly meetings with community health worker Tara Nelson has been life-changing for her and her mother, who is also on Medicaid.

“She’s been a godsend,” said Zein, who noted how Nelson helped her get Social Security disability payments and her mom find affordable housing for disabled adults, as well as get both enrolled for food stamps.

“It’s made such an impact on our health,” Zein said. “My mom has depression issues, and with Tara helping us with housing, it helped her depression.”

With the opportunity to share in financial savings, North Memorial has hired additional community paramedics to visit high-risk patients. Mayo Clinic has added community health workers to help patients find housing and transportation and nurses to make home visits to patients after leaving the hospital. Hennepin set up special clinics for the most challenging Medicaid patients and sends doctors to care for patients in homeless centers, jails and the county’s mental health center — to reach people who may need help even before they are likely to end up in their ER and on Medicaid.

Nearly 20 percent of Hennepin’s adult Medicaid ACO members are homeless. In the past four years, social workers and other staff have helped more than 500 of their Medicaid patients — including in the ACO — get into public housing.

Cuts For Managed-Care Companies

The ACO model has raised concerns among managed-care companies that Minnesota and other states have used for decades to control Medicaid spending. Those companies get a monthly fee from Medicaid for each enrollee and often require those patients to seek care with doctors and hospitals that have contracts with the managed-care firm. The companies profit if they spend less on care than they receive in the state allotment.

“We are aligned with the goals … to explore innovation and provide better delivery of care,” said Scott Keefer, vice president of Minnesota Blue Cross and Blue Shield of Minnesota, which has 300,000 Medicaid members. But, he added, much of the ACO savings cited by state officials are dollars taken from managed-care company profits.

His health plan lost more than $200 million from Medicaid operations during the past two years, partly because it had to pay part of its state funding to ACOs.

“We are not magically saving money. … We are moving the financial deck chairs around,” he said.

In New Hampshire, Even Mothers In Treatment For Opioids Struggle To Keep Children

Kaiser Health News:States - June 15, 2018


Jillian Broomstein starts to cry when she talks about the day her newborn son Jeremy was taken from her by New Hampshire’s child welfare agency. He was 2 weeks old.

“They came into the house and said they would have to place him in foster care and I would get a call and we would set up visits,” she said. “It was scary.”

Broomstein, who was 26 at the time, had not used heroin for months and was on methadone treatment, trying to do what was safest for her child. The clinic social worker told her that since Jeremy would test positive for methadone when he was born, she would need to find safe housing or risk losing custody.

Broomstein moved in with a friend and her kids — but it turned out that friend had her own legal battles with the state’s Division of Children, Youth and Families, known as DCYF. The friend’s home would not pass muster as “safe housing” because of that.

Since Broomstein grew up in foster care and had no family to take her in, Jeremy was taken from her. She had 12 months to try to get her son back or lose her parental rights permanently.

To get their children back from the foster care system in New Hampshire, parents struggling with addiction are required to be compliant in drug treatment and have a safe place to live. If they can’t find housing or if they relapse, the clock does not stop ticking.

“I cannot stress enough that 12 months is a really short window for somebody who’s in early recovery,” said Courtney Tanner, who runs Hope On Haven Hill, one of the few places in New Hampshire where pregnant women and new mothers can live with their children and get treated for addiction. But with just eight beds here, the waitlists can be long.

There are more than 430,000 children in foster care in the U.S., according to the latest government figures. The opioid crisis is definitely a factor in an increasing trend of more children being removed from the home, but the scope of the problem is hard to measure due to poor tracking.

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New Hampshire has some of the highest rates of opioid abuse in the country. One of the fastest-growing groups of heroin users is women of childbearing age. In the past few years the number of children taken into state custody has more than doubled, according to DCYF. Last year, New Hampshire spent $36 million for foster care.

“Here in New Hampshire, what I have seen is a mom can be enrolled in this program and compliant in treatment and they are giving birth to a child and that child is still being removed and put into foster care,” said Tanner.

In 2012 state legislators made major budget cuts to DCYF — and those dollars have not been restored. Child welfare workers in New Hampshire have more than triple the caseloads than in many other states, according to the agency’s director Joseph Ripsam. Also as a result of the budget cuts, DCYF can only engage a family once case workers have opened a legal case of abuse and neglect. There’s little money to support parents before that happens.

“The result of that is … that more children coming into the foster care system that otherwise might not if we had the capacity to serve families more holistically up front,” said Ripsam.

After her son Jeremy was placed into foster care, Jillian Broomstein continued her methadone treatment and her parenting classes.

She was determined to get her son back. She finally got off a waiting list and got a bed at one of the residential treatment centers for young mothers. After a few months she was reunited with Jeremy. But she was told that her case was unusual.

“They said in court that it was an odd case that they gave me my child back so quickly,” Broomstein said. “It made me want to cry.”

“I knew it was going to be hard,” she said. “Not everybody tries to get their children back. A lot of people I’ve known just give up; they just resort back to drugs again.”

This story is part of a reporting partnership that includes NPR and Kaiser Health News.

KHN’s coverage of these topics is supported by Heising-Simons Foundation and The David and Lucile Packard Foundation

HHS Secretary Azar Praises FDA Approval of Generic Drugs for Treating Opioid Dependence

HHS Gov News - June 14, 2018

HHS Secretary Alex Azar issued the following statement regarding the Food and Drug Administration’s approval of generic versions of Suboxone, a medication used to treat opioid dependence:

“Medication-assisted treatment is a vital element of the Trump Administration’s work to combat the opioid crisis. We know it is effective, and we know more Americans need access to it. That is why we are so pleased that the FDA has approved generic versions of one medication-assisted treatment option. These approvals will help increase competition, lower cost, and save lives, advancing HHS’s priorities to lower drug prices and combat the opioid epidemic. The efficient and effective work being done by the FDA in approving addiction treatment options is an important part of HHS’s five-point strategy for the opioid crisis and reflects President Trump’s commitment to helping Americans struggling with addiction.”

Read more about FDA’s actions here: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm610807.htm

Read Secretary Azar’s remarks to the National Governors Association about the importance of medication-assisted treatment here:

https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/plenary-addres-to-national-governors-association.html

HHS Secretary Azar Meets with Kidney Disease and Rare Disease Advocates

HHS Gov News - June 14, 2018

On Wednesday, Secretary Alex Azar met with representatives from Kidney Care Partners, an umbrella organization representing kidney-disease nonprofits and companies, and the National Organization for Rare Disorders.

With Kidney Care Partners, Secretary Azar shared the Trump Administration’s interest in continuing to improve the quality of kidney-disease care provided in the United States, including through payment model advances, reductions in regulatory burden, and new pathways for reimbursement that may support innovation. Participants individually provided feedback on challenges for kidney-disease patients and advances in the kidney space, including the growth in home-based care and ways to support it.

At the kidney disease meeting, Secretary Azar was joined by HHS Acting Chief Technology Officer Ed Simcox, who oversees HHS’s support for KidneyX, a public-private partnership to advance innovation in kidney care.

