Seeking to Grow Market Share?

Get a FREE assessment of your CDH products —
a $3,000 value.

Subscribe to Kaiser Health News:Marketplace feed Kaiser Health News:Marketplace
Updated: 21 hours 22 min ago

Health Giant Sutter Destroys Evidence In Crucial Antitrust Case Over High Prices

November 17, 2017

Sutter Health intentionally destroyed 192 boxes of documents that employers and labor unions were seeking in a lawsuit that accuses the giant Northern California health system of abusing its market power and charging inflated prices, according to a state judge.

In a ruling this week, San Francisco County Superior Court Judge Curtis E.A. Karnow said Sutter destroyed documents “knowing that the evidence was relevant to antitrust issues. … There is no good explanation for the specific and unusual destruction here.”

Karnow cited an internal email by a Sutter employee who said she was “running and hiding” after ordering the records destroyed in 2015. “The most generous interpretation to Sutter is that it was grossly reckless,” the judge wrote in his 12-page ruling.

Use Our Content

This Kaiser Health News story can be republished for free (details).

More Stories To Republish

Sutter, which has 24 hospitals and nearly $12 billion in annual revenue, said the destruction was a regrettable mistake.

Employers and policymakers across the country are closely watching this legal fight amid growing concern about the financial implications of industry consolidation. Large health systems are gaining market clout and the ability to raise prices by acquiring more hospitals, outpatient surgery centers and physician offices.

“It’s stunning what Sutter did to cover up incriminating documents in this case,” said Richard Grossman, the lead plaintiffs’ lawyer representing a class of more than 1,500 employer-funded health plans.

In April 2014, a grocery workers’ health plan sued Sutter and alleged it was violating antitrust and unfair competition laws. The plaintiffs began requesting documents related to contracting practices, such as “gag clauses” that prevent patients from seeing negotiated rates and choosing a cheaper provider and “all-or-nothing” terms that require every facility in a health system to be included in insurance networks.

Sutter disputes the broader allegations in the lawsuit over its market conduct and said its charges are in line with its competitors’.

The judge said that in 2015 Melissa Brendt, Sutter’s chief contracting officer in the managed-care department, and an assistant general counsel, Daniela Almeida, authorized Brendt’s executive assistant to destroy 10 years’ worth of managed-care documents going back to 1995. The company earlier had scheduled the documents to be destroyed in 2035 — 20 years later.

The executive assistant, Sina Santagata, testified in a deposition she wasn’t aware of any other time in her 17 years at Sutter when the managed-care department destroyed records held in storage.

In his Nov. 13 ruling against Sutter, the judge singled out an email by Santagata as “particularly noteworthy.”

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

The executive assistant emailed Brendt, the chief contracting officer, on July 30, 2015, after sending the order to destroy the records. She wrote, “I’ve pushed the button … if someone is in need of a box between 3/15/95 & 11/23/05 … I’m running and hiding. … ‘Fingers crossed’ that I haven’t authorized something the FTC will hunt me down for.”

The Federal Trade Commission (FTC) enforces antitrust laws in health care to prevent hospitals, drugmakers and other industry players from engaging in anti-competitive behavior that could harm consumers.

Santagata testified that she was being “sarcastic” in her email, and Sutter told the judge that the FTC reference was just a “joke.”

Karnow saw no humor in it. “There are infinite topics for jokes, and the choice of this one is strong evidence” in the plaintiffs’ favor, he wrote in his order Monday.

As part of his sanctions against Sutter, the judge ordered the health system to examine email backup tapes covering 2002 through 2005 to search for documents on some of the same topics as the destroyed records. Also, Karnow said he will consider a plaintiffs’ motion for issuing jury instructions that are adverse to Sutter in light of the document destruction. The trial is scheduled for June 2019.

“The record shows that Sutter’s conduct was more than just an inadvertent error,” Karnow wrote.

Sutter spokeswoman Karen Garner said the incident was a “mistake made as part of a routine destruction of old paper records” and the Sacramento-based health system disclosed the error as soon as it was discovered.

“We regret that as part of a routine archiving process we failed to preserve some boxes of decades-old hard-copy documents,” Garner said.

The United Food and Commercial Workers and its Employers Benefit Trust initially filed the case against Sutter in 2014. The joint employer-union health plan represents more than 60,000 employees, dependents and retirees. The court certified the case as a class action in August, allowing hundreds of other employers and self-funded health plans to potentially benefit from the litigation.

In addition to its 24 hospitals, Sutter’s nonprofit health system has 35 surgery centers and more than 5,000 physicians in its network. It reported $11.9 billion in revenue last year and income of $554 million.

Grossman, the plaintiffs’ counsel, said he welcomed the judge’s ruling. But he said much of the evidence is irreplaceable, particularly handwritten notes from negotiating sessions and meetings involving key Sutter executives.

He said those records covered a critical period in the early 2000s when there was a “sea change in Sutter’s contracting strategy” and it implemented provisions that insulated the health system from price competition.

“This was groundbreaking in the industry,” Grossman said. “Until we address the anti-competitive behavior of entities like Sutter, we will not solve the problem of high costs in health care.”

The plaintiffs are seeking to recover hundreds of millions of dollars from Sutter from what it claims are illegally inflated prices. The lawsuit alleges that an overnight hospital stay at Sutter hospitals in San Francisco or Sacramento costs at least 38 percent more than a comparable stay in the more competitive Los Angeles market.