With the National Organization for Rare Disorders, Secretary Azar expressed the Trump Administration’s strong support for biomedical innovation, including patient-focused drug development and drug pricing reforms to improve the affordability and access of rare disease therapies. The individuals meeting with the Secretary expressed interest in similar issues and support for the Food and Drug Administration’s recent efforts to end gaming of orphan drug designation loopholes.

Most Texans Want State To Expand Medicaid And Help Poor Get Health Care

Texans think the Legislature should expand Medicaid to more low-income people and make health care more affordable, according to a survey released Thursday.

Researchers surveyed 1,367 Texans between March and May of this year about topics ranging from Medicaid, the Affordable Care Act, maternal mortality and the role of government in tackling health care issues.

Here are some takeaways from the survey by the Kaiser Family Foundation and the Episcopal Health Foundation. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

1) Almost All Texans See A Role For The Texas Legislature

Texans overwhelmingly agree that the state should have a role in making health systems work. According to the survey, 67 percent of those surveyed said the state should have a “major role” and 28 percent said a “minor role” in health care. Only 5 percent of Texans said the state should have no role.

“A majority of Texans say that the state has an important role to play in health care,” said Elena Marks, the president and chief executive officer of the Episcopal Health Foundation. “The state is not doing enough and the state should spend more. And people also believe that the state has a role to play in increasing access to insurance.”

2) Texans Are Concerned About Maternal Deaths

When asked what the state Legislature should make a top health care priority, 59 percent of Texans said “reducing the number of women who die from causes related to pregnancy and childbirth.”

That response came in a close second to “lowering the amount individuals pay for health care” (61 percent).

Marks says she thinks a lot of this concern is probably related to media coverage around maternal mortality and that the question itself is really a “no-brainer.”

“‘You mean people are dying from pregnancy and childbirth?’” she said. “I think people may just look at that and go, ‘Well, of course you should be doing something about that.’”

3) Medicaid Expansion Is Popular

About two-thirds of Texans (64 percent) said they think Texas should expand Medicaid to cover more low-income people. Texas is 1 of the 17 states that have not expanded Medicaid under the Affordable Care Act.

Even though feelings in the state are still mixed on the ACA, the survey found that Medicaid is quite popular.

“Roughly 4 million people are covered by Medicaid in Texas, nearly three-quarters of whom are children,” according to the survey’s authors. When asked, 6 in 10 Texans said Medicaid is important to their families.

Marks said she thinks the conversation about Medicaid expansion in Texas is limiting for people seeking more insurance coverage here. She says the state should have a conversation about coming up with its own way to expand access to affordable coverage, which is a popular idea across the political spectrum.

“Let’s stop talking about Medicaid expansion and let’s start talking about expanding access to affordable health insurance coverage,” Marks said.

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4) Texans Say We Aren’t Helping The Poor Enough

Roughly two-thirds of Texans also say the state is not doing enough to make sure low-income people get the health care they need.

Respondents also think lawmakers could do more to help children (45 percent) and immigrants (41 percent) get coverage. Broken down by party, Republicans were less likely to say that the state is not doing enough to help vulnerable populations get health care services.

5) A Lot Of Texans Don’t Know Basic Facts About Health Care Here

One of the standouts in this survey is how little people know about the state’s health care system. Consistently, however, Republican respondents were more likely to be misinformed.

For example, groups asked Texans whether the state’s uninsured rate is higher compared to other states. According to the survey, 3 in 10 Texans (31 percent) correctly answer that it is higher. Broken down by party, only 24 percent of Republicans knew Texas has a larger than average share of uninsured people, while 38 percent of Democrats did.

Marks says that could explain why Republicans are less likely to say they think there are problems with the state’s health care system.

“If you think we have about the same or lower uninsured rates, then you don’t think there’s a problem unique to us that we need to solve,” she said.

Texans were also asked whether Medicaid had been expanded in the state; 51 percent of those surveyed correctly said the state had not expanded it.

According to the study’s authors, “Democrats are somewhat more likely than Republicans and independents to know that Texas has not expanded its Medicaid program” (62 percent, 43 percent, and 52 percent, respectively).

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

Podcast: KHN’s ‘What The Health?’ California Here We Come

 

Health care is a big political issue, but no place more than in California. In San Francisco last week, voters overwhelmingly approved a ballot measure upholding a ban on flavored tobacco products — over the vehement objections of the tobacco industry.

And the state’s activist attorney general, Xavier Becerra, is leading a group of Democratic officials from more than a dozen states defending the Affordable Care Act in a case filed in Texas. That is important given that the Trump administration’s Justice Department decided not to defend the law in full from charges that changes made by Congress in last year’s tax law invalidates the health law.

This week’s panelists for KHN’s “What the Health?” are: Julie Rovner of Kaiser Health News, Anna Maria Barry-Jester of FiveThirtyEight.com, Carrie Feibel of KQED San Francisco and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Republicans and Democrats had been gearing up for a midterm election debate on who is responsible for higher health insurance costs. But that shifted last week to an argument over whether consumers with preexisting conditions should be guaranteed coverage following the Justice Department’s brief saying changes to the ACA invalidated those protections.
  • In California, there is widespread support among Democrats for a single-payer health system. But the term is somewhat amorphous. For some officials, it is a catch-all phrase that seems to suggest strong efforts with current programs to get the uninsured rate down to zero, while still keeping much of the current insurance system in place.
  • Becerra has filed a suit against Sutter Health, a giant in the hospital industry in Northern California, alleging that consolidation has resulted in anti-competitive pricing practices.
  • San Francisco’s adoption of a referendum to ban flavored tobacco products could lead other local governments to follow suit. The measure included not only products with flavors allegedly geared to young people, but also menthol cigarettes, which make up about 30 percent of the market.

Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too:

Julie Rovner: The New York Times, “Elizabeth Warren And A Scholarly Debate Over Bankruptcy That Won’t Go Away,” by Margot Sanger-Katz.

Anna Maria Barry-Jester: The Atlantic, “Being Black In America Can Be Hazardous To Your Health,” by Olga Khazan.

Carrie Feibel: KQED, “In The Land Of Legal Weed, Drug Education Moves From ‘Don’t’ To ‘Delay,’” by Carrie Feibel.

Joanne Kenen: The Miami Herald, “She Dreamed Of Getting Plastic Surgery In Miami. Three Days Later, She Was Dead,” by Sarah Blaskey, Sonia Osorio, and Daniel Chang.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

5 Things To Know About Medicaid Work Requirements

The Trump administration’s decision in January to give states the power to impose work requirements on Medicaid enrollees faces a federal court hearing Friday.

The lawsuit before the U.S. District Court in Washington, D.C., will determine whether tens of thousands of low-income adults in Kentucky will have to find jobs or volunteer in order to retain their health coverage.

But the ruling could have far-reaching implications affecting millions of enrollees nationwide and determining how far the Trump administration can go in changing Medicaid without congressional action.