A study published last year found that hospital prices at Sutter and Dignity Health, the two biggest hospital chains in California, were 25 percent higher than at other hospitals around the state. Researchers at the University of Southern California said the giant health systems used their market power to drive up prices — making the average patient admission at both chains nearly $4,000 more expensive.

“Sutter is a pretty extreme case of market power, but health care consolidation has become a really important issue across the country,” said Kathy Hempstead, a health care researcher at the Robert Wood Johnson Foundation. “It’s been on the back burner somewhat because of the debate over the Affordable Care Act, but there is bipartisan interest in tackling this.”

How Older Patients Can Dodge Pitfalls Entrenched In Health Care System

November 16, 2017
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.

See All Columns

Being old and sick in America frequently means a doctor won’t ask you about troublesome concerns you deal with day to day — difficulty walking, dizziness, a leaky bladder, sleep disturbances memory lapses, and more.

It means that if you’re hospitalized, you have a good chance of being treated by a physician you’ve never met and undergoing questionable tests and treatments that might end up compromising your health.

It means that if you subsequently seek rehabilitation at a skilled nursing facility, you’ll encounter another medical team that doesn’t know you or understand your at-home circumstances. Typically, a doctor won’t see you very often. In her new book, “Old & Sick in America: The Journey Through the Health Care System,” Dr. Muriel Gillick, a professor of population medicine at Harvard Medical School and director of the Program in Aging at Harvard Pilgrim Health Care Institute, delves deeply into these concerns and why they’re widespread.

Her answer: a complex set of forces is responsible.  Some examples:

  • Medical training doesn’t make geriatric expertise a priority.
  • Care at bottom-line-oriented hospitals is driven by the availability of sophisticated technology.
  • Drug companies and medical device manufacturers want to see their products adopted widely and offer incentives to ensure this happens.
  • Medicare, the government’s influential health program for seniors, pays more for procedures than for the intensive counseling that older adults and caregivers need.

In an interview, Gillick offered thoughts about how older adults and their caregivers can navigate this treacherous terrain. Her remarks have been edited for clarity and length:

Q: What perils do older adults encounter as they travel through the health care system?

The journey usually begins in the doctor’s office, so let’s start there. In general, physicians tend to focus on different organ systems. The heart. The lungs. The kidneys. They don’t focus so much on conditions that cross various organ systems, so-called geriatric syndromes. Things like falling, becoming confused or dealing with incontinence.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

Q: What can people do about that?

Older people are often unwilling to bring these issues to the attention of their doctors. But if a family member is accompanying the patient, they should speak up.

In some practices, a nurse practitioner may be more attuned to these issues than the physician. So, it’s a good idea to learn who in the medical office you go to is good at what.

Another approach is to request a geriatric assessment or consultation that will bring these issues to the forefront.

Q: How do geriatric assessments work?

A geriatric assessment does two major things. It looks at the whole person. And it focuses on that person’s functioning — on what they can do. Can they dress themselves, walk, get to the bathroom? Can they cook meals? Take a bus downtown? Balance their checkbook?

An outpatient geriatric assessment is typically 1½ to two hours and conducted by an interdisciplinary team. A social worker or a mental health professional will ask about the person’s family situation. Are they living alone? Do they have support? A nurse practitioner will look at physical function. And a physician will go over medical concerns and examine the cognitive performance of the individual. Then, the team pulls all these pieces together to look at what’s going on with that person.

When someone starts being frail — having consistent difficulty doing things — an assessment of this kind is often a good idea.

More Columns See All Columns

Q: The next step you talk about in your book is the hospital.

One of the big perils in the hospital is technology, which is also its great virtue.  Technology can improve quality of life and be life-extending. But, sometimes, it creates endless complications.

An example are imaging tests such as CT scans. Physicians hardly think of this as an invasive test. But often one has to administer a dye to see what’s going on.  That dye can cause kidney failure in someone with impaired kidney function — something that’s common in older adults.

Sometimes there’s no real need for scans. An example would be an older person who becomes acutely confused in the hospital, which happens a lot. The appropriate response is to look at what’s causing the confusion and take away the offending agent. Often, that’s a medication that was started in the hospital. Or, it’s an infection. But the routine knee-jerk reaction is to do a CT scan to rule out the possibility of a stroke or bleeding in the brain.

For the most part, doctors want to do whatever it takes to diagnose a problem.  For younger patients, this may make sense. But for frail older patients with multiple medical conditions, a cascade of complications can result.

Q: What do you advise older patients and their families do?

When a test is proposed, ask the doctor “how important is it to pursue this diagnosis” and “how will the results change what you do?”

It’s also reasonable to say something along the lines of “every time I’ve had a test, it seems like I get into some kind of trouble. So, I really want to know, with this test or this treatment, what kind of trouble could I get into?”

Q: In your book, you talk about how a doctor-patient relationship can be sidelined when someone goes to the hospital. Instead, hospitalists provide care. How should people respond?

It’s really important to give that doctor a sense of the patient and who they are.  Say, your 88-year-old mother is in the hospital, and she’s become profoundly confused. The doctor doesn’t know what she was like a week or a month ago. He may assume she has dementia unless he hears otherwise. He won’t understand it might be delirium.

You or a caregiver want to come across as someone who can make it easier for the doctor to do his or her job — versus someone who’s a nuisance. You want to build trust, not annoyance.

Use Our Content

This Kaiser Health News story can be republished for free (details).

More Stories To Republish

Q: What about skilled nursing facilities?

These are settings that people go to after the hospital, to get rehabilitation.  Typically, the contact with doctors is minimal after an initial evaluation, though there’s a spectrum as to how much medical care there is.

A subset of older adults go to rehab just to get physical therapy after they’ve had a joint replacement or a hip fracture. They are really pretty stable, medically. If they get good physical therapy and nursing care, it’s probably OK that the doctor isn’t around much.

But there are also older patients who come to skilled nursing facilities, or SNFs, after having had one complication after another in the hospital. These patients can be very fragile, with many medical problems. They’re at risk of getting some new problem in the SNF — perhaps an infection — or an exacerbation of one of the problems they already have that hasn’t resolved.

Q: What do you recommend?

When you arrive at an SNF, it’s a new cast of characters. A physician whom you’ll see fleetingly. Nurses. Physical therapists. Aides. If you’re a caregiver, make sure you have face-to-face time with these staffers.

SNFs are required within the first week or so to have a care planning meeting with the team. They’re supposed to invite patients and their representatives to the meeting. This is a good place to say something along the lines of “My mother has been through a lot, and now that we’ve met you and seen what you can do, we’d like you to do your best to treat her here and not send her back to the hospital.”

You have to have trust to make that happen. The family has to trust the medical team. And the team has to trust that the family isn’t going to get upset and sue them. A meeting of this kind has the potential to allow everyone to figure out what’s important and what the plan will be going forward.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit to submit your requests or tips.

California Firm Running Physician Practices Is Closing Down as Scrutiny Ramps Up

November 15, 2017

SynerMed, a company that manages physician practices serving hundreds of thousands of Medicaid and Medicare patients across California, is planning to shut down amid scrutiny from state regulators and health insurers.

The company’s chief executive, James Mason, notified employees in an internal email Nov. 6, obtained by Kaiser Health News, that audits by health plans found “several system and control failures within medical management and other departments.”

As a result, Mason wrote, the company “will begin the legal and operational steps to shut down all operations.” He said he was working on the transition of SynerMed’s clients to another management firm within the next 180 days.

Separately, the California Department of Managed Health Care confirmed it is investigating the company.

“There is an open investigation of SynerMed, but the details are confidential right now,” said spokesman Rodger Butler. His agency monitors the financial solvency and claims-payment practices of many physician groups that contract with health plans.

The company’s sudden decision to shut down has sparked alarm among some doctors and medical groups that have relied on the company to handle their finances and business operations.

For years, SynerMed has served as a key middleman between health plans and independent physician practices, handling insurance contracting, paying claims and performing other administrative tasks so doctors can focus on treating patients. That role has expanded as millions more Californians are enrolled in Medicaid managed-care plans under the Affordable Care Act.

SynerMed has billed itself as “one of the largest Medicaid/Medicare management service organizations in the nation.” Last year, the company boasted that it had enrollment of 1 million patients in California, aided by an influx of enrollees who got coverage under the federal health law.

Mason, the CEO, didn’t respond to requests for comment. The company referred calls to its general counsel, but she couldn’t be reached.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

In his email to employees, Mason said he had “discovered certain internal control issues within the medical management department.”

“Well,” he wrote, “as a result of the manner in which those issues were disclosed to the health plans and regulatory agencies, we have been subject to unannounced audits by almost all of our health plan partners.”

The CEO said two medical groups, AlphaCare and EHS (Employee Health Systems) Medical Group, have already terminated their contracts with SynerMed.

“I am heartbroken and saddened by these events after we have worked so hard to build our reputation as a company that operates with integrity,” Mason wrote in his email to employees.

Part of SynerMed’s growth had come from managing care for low-income seniors and people with disabilities who are eligible for both Medicare and Medicaid, called Medi-Cal in California. The state has been at the forefront nationally in trying to shift those “dual-eligible” patients into managed-care plans, which are paid a fixed rate per patient to coordinate a range of medical care.

A spokesman for the Medi-Cal program said the agency had no information to share on SynerMed.

SynerMed is a subsidiary of PAMC, Ltd., which also owns Pacific Alliance Medical Center in Los Angeles’ Chinatown. The hospital agreed to pay $42 million in June to settle federal allegations of improper kickbacks to referring physicians.

The U.S. Justice Department said Pacific Alliance Medical Center agreed to the settlement to resolve a whistleblower lawsuit alleging that the hospital submitted false claims to Medi-Cal and Medicare. In a news release at the time, federal officials said the hospital and its owners did not admit liability in settling the case.

The hospital is closing later this month. Officials there attributed the closure to the fact that the lease on the property is ending and it wasn’t financially feasible to retrofit facilities to meet the state’s seismic requirements.

In a statement to Kaiser Health News, PAMC said “there is no connection between the closure of [the hospital] and any matters involving SynerMed. SynerMed is a wholly owned subsidiary that provides completely different services.”

Taking A Page From Pharma’s Playbook To Fight The Opioid Crisis

November 14, 2017

Dr. Mary Meengs remembers the days, a couple of decades ago, when pharmaceutical salespeople would drop into her family practice in Chicago, eager to catch a moment between patients so they could pitch her a new drug.