Kentucky was the first of four states, so far, to win federal approval to advance a work requirement. Indiana, Arkansas and New Hampshire are the others. Each is now in the early stages of implementation.

Arkansas, for instance, in June began having Medicaid enrollees inform the state about their work status. In September, the state could begin disenrolling members who fail to report or meet the work rules.

Seven more states — Arizona, Kansas, Maine, Mississippi, Ohio, Utah and Wisconsin — have applications pending and several others are poised to join them.

Kentucky’s legal challenge encapsulates a debate about two competing views of the role of Medicaid, the nation’s largest health program that covers nearly 75 million low-income Americans.

The Trump administration and many conservatives see it as a welfare program that should provide only temporary help and should prepare enrollees to gain employment and negotiate private health insurance.

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Democrats, advocates for the poor and most legal experts see Medicaid as a health program meant to help the nation’s poorest citizens access health coverage. They say the administration’s approach of requiring enrollees to work to get health coverage is backward because enrollees need health coverage so they are healthy enough to work.

“There is zero evidence to suggest that depriving people of Medicaid will lead to greater levels of employer insurance,” 40 health policy scholars wrote in an amicus brief supporting the lawsuit filed on behalf of several Kentucky Medicaid enrollees.

“The CMS work ‘demonstration’ destroys, not improves, Kentucky’s substantial health care achievements and defeats, rather than promotes, Medicaid’s purpose as a safety net insurer,” according to the brief.

The 2010 Affordable Care Act spurred 33 states to expand Medicaid to nondisabled adults without children. Before that, the program mainly served children, pregnant women and people with disabilities.

That expansion, which provided billions in new federal funding to states, triggered an unprecedented drop in uninsured rates nationwide and tempted some Republican governors to pursue the additional health care dollars. But some of these GOP-controlled states also sought to add the new work requirement, in part to show conservative voters they weren’t simply providing a government handout to poor adults.

States that didn’t expand Medicaid and have some of the strictest eligibility limits in the country —including Kansas and Mississippi — also applied for work requirement waivers.

Here are five things to know as this court case unfolds:

1. Why do the Trump administration and states want to add the new work requirement?

Top Trump officials say the work requirement is meant to help enrollees find jobs. They say people who work or do volunteer service are healthier. Seema Verma, administrator of the U.S. Centers for Medicare & Medicaid Services, said Medicaid should be a “hand up” not a handout.

According to CMS, while the work requirement is a change in policy, it still fits within the agency’s long-standing missions of promoting health and improving health outcomes.

2. How does the work requirement work?

Kentucky’s program would require nondisabled adults each month to participate in 80 hours of work, job training, education or other qualified “community engagement.”

Those who are exempt include children and former foster care kids; pregnant women; seniors; people who are the primary caretakers for a child or a disabled adult; those who are deemed medically frail or diagnosed with an acute medical condition that would prevent them from working; and full-time students.

Adults in northern Kentucky would have to begin registering their work hours this summer, and the rest of the state would follow by the end of 2018.

State officials acknowledge the new requirement could be complicated for many enrollees. “We need to be careful and thoughtful how we roll out the ‘community engagement,’ recognizing this is a huge change,” said Kristi Putnam, deputy secretary for Kentucky’s Cabinet for Health and Family Services.

States have set up different rules on how many hours a month Medicaid enrollees must work or volunteer and who is exempt.

In Arkansas, everyone enrolled in Medicaid has to document their work hours through an online portal created by the state — with no option to submit information in person, over the phone or by mail. Critics of the work requirement fear that will be a barrier, considering the state has the second-lowest rate of home internet access in the nation.

3. What are the main objections to the work requirement from a legal and practical standpoint?

Critics say the requirement would lead many low-income people to lose their health coverage and, therefore, hinder their ability to get medical care. They note Kentucky’s own projections show that 95,000 Medicaid enrollees would lose coverage within five years.

The work-requirement approvals were based on the Health and Human Services secretary’s authority to test new ways of providing Medicaid coverage. The critics also argue, though, that the Trump administration is overstepping its statutory boundaries because the requirement would reduce eligibility rather than expand it.

Lastly, work requirement opponents note most people on Medicaid already work — or go to school, have a disability or care for relatives.

A June 12 Kaiser Family Foundation study concluded that only 6 percent of able-bodied adults on Medicaid who are targeted by states’ work requirements are not already working and unlikely to qualify for an exemption. In addition, 6 in 10 nondisabled adults on Medicaid work at least part time, although they often aren’t offered health benefits through those jobs or can’t afford them. (Kaiser Health News is an editorially independent program of the foundation.)

Surveys show that many Medicaid enrollees who don’t work are in job training, go to school or are taking care of a child or an elderly relative, conditions that would make them exempt from the new mandate.

4. When is the court expected to rule, and could this issue go to the Supreme Court?

Both sides expect a quick decision, likely by late June. But an appeal is likely no matter who wins.

If the Trump administration wins, it’s uncertain if plaintiffs will be able to get a stay on the work requirement taking effect while an appeal is in process.

5. While the work requirement is getting most of the attention, what else is at stake in the court case Friday?

The lawsuit filed by advocates on behalf of Medicaid enrollees seeks to overturn the entire Kentucky Medicaid waiver approved by the Trump administration in January.

Kentucky’s waiver also sets precedent because it would become the first state to charge Medicaid premiums of up to 4 percent of an individual’s income. The current limit has been 2 percent. Moreover, Kentucky would become the first state to lock out Medicaid enrollees from coverage for up to six months for failure to timely renew their coverage or failure to alert the state if their income or family circumstances have changed.

That ‘Living Will’ You Signed? At The ER, It Could Be Open To Interpretation.

Navigating Aging

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

To contact Judith Graham with a question or comment, click here.

Join the Navigating Aging Facebook Group.

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“Don’t resuscitate this patient; he has a living will,” the nurse told Dr. Monica Williams-Murphy, handing her a document.

Williams-Murphy looked at the sheet bearing the signature of the unconscious 78-year-old man, who’d been rushed from a nursing home to the emergency room. “Do everything possible,” it read, with a check approving cardiopulmonary resuscitation.

The nurse’s mistake was based on a misguided belief that living wills automatically include “do not resuscitate” (DNR) orders. Working quickly, Williams-Murphy revived the patient, who had a urinary tract infection and recovered after a few days in the hospital.

Unfortunately, misunderstandings involving documents meant to guide end-of-life decision-making are “surprisingly common,” said Williams-Murphy, medical director of advance-care planning and end-of-life education for Huntsville Hospital Health System in Alabama.

But health systems and state regulators don’t systematically track mix-ups of this kind, and they receive little attention amid the push to encourage older adults to document their end-of-life preferences, experts acknowledge. As a result, information about the potential for patient harm is scarce.

A new report out of Pennsylvania, which has the nation’s most robust system for monitoring patient safety events, treats mix-ups involving end-of-life documents as medical errors — a novel approach. It found that in 2016, Pennsylvania health care facilities reported nearly 100 events relating to patients’ “code status” — their wish to be resuscitated or not, should their hearts stop beating and they stop breathing. In 29 cases, patients were resuscitated against their wishes. In two cases, patients weren’t resuscitated despite making it clear they wanted this to happen.