Now living in Humboldt County, Calif., Meengs is taking a page from the pharmaceutical industry’s playbook with an opposite goal in mind: to reduce the use of prescription painkillers.

Meengs, medical director at the Humboldt Independent Practice Association, is one of 10 California doctors and pharmacists funded by Obama-era federal grants to persuade medical colleagues in Northern California to help curb opioid addiction by altering their prescribing habits.

This story also ran on KQED’s California Report. It can be republished for free (details).

She committed this past summer to a two-year project consisting of occasional visits to medical providers in California’s most rural areas, where opioid deaths and prescribing rates are high.

“I view it as peer education,” Meengs said. “They don’t have to attend a lecture half an hour away. I’m doing it at [their] convenience.”

This one-on-one, personalized medical education is called “academic detailing” — lifted from the term “pharmaceutical detailing” used by industry salespeople.

Detailing is “like fighting fire with fire,” said Dr. Jerry Avorn, a Harvard Medical School professor who helped develop the concept 38 years ago. “There is some poetic justice in the fact that these programs are using the same kind of marketing approach to disseminate helpful evidence-based information as some [drug] companies were using … to disseminate less helpful and occasionally distorted information.”

Recent lawsuits have alleged that drug companies pushed painkillers too aggressively, laying the groundwork for widespread opioid addiction.

Avorn noted that detailing has also been used to persuade doctors to cut back on unnecessary antibiotics and to discourage the use of expensive Alzheimer’s disease medications that have side effects.

Kaiser Permanente, a large medical system that operates in California, as well as seven other states and Washington, D.C., has used the approach to change the opioid-prescribing methods of its doctors since at least 2013. (Kaiser Health News is not affiliated with Kaiser Permanente.)

In California, detailing is just one of the ways in which state health officials are attempting to curtail opioid addiction. The state is also expanding access to medication-assisted addiction treatment under a different, $90 million grant through the federal 21st Century Cures Act.

The total budget for the detailing project in California is less than $2 million. The state’s Department of Public Health oversees it, but the money comes from the federal Centers for Disease Control and Prevention through a program called “Prevention for States,” which provides funding for 29 states to help combat prescription drug overdoses.

The California doctors and pharmacists who conduct the detailing conversations are focusing on their peers in the three counties hardest hit by opioid addiction: Lake, Shasta and Humboldt.

They arrive armed with binders full of facts and figures from the CDC to help inform their fellow providers about easing patients off prescription painkillers, treating addiction with medication and writing more prescriptions for naloxone, a drug that reverses the toxic effects of an overdose.

“Academic detailing is a sales pitch, an evidence-based … sales pitch,” said Dr. Phillip Coffin, director of substance-use research at San Francisco’s Department of Public Health — the agency hired by the state to train the detailers.

In an earlier effort, Coffin said, his department conducted detailing sessions with 40 San Francisco doctors, who have since increased their prescriptions of naloxone elevenfold.

“One-on-one time with the providers, even if it was just three or four minutes, was hugely beneficial,” Coffin said. He noted that the discussions usually focused on specific patients, which is “way more helpful” than talking generally about prescription practices.

Meengs and her fellow detailers hope to make a dent in the magnitude of addiction in sparsely populated Humboldt County, where the opioid death rate was the second-highest in California last year — almost five times the statewide average. Thirty-three people died of opioid overdoses in Humboldt last year.

One recent afternoon, Meengs paid a visit during the lunch hour to Fortuna Family Medical Group in Fortuna, a town of about 12,000 people in Humboldt County.

“Anybody here ever known somebody, a patient, who passed away from an overdose?” Meengs asked the group — a physician, two nurses and a physician assistant — who gathered around her in the waiting room, which they had temporarily closed to patients.

“I think we all do,” replied the physician, Dr. Ruben Brinckhaus.

Brinckhaus said about half the patients at the practice have a prescription for an opioid, anti-anxiety drug or other controlled substance. Some of them had been introduced to the drugs years ago by other prescribers.

Dr. Ruben Brinckhaus says his small family practice in Fortuna, Calif., has been trying to wean patients off opiates. (Pauline Bartolone/California Healthline)

Meengs’ main goal was to discuss ways in which the Fortuna group could wean its patients off opioids. But she was not there to scold or lecture them. She asked the providers what their challenges were, so she could help them overcome them.

Meengs will keep making office calls until August 2019 in the hope that changes in the prescribing behavior of doctors will eventually help tame the addiction crisis.

“It’s a big ship to turn around,” said Meengs. “It takes time.”

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

Vaccine Shortage Complicates Efforts To Quell Hepatitis A Outbreaks

November 14, 2017

San Diego County, battling a deadly outbreak of hepatitis A, is postponing an outreach campaign to provide the second of two inoculations against the contagious liver disease until a national shortage of the vaccine is resolved, the county’s chief public health officer said.

“Our goal is to get that vaccine in as many arms as possible for that first dose,” said Dr. Wilma Wooten, who is leading the fight against an epidemic that has ravaged unsanitary homeless encampments in San Diego County for the past year, sickening 544 people and killing 20 of them as of Nov. 6.

Nurses and other county medical workers are fanning out across the most at-risk areas to offer onsite inoculations, and if they run into people who are due for the second shot, they will still give it to them, said Wooten, Public Health Director at the county’s Health and Human Services Agency.

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

The two hepatitis A vaccinations, considered the best way to control the spread of the virus, should be administered six months apart. The first shot is the most important, Wooten said, because it protects people 90 to 95 percent of the time against the virus that causes the disease. The second shot raises the protection level to “close to 100 percent,” she said.

So far, 90,735 people have received vaccinations in San Diego County — most of them the first of the two-shot series, according to the county’s health agency.

The San Diego outbreak, and a number of others in California and across the United States, have generated a spike in demand for hepatitis A vaccine and put a squeeze on supplies, according to the federal Centers for Disease Control and Prevention. Unexpectedly high demand worldwide has constrained availability outside the U.S. as well, the agency said.

Merck & Co. and GlaxoSmithKline, the two companies with approval from the Food and Drug Administration to sell the vaccine in the United States, said they have been hard-pressed to keep up with the demand and are working to boost their production.

The effects of hepatitis A can range from mild to fatal. In addition to the deaths in San Diego, an outbreak of the illness in Michigan has sickened 486 people and killed 19, as of last Friday, according to the Michigan Department of Health & Human Services.

Los Angeles and Santa Cruz counties are also fighting the illness, and infections linked to California’s outbreaks are spreading to homeless people in Utah and Arizona, and to men engaging in gay sex in Colorado, the CDC said. In New York City, health officials are confronting a smaller outbreak, mostly among gay or bisexual men.

The deadly nature of the epidemics in San Diego and Michigan worries public health officials the most, said Dr. Noele Nelson, a CDC specialist in hepatitis vaccine research and policy. “The number of deaths in the Michigan and San Diego outbreaks are quite high from what we’ve seen in the past,” she told members of the CDC’s Advisory Committee on Immunization Practices at a late-October meeting in Atlanta.

Hepatitis A is typically spread through the ingestion of fecal matter from an infected person — even in microscopic amounts. That can happen when people carrying the virus fail to wash their hands after defecating and then contaminate objects, food or water used by others. It can also spread through sexual contact.

On Oct. 13, California Gov. Jerry Brown declared a state of emergency in an effort to increase the state’s supply of adult hepatitis A vaccine. The declaration allowed the state “to immediately purchase additional vaccines directly from manufacturers and coordinate distribution to people at greatest risk in affected areas,” the California Department of Public Health said.

Before Brown’s emergency declaration, the department had distributed nearly 80,000 doses of the vaccine obtained through a federal vaccine program, but those supplies were insufficient, it said.

Merck and GlaxoSmithKline sell the hepatitis A vaccine in pre-filled syringes and less costly single-dose vials.

Pamela Eisele, a Merck spokeswoman, said the unexpectedly sharp rise in demand for the vaccine has limited availability of the company’s vaccine this year.

Single-dose vials of the company’s VAQTA brand vaccine have been on backorder since May and weren’t available until last week, Eisele said. The company expects prefilled syringes to be unavailable until the first quarter of next year, she added.

Likewise, GlaxoSmithKline has been struggling to fill orders for its Havrix brand of the vaccine.

“It’s unprecedented, and it’s very large what’s happening,” said Robin Gaitens, a spokeswoman for the company. GlaxoSmithKline only recently received a shipment of prefilled syringes and has a “limited supply of vials in stock,” she said.

“We will continue to work with CDC, the California Department of Public Health, which is coordinating vaccine orders and distribution on behalf of the counties, and our private customers in California to help address the needs in the state,” Gaitens added.

San Diego County’s Wooten said that despite the supply constraints nationwide, the county now has enough vaccine on hand to give the first injection, but not the second, to those most at risk of contracting the virus — namely, the county’s homeless people, illicit drug users and the professionals who provide care to them.

The biggest challenge posed by the San Diego outbreak is getting the vaccines to people in the transient homeless population, Wooten said. To help address that, the county has hired about 100 temporary nurses to supplement the public health nursing staff, nurse volunteers from local hospitals, paramedics and homeless outreach workers who are on the front lines of the vaccination effort.

The city of San Diego has also been taking actions to curb the spread of the infection. In addition to spraying the streets in infected areas with a bleach solution, it has so far installed 78 hand-washing stations and 16 portable toilets for the homeless.

The city has also opened a public campsite with tents, sinks and restrooms for up to 200 people in a municipal operations yard downtown, said Katie Keach, spokeswoman for the city.

Amy Gonyeau, chief operating officer of the Alpha Project, a homeless outreach organization that is operating the campsite for the city, said 181 people, including 40 children, are living there so far.

Whether those efforts are making a dent in the spread of the hepatitis A infection isn’t yet known.

“San Diego has reported fewer cases per week over the past two weeks than it reported previously,” the CDC’s Nelson said at last month’s advisory committee meeting in Atlanta. “But it’s too early to say this indicates a downward trend in the overall outbreak.”

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

Charlan sobre posponer la maternidad mientras toman vino en “fiestas de óvulos”

November 13, 2017

Dos asistentes del Southern California Reproductive Center registran a los asistentes a una “reunión de óvulos” en la suite presidencial del Viceroy L’Ermitage en Beverly Hills, California. (Anna Gorman/KHN)

Dominika Martínez, de 35 años, quien decidió con su esposo congelar embriones después de casarse el año pasado, asistió a una “reunión de óvulos”. (Anna Gorman/KHN)

BEVERLY HILLS, California. – Tu abuela fue anfitriona de fiestas de Tupperware. Tu mamá asistió a las veladas de Mary Kay.