The rest of the cases were “near misses” — problems caught before they had a chance to cause permanent harm.

Most likely, this is an undercount, said Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, adding that she was unaware of similar data from any other state.

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Asked to describe a near miss, Hoffman, co-author of the report, said: “Perhaps I’m a patient who’s come to the hospital for elective surgery and I have a DNR (do not resuscitate) order in my [medical] chart. After surgery, I develop a serious infection and a resident [physician] finds my DNR order. He assumes this means I’ve declined all kinds of treatment, until a colleague explains that this isn’t the case.”

The problem, Hoffman explained, is that doctors and nurses receive little, if any, training in understanding and interpreting living wills, DNR orders and Physician Orders for Life-Sustaining Treatment (POLST) forms, either on the job or in medical or nursing school.

Communication breakdowns and a pressure-cooker environment in emergency departments, where life-or-death decisions often have to be made within minutes, also contribute to misunderstandings, other experts said.

Research by Dr. Ferdinando Mirarchi, medical director of the department of emergency medicine at the University of Pittsburgh Medical Center Hamot in Erie, Pa., suggests that the potential for confusion surrounding end-of-life documents is widespread. In various studies, he has asked medical providers how they would respond to hypothetical situations involving patients with critical and terminal illnesses.

In one study, for instance, he described a 46-year-old woman brought to the ER with a heart attack and suddenly goes into cardiac arrest. Although she’s otherwise healthy, she has a living will refusing all potentially lifesaving medical interventions. What would you do, he asked more than 700 physicians in an internet survey?

Only 43 percent of those doctors said they would intervene to save her life — a troubling figure, Mirarchi said. Since this patient didn’t have a terminal condition, her living will didn’t apply to the situation at hand and every physician should have been willing to offer aggressive treatment, he explained.

In another study, Mirarchi described a 70-year-old man with diabetes and cardiac disease who had a POLST form indicating he didn’t want cardiopulmonary resuscitation but agreeing to a limited set of other medical interventions, including defibrillation (shocking his heart with an electrical current). Yet 75 percent of 223 emergency physicians surveyed said they wouldn’t have pursued defibrillation if the patient had a cardiac arrest.

One issue here: Physicians assumed that defibrillation is part of cardiopulmonary resuscitation. That’s a mistake: They’re separate interventions. Another issue: Physicians are often unsure what patients really want when one part of a POLST form says “do nothing” (declining CPR) and another part says “do something” (permitting other interventions).

Mirarchi’s work involves hypotheticals, not real-life situations. But it highlights significant practical confusion about end-of-life documents, said Dr. Scott Halpern, director of the Palliative and Advanced Illness Research Center at the University of Pennsylvania’s Perelman School of Medicine.

Attention to these problems is important, but shouldn’t be overblown, cautioned Dr. Arthur Derse, director of the center for bioethics and medical humanities at the Medical College of Wisconsin. “Are there errors of misunderstanding or miscommunication? Yes. But you’re more likely to have your wishes followed with one of these documents than without one,” he said.

Make sure you have ongoing discussions about your end-of-life preferences with your physician, surrogate decision-maker, if you have one, and family, especially when your health status changes, Derse advised. Without these conversations, documents can be difficult to interpret.
Use Our Content This story can be republished for free (details).
Here are some basics about end-of-life documents:

Living wills. A living will expresses your preferences for end-of-life care but is not a binding medical order. Instead, medical staff will interpret it based on the situation at hand, with input from your family and your surrogate decision-maker.

Living wills become activated only when a person is terminally ill and unconscious or in a permanent vegetative state. A terminal illness is one from which a person is not expected to recover, even with treatment — for instance, advanced metastatic cancer.

Bouts of illness that can be treated — such as an exacerbation of heart failure — are “critical” not “terminal” illness and should not activate a living will. To be activated, one or two physicians have to certify that your living will should go into effect, depending on the state where you live.

DNRs. Do-not-resuscitate orders are binding medical orders, signed by a physician. A DNR order applies specifically to cardiopulmonary resuscitation (CPR) and directs medical personnel not to administer chest compressions, usually accompanied by mouth-to-mouth resuscitation, if someone stops breathing or their heart stops beating.

The section of a living will specifying that you don’t want CPR is a statement of a preference, not a DNR order.

A DNR order applies only to a person who has gone into cardiac arrest. It does not mean that this person has refused other types of medical assistance, such as mechanical ventilation, defibrillation following CPR, intubation (the insertion of a breathing tube down a patient’s throat), medical tests or intravenous antibiotics, among other measures.

Even so, DNR orders are often wrongly equated with “do not treat” at all, according to a 2011 review in the Journal of General Internal Medicine.

POLST forms. A POLST form is a set of medical orders for a seriously ill or frail patient who could die within a year, signed by a physician, physician assistant or nurse practitioner.

These forms, which vary by state, are meant to be prepared after a detailed conversation about a patient’s prognosis, goals and values, and the potential benefits and harms of various treatment options.

Problems have emerged with POLST’s increased use. Some nursing homes are asking all patients to sign POLST forms, even those admitted for short-term rehabilitation or whose probable life expectancy exceeds a year, according to a recent article authored by Charlie Sabatino, director of the American Bar Association Commission on Law and Aging. Also, medical providers’ conversations with patients can be cursory, not comprehensive, and forms often aren’t updated when a patient’s medical condition changes, as recommended.

“The POLST form is still relatively new and there’s education that needs to be done,” said Amy Vandenbroucke, executive director of the National POLST Paradigm, an organization that promotes the use of POLST forms across the U.S. In a policy statement issued last year and updated in April, it stated that completion of POLST forms should always be voluntary, made with a patient’s or surrogate decision-maker’s knowledge and consent, and offered only to people whose physician would not be surprised if they die within a year.

KHN’s coverage of these topics is supported by John A. Hartford Foundation, Gordon and Betty Moore Foundation and The SCAN Foundation

How America Got Hooked On A Deadly Drug

(Maria Fabrizio for KHN)

This story also ran on Daily Beast. This story can be republished for free (details). Purdue Pharma left almost nothing to chance in its whirlwind marketing of its new painkiller OxyContin.

From 1996 to 2002, Purdue pursued nearly every avenue in the drug supply and prescription sales chain — a strategy now cast as reckless and illegal in more than 1,500 federal civil lawsuits from communities in Florida to Wisconsin to California that allege the drug has fueled a national epidemic of addiction.

Read The Documents

Click here to dive into Purdue’s internal budget documents from 1996 through 2002, a 2001 sales bonus program and more.

Kaiser Health News is releasing years of Purdue’s internal budget documents and other records to offer readers a chance to evaluate how the privately held Connecticut company spent hundreds of millions of dollars to launch and promote the drug, a trove of information made publicly available here for the first time.

All of these internal Purdue records were obtained from a Florida attorney general’s office investigation of Purdue’s sales efforts that ended late in 2002.