Use Nuestro Contenido

Este contenido puede usarse de manera gratuita (detalles).

Ahora, podrías estar bebiendo cócteles en una fiesta de congelamiento de huevos.
A juzgar por un reciente evento en un ostentoso hotel de Beverly Hills, la fertilidad femenina podría ser la próxima gran novedad en el campo del marketing directo.

Unas 20 mujeres, y algunos hombres, se reunieron recientemente en la suite presidencial del Virrey L’Ermitage en esta lujosa ciudad para conversar, beber vino y comer hors d’oeuvres mientras escuchaban sobre la posibilidad de congelar sus huevos para una futura concepción.

Algunas de las mujeres dijeron que no habían encontrado a la pareja perfecta y que querían mantener abiertas sus opciones de fertilidad. Otras dijeron que ahora estaban enfocadas en sus carreras y no querían comprometer sus posibilidades de tener una familia más tarde.

Todas estaban dispuestas a dejar de lado sus inhibiciones por una noche para aprender sobre un tema intensamente privado en un entorno inusual: un happy hour.
Frances Hagan, de 35 años, había escuchado sobre las “reuniones de óvulos” (egg social en inglés) de un amigo y estaba ansiosa por saber cómo funcionaba la congelación de huevos. Hagan, quien es abogada, dijo que es soltera y que todavía espera encontrar a alguien con quien pueda tener hijos en la forma tradicional. Pero agregó que no hace daño considerar congelar sus huevos como respaldo.

“Me gustaría esperar y ver qué pasa”, dijo Hagan. “Pero si espero demasiado, tal vez no suceda. Estoy tratando de ser proactiva”.

Probablemente no sea una coincidencia que el evento haya tenido lugar en un lugar como Beverly Hills, dado el gasto considerable que implica congelar óvulos para utilizarlos más tarde.

El congelamiento de óvulos cuesta entre $10,000 y $ 15,000 entre procedimiento y los medicamentos. Descongelar los óvulos, fertilizarlos y transferir un embrión al útero podría costar otros miles, más adelante. Algunos empleadores de Silicon Valley, incluidos Facebook y Apple, cubren el congelamiento de huevos para sus trabajadores, pero la mayoría de los empleadores y las aseguradoras no.

Email Sign-Up

Subscribe to KHN’s free Morning Briefing.

Sign Up Please confirm your email address below: Sign Up

En el pasado, se congelaban óvulos era principalmente en el caso de mujeres que corrían el riesgo de infertilidad debido a tratamientos contra el cáncer. Pero en los últimos años, más mujeres han optado por congelar sus óvulos por razones no médicas, como por ejemplo no estar listas para tener un bebé.

A medida que la práctica se generaliza, también lo hacen los eventos diseñados para dar a conocer y reclutar pacientes para las clínicas que realizan el procedimiento. En los últimos años, ciudades como Los Ángeles, Nueva York y San Francisco han sido las sedes de las fiestas de congelamiento de óvulos.

En el hotel Beverly Hills, los médicos del Centro Reproductivo del Sur de California, la clínica de fertilidad que patrocinó el evento, proyectaron diapositivas sobre una pared y explicaron la historia y la ciencia del congelamiento de óvulos. Les dijeron a los invitados que era una póliza de seguro para las mujeres que quieren hijos en el futuro.

“Es lo más inteligente que una mujer puede hacer si no está en una relación seria que la está llevando a tener hijos”, dijo Shahin Ghadir, especialista en fertilidad del centro.
Ghadir dijo que reunir mujeres en un ambiente informal hace que la idea sea menos intimidante y estigmatizante. “Les permite a las personas saber que no es un problema médico, es un problema social”, dijo.

Además, dijo Ghadir, “con un vaso de vino, todo suena mejor”.

El primer bebé creado a partir de un óvulo congelado nació hace unos 30 años, pero no fue sino hasta 2012 que la Sociedad Estadounidense de Medicina Reproductiva declaró que el congelamiento de óvulos ya no debería considerarse experimental. Eso abrió la puerta para que más mujeres congelaran sus óvulos, dijo Evelyn Mok-Lin, directora médica del Centro de Salud Reproductiva de UC-San Francisco.

UC-San Francisco comenzó a ofrecer congelamiento de óvulos “de manera electiva” poco después, y el número de mujeres que optaron por congelar sus huevos ha aumentado desde entonces, dijo Mok-Lin.

Más de 6,200 mujeres en Estados Unidos congelaron sus óvulos en 2015, frente a 475 en 2009, según la Society for Assisted Reproductive Technology. Y 155 nacimientos fueron el resultado de la fertilización de óvulos congelados en 2014, frente a 28 en 2009.

Congelar los óvulos les da a las mujeres control sobre su salud reproductiva y fertilidad, y los riesgos médicos son muy bajos, dijo Mok-Lin. Pero dado el alto costo, no todas pueden hacerlo, y no siempre funciona. “Es un lujo para muchas personas y sin ninguna garantía de que la inversión valdrá la pena”, dijo.

El proceso implica estimular la ovulación, extraer los óvulos y congelarlos.
Necka Taylor, una enfermera que asistió a la velada de Beverly Hills, dijo que su primer ciclo de fertilización in vitro no tuvo éxito, pero que espera volver a intentarlo. Taylor, de 32 años, dijo que tiene varios amigos que han tenido bebés y que ella también quiere tener hijos.