I have had copies of those records in my basement for years. I was a reporter at the South Florida Sun-Sentinel, which, along with the Orlando Sentinel, won a court battle to force the attorney general to release the company files in 2003. At the time, the Sun-Sentinel was writing extensively about a growing tide of deaths from prescription drugs such as OxyContin.

We drew on the marketing files to write two articles, including one that exposed possible deceptive marketing of the drug. Now, given the disastrous arc of prescription drug abuse over the past decade and the stream of suits being filed — more than a dozen on some days — it seemed time for me to share these seminal documents that reveal the breadth and detail of Purdue’s efforts.

Asked by Kaiser Health News for comment on the OxyContin marketing files and the suits against the company, Purdue Pharma spokesman Robert Josephson issued a statement that reads in part:

“Suggesting activities that last occurred more than 16 years ago, for which the company accepted responsibility, helped contribute to today’s complex and multi-faceted opioid crisis is deeply flawed. The bulk of opioid prescriptions are not, and have never been, for OxyContin, which represents less than 2% of current opioid prescriptions.”

Purdue first marketed OxyContin for cancer pain but planned to expand that use to meet its multimillion-dollar sales goals.(John Ewing/Portland Press Herald via Getty Images)

The marketing files show that about 75 percent of more than $400 million in promotional spending occurred after the start of 2000, the year Purdue officials told Congress they learned of growing OxyContin abuse and drug-related deaths from media reports and regulators. These internal Purdue marketing records show the drugmaker financed activities across nearly every quarter of medicine, from awarding grants to health care groups that set standards for opioid use to reminding reluctant pharmacists how they could profit from stocking OxyContin pills on their shelves.

Purdue bought more than $18 million worth of advertising in major medical journals that cheerily touted OxyContin. Some of the ads, federal officials said in 2003, “grossly overstated” the drug’s safety.

The Purdue records show that the company poured more than $8 million into a website and venture called “Partners Against Pain,” which helped connect patients to doctors willing to treat their pain, presumably with OxyContin or other opioids.

It made and distributed 14,000 copies of a video that claimed opioids caused addiction in fewer than 1 percent of patients, a claim Food and Drug Administration officials later said “has not been substantiated.”

Purdue hoped to grow into one of the nation’s top 10 drug companies, both in sales and “image or professional standing,” according to the documents; OxyContin was the means to that end.

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Purdue first marketed the drug for cancer pain but planned to expand that use to meet its multimillion-dollar sales goals. In 1998, the market for treating cancer with opioids stood at $261 million, compared with $1.3 billion for treating other types of pain, the Purdue reports note.

Purdue’s OxyContin sales objectives were clearly stated in the earliest marketing plan in the records, for 1996. It sought $25 million in sales and to generate 205,000 prescriptions. By the next year, its goals had tripled: $77.9 million in sales and to generate 600,000 prescriptions.

Purdue bombarded doctors and other health workers with literature and sales calls. Records show that in 1997 the company budgeted $300,000 for mailings to doctors who prescribed opioids liberally, based on sales data that drug companies purchase. The mailers recommended OxyContin for “pain syndromes,” including osteoarthritis and back pain. It added $75,000 for mailings “to keep in touch with our best customers for OxyContin to ensure they continue prescribing it.”

Sales agents made thousands of visits to general practice doctors and others who had little training or experience using potent opioids, according to a 2003 Government Accountability Office audit. The OxyContin slogan in 1999 was: “The One to Start With and the One to Stay With.” OxyContin earned Purdue about $2.8 billion in revenue from the start of 1996 through June 2001, according to the Justice Department.

In May 2000, Purdue’s hope to conquer the arthritis market hit a snag when the FDA criticized an ad for OxyContin in the New England Journal of Medicine. The FDA said the ad, which Purdue Pharma agreed to stop using, overstated the drug’s benefits for treating all types of arthritis without pointing out risks.

News reports of abuse and overdose deaths also were surfacing. Purdue’s 2001 marketing document noted that OxyContin had “experienced significant challenges” the year before because of abuse and unlawful diversion in Maine, Ohio, Virginia, Louisiana and Florida.

OxyContin pills contain oxycodone, an opioid as potent as morphine and maybe more so. Abusers quickly figured out they could crush the pills and snort or inject the dust

In response, Purdue’s 2001 marketing budget included funding to help doctors recognize patients who were in need of “substance abuse counseling” and do more to “prevent abuse and diversion.” It added $1.2 million in spending for what it called “anti-diversion” efforts in 2002, according to the internal records.

Potent Sales Force

In 2002, The Florida attorney general’s office was one of the first law enforcement agencies to investigate Purdue. The state ended its probe after Purdue agreed to pay Florida $2 million to help fund a data system to monitor narcotics prescriptions. It did not admit to any wrongdoing in the settlement.

Yet handwritten notes of a state investigator’s interview with a former Purdue sales manager for West Virginia and western Pennsylvania named Bill Gergely, then 58, suggested otherwise. The notes were part of the documents released by the state.

Gergely, who worked for the company from 1972 until 2000, said Purdue executives told sales staff at a launch meeting that OxyContin “was non-habit forming,” according to the undated investigator’s notes. Gergely said Purdue gave its sales force material — some of which was not approved by the FDA — for “education,” the notes show. He told the investigator that Purdue had a bonus system and paid well; the last year he worked for Purdue, Gergely earned $238,000.

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As Purdue charged ahead with OxyContin, prescription pills overtook illegal drugs like heroin and cocaine as killers in Florida, according to medical examiner files. In May 2002, the South Florida Sun-Sentinel documented nearly 400 pill deaths in three South Florida counties the previous two years, based on an examination of autopsy and police records.

Half the deaths involved drugs that contained oxycodone, according to medical examiner records. But it was not always clear in these records that it was OxyContin because oxycodone was an ingredient in many other narcotic pills. In 70 of the deaths, however, police or medical examiner records specifically identified OxyContin as one of the drugs. Though some people who died bought pills on a thriving black market, many were under the care of doctors for what appeared, at least at some point, to be legitimate injuries, according to medical examiner files.

Purdue did not challenge the accuracy of the newspaper’s reporting. It countered that the articles “did a disservice” to the company and patients who take their medicine “according to the directions of their doctors.” While the company said its executives “deeply regret the tragic consequences that have resulted from the misuse and abuse of our pain medicine … advances in the treatment of pain should not be limited or reversed because some people illegally divert, abuse or misuse these drugs.”

To its sales force, the internal Purdue records show, Purdue blamed bad press for cutting into sales. “The media’s attention to abuse and diversion of OxyContin tablets has provided state Medicaid plans and some HMOs, concerned about the effect the product is having on their budget, an excuse to look for ways to limit the prescribing of OxyContin tablets,” the 2002 marketing document said.

But five years after its legal battle with Florida officials, Purdue made a startling admission in federal court in Virginia. The company pleaded guilty in 2007 to felony charges of “misbranding” OxyContin “with the intent to defraud or mislead.” The company paid $600 million in fines and other penalties. Among the deceptions it confessed to was directing its salespeople to tell doctors the drug was less addictive than other opioids.