“Simplemente no sé cuándo va a suceder”, dijo. “Sabía que tenía que tomar medidas para tener un bebé saludable”.

Su amiga, Dominika Martínez, de 35 años, dijo que había considerado el congelamiento de óvulos en el pasado, pero que no fue hasta que se casó el año pasado que decidió con su esposo congelar embriones.

“Todavía no estoy donde quiero estar en mi carrera”, dijo Martínez, quien trabaja en marketing de redes sociales. “Siento que necesito un poco más de tiempo”.
Martínez dijo que cuando ella y su esposo estén listos, tratarán de concebir naturalmente. Pero si no funciona, dijo, “tenemos un plan de respaldo”.

Ghadir, del Centro Reproductivo del Sur de California, le dijo al grupo que tenía hijos y que no había anticipado el gasto, el tiempo y la energía de la crianza de los hijos. Los óvulos congelados pueden ayudar a las mujeres a tener hijos a su propio ritmo, dijo.
“Si estuviera haciendo esto en el momento equivocado de mi vida, hubiera sido un desastre”, dijo. “Hacer las cosas en el momento correcto, cuando sabes que estás listo… es una de las razones más importantes para congelar tus óvulos”.

La cobertura de KHN en California está financiada en parte por Blue Shield of California Foundation. La cobertura de los problemas de salud de las mujeres es apoyada en parte por The David and Lucile Packard Foundation.

Sip Wine And Chat About Postponing Motherhood — At An ‘Egg Social’

November 13, 2017

Two Southern California Reproductive Center employees register attendees of an “egg social” at the presidential suite of the Viceroy L’Ermitage in Beverly Hills, Calif. (Anna Gorman/KHN)

Dominika Martinez, 35, who decided to freeze embryos with her husband after getting married last year, attends an “egg social.” (Anna Gorman/KHN)

This story also ran on USA Today. This story can be republished for free ( details ). BEVERLY HILLS, Calif. — Your grandma hosted Tupperware parties. Your mom attended Mary Kay soirees.

Now, you might be sipping cocktails at an egg-freezing fête.

Judging from a recent event at a swanky Beverly Hills hotel, female fertility could be the next big thing in direct marketing.

About 20 women — and a few men — gathered recently in the presidential suite of the Viceroy L’Ermitage in this famously upscale city to chat, drink wine and eat hors d’oeuvres while hearing about the possibility of freezing their eggs for future conception.

Some of the women said they hadn’t found the perfect partner and wanted to keep their fertility options open. Others said they were focused on their careers now and didn’t want to compromise their chances of having a family later.

All were willing to put aside their inhibitions for one evening to learn about an intensely private subject in an unusual setting: a cocktail party.

Frances Hagan, 35, had heard about the “egg social” from a friend and was eager to find out how egg freezing worked. Hagan, a lawyer, said she is single and still hopes to find someone with whom she can have children the old-fashioned way. But she said it doesn’t hurt to consider freezing her eggs as a backup.

“I’d like to wait and just see what happens,” Hagan said. “But if I wait too long, maybe it won’t happen. I’m trying to be proactive.”

It is probably no coincidence that the event was held in a place like Beverly Hills, given the considerable expense of freezing eggs — and of using them later.

Egg freezing costs between $10,000 and $15,000 for the procedure and the medications. Thawing the eggs and fertilizing and transferring an embryo could cost thousands more later on. A few Silicon Valley employers, including Facebook and Apple, cover egg freezing for their workers, but most employers and insurers do not.

In the past, egg freezing was primarily for women who risked infertility because of cancer treatments. But in recent years, more women have been choosing to freeze their eggs for non-medical reasons — such as not being ready to have a baby.

As the practice becomes more widespread, so do events designed to raise awareness of it and recruit patients for clinics that perform the procedure. In recent years, cities such as Los Angeles, New York and San Francisco have been the venues of egg-freezing parties.

At the Beverly Hills hotel, physicians from the Southern California Reproductive Center, the fertility clinic that sponsored the event, projected slides on a wall and explained the history and science of egg freezing. They told the guests that it was an insurance policy for women who want children in the future.

“It’s the smartest thing any woman can do if they are not in a serious relationship that is leading to children,” said Shahin Ghadir, a fertility specialist at the practice.

Ghadir said hosting women in a casual environment makes the idea less intimidating and stigmatizing. “It lets people know it’s not a medical issue — it’s a social issue,” he said.

Besides, Ghadir said, “with a glass of wine, everything sounds better.”

The first baby created from a frozen egg was born about 30 years ago, but it wasn’t until 2012 that the American Society for Reproductive Medicine declared that egg freezing should no longer be considered experimental. That opened the door for more women to freeze their eggs, said Evelyn Mok-Lin, medical director of the UC-San Francisco Center for Reproductive Health.

UC-San Francisco started offering “elective” egg freezing soon afterward, and the number of women opting to freeze their eggs has since risen sharply, Mok-Lin said.

More than 6,200 women in the U.S. froze their eggs in 2015, up from 475 in 2009, according to the Society for Assisted Reproductive Technology. And 155 births resulted from the fertilization of women’s frozen eggs in 2014, up from 28 in 2009.

Egg freezing gives women control over their reproductive health and fertility, and the medical risks are very low, said Mok-Lin. But given the high cost, not everyone can afford egg freezing, and it doesn’t always work. “It is a luxury for many people and without any guarantee in the end that the investment will pay off,” she said.