Three Purdue Pharma executives pleaded guilty to misdemeanor criminal charges for their roles in the marketing scheme. The three men paid a total of $34 million in fines and penalties, court records show. Accepting Purdue’s plea deal, U.S. District Judge James P. Jones noted that federal prosecutors believed the Purdue case of 2007 would send a “strong deterrent message to the pharmaceutical industry.”

A Costly Reckoning?

Ten years on, the 1,500-plus lawsuits, filed mostly on behalf of cities, counties and states, could prove to be a costly reckoning for the opioid industry. The suits are demanding payback from Purdue and other drugmakers for the sky-high costs of treating addiction and other compensation, much as the litigation against Big Tobacco in the late 1990s.

Other drug makers named as defendants in most of the suits include those that Purdue considered to be its top competitors in the pain sector: Janssen Pharmaceuticals, Teva Pharmaceutical Industries, Endo International PLC and Mallinckrodt PLC.

Federal officials estimate the economic cost of opioid abuse topped $500 billion in 2015 alone. Since 1999, at least 200,000 people have died in the U.S. from these overdoses, according to the Centers for Disease Control and Prevention. More than 52,000 of those died in 2015 alone, more than were killed in car crashes and gun homicides combined, the suits contend.

A case filed in April by Baltimore County in Maryland makes an argument common to many of the suits:

“From the mid-’90s to the present, manufacturing defendants aggressively marketed and falsely promoted liberal opioid prescribing as presenting little to no risk of addiction, even when used long term for chronic pain. They infiltrated academic medicine and regulatory agencies to convince doctors that treating chronic pain with long-term opioids was evidence-based medicine when, in fact, it was not.

“Huge profits resulted from these efforts — as did the present addiction and overdose crisis.”

Purdue has not yet filed a response to the allegations in the suit.

Other drug manufacturers “emulated Purdue’s false marketing strategy” and sold billions of dollars of prescription opioids “as safe and efficacious for long term use, knowing full well that they were not,” Wisconsin’s Oneida County alleges in its November 2017 federal court suit. Purdue also has not yet filed a response to the allegations in this suit.

But Purdue spokesman Josephson told KHN: “We share public officials’ concern about the opioid crisis, and we are committed to working collaboratively toward meaningful solutions. We vigorously deny these allegations and look forward to the opportunity to present our defense.”

One California doctor who was sentenced to 25 years in prison for overprescribing OxyContin is also suing Purdue. Masoud Bamdad alleges that the company’s representatives made sales calls and gave him “deceitful, misleading and over-hyped information,” which he relied on to prescribe the drug, in some cases with deadly consequences for his patients, according to the suit, which is pending. Purdue has asked that the case be stayed while judges decide if it should be consolidated with others filed against the company. In February, Purdue announced that it would no longer promote opioids to doctors.

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Because the lawsuits from across the U.S. contain similar allegations, many of them have been consolidated in Ohio – as a multi-district litigation. Some days, federal court dockets log a dozen or more new cases. Many of the suits run a hundred pages or more and allege that deceptive opioid marketing schemes continue to this day.

The manufacturers, in a joint court motion late last year, contend that opioids “serve a critical public health role in providing relief to patients suffering from pain that is often debilitating” and that they are being wrongly blamed.

They also point out that the FDA approved all of their products as “safe and effective.”

This month, the manufacturers filed motions to dismiss several of the cases, arguing that the county governments lack a legal basis for their claims. In seeking to blame the drugmakers, these lawsuits ignore “the criminal acts of third parties, the crucial role of health care providers, and the thorny public policy questions surrounding the problem of opioid abuse,” reads a motion to dismiss a case filed by Monroe County, Mich., against Purdue Pharma and other drug companies.

Dan Polster, the federal judge handling the cases, told an overflow crowd in his courtroom that the opioid epidemic has become so severe, that it is cutting the average life expectancy of Americans.

“I’m pretty ashamed that this has occurred while I have been around,” he said in January, adding “I think we all should be.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients

“Oh my God, we dropped her!” Sandra Snipes said she heard the nursing home aides yell as she fell to the floor. She landed on her right side where her hip had recently been replaced.

She cried out in pain. A hospital clinician later discovered her hip was dislocated.

That was not the only injury Snipes, then 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her twice a day with a potent blood thinner despite written instructions to stop.

“She said, ‘I just feel so tired,’” her daughter, Laura Clark, said in an interview. “The nurses were saying she’s depressed and wasn’t doing her exercises. I said no, something is wrong.”

Her children also discovered that Snipes’ surgical wound had become infected and infested with insects. Just 11 days after she arrived at the nursing home to heal from her hip surgery, she was back in the hospital.

The fall and these other alleged lapses in care led Clark and the family to file a lawsuit against the nursing home. Richmond Pines declined to discuss the case beyond saying it disputed the allegations at the time. The home agreed in 2017 to pay Snipes’ family $1.4 million to settle their lawsuit.

While the confluence of complications in Snipes’ case was extreme, return trips from nursing homes to hospitals are far from unusual.

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With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients’ care.

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“There’s this saying in nursing homes, and it’s really unfortunate: ‘When in doubt, ship them out,’” said David Grabowski, a professor of health care policy at Harvard Medical School. “It’s a short-run, cost-minimizing strategy, but it ends up costing the system and the individual a lot more.”

In recent years, the government has begun to tackle the problem. In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.

Starting this October, the government will address the other side of the equation, giving nursing homes bonuses or penalties based on their Medicare rehospitalization rates. The goal is to accelerate early signs of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress’ Medicare Payment Advisory Commission.

“We’re better, but not well,” Grabowski said. “There’s still a high rate of inappropriate readmissions.”

The revolving door is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days.

But nursing homes have to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes.

Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a “bed-hold” fee when a patient is hospitalized.

None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs at the American Health Care Association, a nursing home trade group.

“And they never quite get back to normal,” he said.

‘She Looked Like A Wet Washcloth’

Communication lapses between physicians and nursing homes is one recurring cause of rehospitalizations. Elaine Essa had been taking thyroid medication ever since that gland was removed when she was a teenager. Essa, 82, was living at a nursing home in Lancaster, Calif., in 2013 when a bout of pneumonia sent her to the hospital.

When she returned to the nursing home — now named Wellsprings Post-Acute Care Center — her doctor omitted a crucial instruction from her admission order: to resume the thyroid medication, according to a lawsuit filed by her family. The nursing home telephoned Essa’s doctor to order the medication, but he never called them back, the suit said.

Deborah Ann Favorite holds a photograph of her mother, Elaine Essa. The nursing home and Essa’s primary care practice settled a lawsuit brought by the family. (Heidi de Marco/KHN)

Without the medication, Essa’s appetite diminished, her weight increased and her energy vanished — all indications of a thyroid imbalance, said the family’s attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Family Medical Group never visited her, sending instead their nurse practitioner. He, like the nursing home employees, did not grasp the cause of her decline, although her thyroid condition was prominently noted in her medical records, the lawsuit said.

Three months after her return from the hospital, “she looked like a wet washcloth. She had no color in her face,” said Donna Jo Duncan, a daughter, in a deposition. Duncan said she demanded the home’s nurses check her mother’s blood pressure. When they did, a supervisor ran over and said, “Call an ambulance right away,” Duncan said in the deposition.

At the hospital, a physician said tests showed “zero” thyroid hormone levels, Deborah Ann Favorite, a daughter, recalled in an interview. She testified in her deposition that the doctor told her, “I can’t believe that this woman is still alive.”

Essa died the next month. The nursing home and the medical practice settled the case for confidential amounts. Cynthia Schein, an attorney for the home, declined to discuss the case beyond saying it was “settled to everyone’s satisfaction.” The suit is still ongoing against one other doctor, who did not respond to requests for comment.

Dangers In Discouraging Hospitalization

Out of the nation’s 15,630 nursing homes, one-fifth send 25 percent or more of their patients back to the hospital, according to a Kaiser Health News analysis of data on Medicare’s Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return fewer than 17 percent of residents to the hospital.

Get The Data

Safely Home Or Back To The Hospital?

Download the data to see how skilled nursing homes in the U.S. performed on two metrics of quality.

Many health policy experts say that spread shows how much improvement is possible. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments.

“We’re always worried the bad nursing homes are going to get the message ‘Don’t send anyone to the hospital,’” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

Richmond Pines, where Sandra Snipes stayed, has a higher-than-average rehospitalization rate of 25 percent, according to federal records. But the family’s lawyer, Kyle Nutt, said the lawsuit claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

After Snipes was rehospitalized, her blood thinner was discontinued, her hip was reset, and she was discharged to a different nursing home, according to the family’s lawsuit. But her hospital trips were not over: When she showed signs of recurrent infection, the second home sent her to yet another hospital, the lawsuit alleged.

Ultimately, the lawsuit claimed that doctors removed her prosthetic hip and more than a liter of infected blood clots and tissues. Nutt said if Richmond Pines’ nurses had “caught the over-administration of the blood thinner right off the bat, we don’t think any of this would have happened.”

Snipes returned home but was never able to walk again, according to the lawsuit. Her husband, William, cared for her until she died in 2015, her daughter, Clark, said.

“She didn’t want to go back into the nursing home,” Clark said. “She was terrified.”

KHN’s coverage of these topics is supported by John A. Hartford Foundation and Gordon and Betty Moore Foundation

‘Where The Need Is:’ Tackling Teen Pregnancy With A Midwife At School

Kaiser Health News:States - June 12, 2018
The student comes in for a pregnancy test — the second time she has asked for one in a matter of weeks.

She’s 15. She lives with her boyfriend. He wants kids — he won’t use protection. She loves him, she says. But she doesn’t want to get pregnant. She knows how much harder it would be for her to finish high school.

At many schools, she would have gotten little more than some advice from a school nurse. But here at Anacostia High School in Washington, D.C., she gets a dose of midwife Loral Patchen.

Patchen asks her bluntly what she’s going to do about it. Because one of these days, the test is going to show a positive.

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Patchen talks her through a range of birth control methods. There’s a shot you take every few months, an IUD, or a small implant that goes into your arm, which can prevent pregnancy for years. And, of course there are birth control pills. The student opts for pills, and leaves Patchen’s office with a one-month supply with a standing order for refills through the school clinic.

The hope is that this interaction will mean one fewer teen pregnancy in the city. In the Washington, D.C., neighborhood where this student lives, her chance of getting pregnant is nearly three times the national average.

While U.S. teen pregnancy rates overall have trended steadily downward in the past decade, they remain high in some communities. The rates for black and Latina teens is around twice that of whites, and kids from low-income families tend to have higher rates.

Patchen has been a midwife for 20 years and is the founder of the Teen Alliance for Prepared Parenting, or TAPP, at MedStar Washington Hospital Center. (Meredith Rizzo/NPR)

Anacostia High School’s midwife program is a novel approach that’s showing promise in tackling the problem.

Patchen had been trying to combat the city’s teen pregnancy rates for 20 years as the founder of the Teen Alliance for Prepared Parenting, or TAPP, at MedStar Washington Hospital Center. She was happy with what they accomplished, but she wanted more access to the young people who needed her. Her organization received a 2015 grant from the CareFirst BlueCross BlueShield health insurer to start working in two schools. Now she’s one of a handful of school midwives in the country, she said.

“It’s much better to go where the need is rather than to sit back and wait for the need to come to you,” she said.

And her role goes beyond providing prenatal care for the five to eight pregnant students who get care in the school clinic each year. Being at the school gives her a chance to help prevent pregnancies in the first place. “I wouldn’t have seen these youth in any other setting — not easily, anyway,” she said.

As the school midwife, Patchen can be an informal — and reliable — resource for students’ questions about sex and contraception and relationships.

“I love it when I’m walking in or in the hall during lunch because I see people and they recognize me,” Patchen said. “And they come in to ask me a question and they’ve got their two girlfriends with them. And we’ll talk about condom use or a side effect of a particular method or they’ll say ‘I heard …'”

If she were in a hospital, seeing young people only after they’re pregnant, she would never get this kind of interaction, Patchen said. Plus, the information she gives them spreads through their circle of friends.

At the school, Patchen keeps her schedule flexible to leave room for informal interactions and walk-in appointments, alongside her regular appointments with students.

When a student comes in, Patchen can offer counseling and immediate options. If a student decides she wants an IUD, Patchen can insert it on the spot. She can prescribe birth control pills and then hand the student a packet.

Patchen consults with a student about available pregnancy prevention options. (Meredith Rizzo/NPR)

The CareFirst grant pays for the services and any contraception the students request, so students don’t have to rely on insurance to cover them.

“I feel really good about the fact that we offer the full range of options and we have very, very low removal rates,” Patchen said. She said that she talks students through the different methods and their adverse effects, and leaves the decision about which — if any — method they want to use. “And if the decision is ‘yes,’ it’s a very informed and well-grounded decision,” she said.

In the three years that she’s been working out of Anacostia High School, Patchen said, no students participating in the program have had a subsequent pregnancy. And after choosing a long-term birth control method like an IUD, 85 percent of Anacostia students are still using it one year later.

Patchen discusses a long-term implant as a birth control option. A grant pays for the cost of contraceptives that students ask for. (Meredith Rizzo/NPR)

Patchen can also test for sexually transmitted diseases, or STDs, including doing rapid HIV tests in the school clinic’s lab.

Just as critical, she said, is the ability to spend time talking with students about their lives — from deciding not to have sex, to navigating relationships.

For instance, she asks: “‘Who makes a good girlfriend or a boyfriend? What is that kind of person? How do you make decisions together? What do you do when you have conflict?'”

The other part of Patchen’s job is on-site prenatal care for students who do get pregnant.

Last year, one of those students was Kiera — we’re using students’ first names only, to protect their privacy. When Kiera got pregnant, she was 15 — and scared.

D’Monte and Kiera stop by the clinic because their daughter is running a fever. (Meredith Rizzo/NPR)

“When I met Loral and she started taking care of me in my pregnancy, she made me feel happier about being a parent,” Kiera said. “She helped me out a lot.”

Patchen said being in the school made it easy for Kiera to come in many times throughout her pregnancy, and talk about things like getting a required blood glucose test, or the benefits of breastfeeding — and also about her relationship with the baby’s father, D’Monte.

Since D’Monte is also a student at the school, Patchen could talk to them about parenting together. And even since Kiera and D’Monte broke up, Patchen still helps them figure out how to maintain a relationship so their daughter will have two parents.

Patchen was there, along with D’Monte and Kiera’s mother, when Kiera gave birth to her daughter last January.

“All I saw was excitement on [Patchen’s] face,” D’Monte recalled. “She was just so excited and she was so proud. So I couldn’t let her down.”

The baby is now a toddling 1-year-old who goes to the day care on-site at the high school. Kiera can bring her by the school clinic whenever she needs a visit with the pediatrician, or just to say hi.

“I love it when they come to the office because her daughter is laughing and she’s responsive to things and they’re responsive to her. And it’s a beautiful thing,” Patchen said.

New parents Kiera and D’Monte attend the same school and Patchen uses every chance to talk to them together about issues they’re facing. (Meredith Rizzo/NPR)

The fact that this is a happy, communicative family is not an accident, Patchen said. There were times of frustration, times of disagreement — it could have gone badly. But everyone — the TAPP team, the school clinic staff and the student parents — put in a lot of hard work to do the best they could by this child.

Midwife Loral Patchen wants to be clear: She is by no means saying that teen pregnancy is a great thing. But Patchen feels strongly that once pregnant, a student needs real, steady support.

“Youth that are pregnant, they are very aware of all the judgment, the assumption they will fail: ‘You won’t be able to. Now you can’t.'” Patchen said. “It’s our mandate to make sure they still see themselves as having a future and an opportunity. And that means not buying in to the fact that they will fail with the next 60 years of their lives.”

She said a lot of people tell her her job sounds “dire” — working with young people facing the challenge of dealing with parenthood and high school at the same time. She said that’s not her experience.

Patchen works in two D.C.-area schools. She says she believes she’s one of a very few school midwives in the nation. (Meredith Rizzo/NPR)

“My day at the school health center is the highlight of my week,” Patchen said. “I see young people be brave every single day that I show up there. And I see people willing to figure out how to do really hard things. What’s better than that?”

She wants more — more days in the school clinic, more schools in the program, more staff — to meet the need she sees every day she’s there. She thinks this is one of the few interventions that could have a direct impact on bringing down the high rate of teen pregnancy for these young women in the district.

This story is part of NPR’s reporting partnership with Kaiser Health News.

California’s Attorney General Vows National Fight To Defend The ACA

California Attorney General Xavier Becerra pledged Friday to redouble his efforts as the Affordable Care Act’s leading defender, saying attacks by the Trump Administration threaten health care for millions of Americans.

Becerra’s pledge came in response to an announcement from the administration Thursday that it would not defend key parts of the Affordable Care Act in court. The administration instead called on federal courts to scuttle the health law’s protection for people with preexisting medical conditions and its requirement that people buy health coverage.

Becerra accused the administration of going “AWOL.” It “has decided to abandon the hundreds of millions of people who depend on” the law, he said in an interview with Kaiser Health News.

“It’s, simply put, an attack on the health care that millions of Americans have come to count on, and California, being the most successful state in implementing the Affordable Care Act, stands to lose perhaps more than anyone else.”

About 1.5 million Californians buy coverage through the state’s ACA exchange, Covered California, and nearly 4 million have joined Medicaid as a result of the program’s expansion under the law.

The state has been at the forefront in resisting many Trump Administration policies, including on health care and immigration.

“This is not a new experience for us under this new Trump era of having to defend Californians,” Becerra said. In the case of health care, “fortunately we have 16 other [Democratic attorneys general] who are prepared to do it with us. ”

At issue is a lawsuit filed by 20 Republican state attorneys general on Feb. 26, which charged that Congress’ changes to the law in last year’s tax bill rendered the entire ACA unconstitutional. In the tax law, Congress repealed the penalty for people who fail to have health insurance starting in 2019.

Becerra is leading an effort by Democratic attorney generals from others states and the District of Columbia to defend the ACA against that lawsuit. In May, the court allowed them to “intervene” in the case.

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The Trump administration filed a brief in the case on Thursday, arguing that without the tax to encourage healthy people to sign up, the parts of the law guaranteeing coverage to people with previous health conditions — without charging them higher rates — should be struck down as well.

In a letter to House Speaker Paul Ryan explaining the administration’s decision, U.S. Attorney General Jeff Sessions cited the Justice Department’s “longstanding tradition” of defending the constitutionality of federal laws “if reasonable arguments can be made in their defense.”

But in this case, he wrote, he could not find those arguments to defend the constitutionality of the provisions and “concluded that this is a rare case where the proper course is to forgo defense.”

The administration called on the court to declare the provisions that guarantee coverage to be invalid beginning on January 1, 2019, when the mandate penalty goes away.

Because the lawsuit could easily go all the way to the U.S. Supreme Court, a process that could take years, the protections for people with preexisting conditions are likely to stay in place during that period.

Lieutenant Governor Gavin Newsom, the Democratic front-runner in the race for California’s next governor, breathed the same fire as Becerra against the federal government on Friday.

“Trump and his cronies can’t unilaterally roll back preexisting protections for millions of Californians,” Newsom said. “California will fight like hell to protect our families and their healthcare.”

A spokesman for his opponent in the race, Republican gubernatorial candidate John Cox, declined to comment.

If the court ultimately declared the provisions targeted by the Trump Administration unconstitutional, California would be temporarily cushioned from the effects because there are laws already on the books should the ACA – or its provisions – go away.

For instance, existing rules would protect people with pre-existing conditions for twelve months if the ACA were struck down.

During that time, “policymakers in California would look really hard at being able to try to do something so we don’t lose those gains,” said Deborah Kelch, director of the Insure the Uninsured Project in Sacramento.

“It’s hard to look at California and imagine just folding it up and starting over.”

Some critics of the administration’s decision said California should go forward with enacting its own mandate for individual coverage, as a few other states have done. No one has pushed that issue forward in the Legislature.

Since he took office in January 2017, Becerra has emerged as a top opponent of the Trump administration, filing more than 30 lawsuits on health care and other issues.

In California’s primary election Tuesday, Becerra, a Democrat, dominated the race with 45 percent of the vote. He will face retired judge Steven Bailey, a Republican, in the November general election.

Bailey’s spokesman Corey Uhden said Friday that he wouldn’t comment on the constitutionality of the ACA provisions. However, he said, Bailey opposes the individual mandate and wants less government regulation of health insurance.

Alex Leeds Matthews contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

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