The process involves stimulating the ovaries, extracting the eggs and flash-freezing them.

Necka Taylor, a nurse who attended the Beverly Hills soiree, said her first cycle of in vitro fertilization was unsuccessful, but she’s hoping to try again. Taylor, 32, said she has several friends who have had babies, and she knows she wants children herself.

“I just don’t know when it’s going to happen,” she said. “I knew I needed to take steps to have a healthy baby.”

Her friend Dominika Martinez, 35, said she had considered egg freezing in the past but it wasn’t until she got married last year that she decided to freeze embryos with her husband.

“I am still not where I want to be in my career,” said Martinez, a social media marketer. “I feel like I need a little more time.”

Martinez said that when she and her husband are ready, they will try to conceive naturally. But if it doesn’t work, she said, “we have a backup plan.”

Ghadir, of the Southern California Reproductive Center, told the group that he had children and had not anticipated the expense, time and energy of parenting. Freezing eggs can help women have children on their own timeline, he said.

“If I was doing this at the wrong time in my life, it would have been a disaster,” he said. “Doing things at the right time, when you know you are ready … is one of the most important reasons to freeze your eggs.”

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

Grass-Roots Network Of Doctors Delivers Supplies To Puerto Rico

November 09, 2017

After Hurricane Harvey flooded her city of Houston in August, Dr. Jennifer McQuade planned to donate socks to those affected. Instead, surprised by the lack of medical care at a nearby shelter, McQuade, an oncologist, became the unofficial leader of a group of physicians and mothers providing emergency aid at the George R. Brown Convention Center in Houston. She triaged patients, solicited donations and recruited more doctors to join.

Their efforts were so successful that McQuade and the other volunteers still had 2,500 pounds of medical supplies when federal authorities took over the Houston shelter after about a week. So, when Hurricane Maria devastated Puerto Rico on Sept. 20, leaving hospitals without power and short of supplies and drugs, the challenge was finding a plane to deliver the precious cargo to the island.

“Asking for planes, it’s a crazy ask,” said Dr. Ashley Saucier, a pediatric emergency physician in Baton Rouge, La., who was working with McQuade on the effort in Houston. But that didn’t stop her.

This KHN story also ran on It can be republished for free (details).

Across the United States mainland, an agile, jury-rigged network of doctors has scrambled to deliver aid to their counterparts in Puerto Rico, often reaching clinics before federal assistance arrived. They draw on a sense of solidarity in the medical community, connections formed through the hurricanes in Houston and Florida — and the use of private jets belonging to corporations, sports teams and individual donors.

By mid-October, doctors in the states estimate, they delivered 40 tons of supplies.

Saucier, working through a Facebook introduction, got in touch with the Cajun Airlift, a loosely organized group of Louisiana pilots who had volunteered their planes for Texas flood victims. They moved some of the supplies.

Rick Shadyac, the CEO of St. Jude’s Hospital in Memphis, Tenn., put Saucier in touch with FedEx, which is also headquartered in Memphis, to pick up more surplus supplies from McQuade in Houston and then fly them to Puerto Rico.

And through another doctor, McQuade was introduced to Hilda and Greg Curran, a couple who have family in Puerto Rico and a jet they planned to use.

Five days after Maria made landfall, the Currans delivered 1,000 pounds of medical supplies — additional donations supplied by the Texas Children’s Hospital or purchased through funds raised by Saucier — to the University of Puerto Rico Comprehensive Cancer Center in San Juan.

Hospitals on Puerto Rico remain without electricity, forced to rely on generators. Clinics were left in shambles in many parts of the island, desperate for supplies and drugs, including tetanus and influenza vaccines, antibiotics, insulin and anti-inflammatory drugs.

Many of the physicians organizing the donation drive have family in Puerto Rico, while others — including Saucier and McQuade — had no previous connections to the U.S. territory.

Saucier’s experience with front-line disaster relief dates to August 2016, when southern Louisiana was hit with deadly floods. Shortly after, she formed a small nonprofit called Baton Rouge Emergency Aid Coalition, which raised funds and organized physicians who were ready to spring into action. When Puerto Rico was devastated by Hurricane Maria, that small network joined something much bigger, which grew organically and by word-of-mouth as the scope of the medical disaster on the island unfolded.

The grass-roots network tends to skew younger and female. “It’s 90 to 95 percent women I’m working with, both here and in Puerto Rico,” said Rafael Enrique Guerrero-Preston, a cancer researcher and geneticist in Baltimore, who was born in Puerto Rico. He “met” McQuade and Saucier online on the recommendation of another physician.

“We don’t know each other personally,” he said.

Dr. Dalian Caraballo, a family physician in Miami, was organizing a separate donation campaign and Facebook page for Puerto Rican doctors when one contact introduced her to the volunteers in Texas and Louisiana. Because she lives in a city that is a convenient pit stop for pilots to fuel up, Caraballo has taken charge of collecting supplies and loading them onto jets before they travel to Puerto Rico.

The planes typically fit 1,000 pounds at most, so only supplies that a doctor in Puerto Rico specifically requests will go onboard. Every box is weighed, labeled and accompanied by a “manifesto,” or instructions of who it goes to next. “Even if [the shipment] is small, you know it’s getting to the right doctors,” Caraballo said.

Doctors help for personal reasons and in ways that tie in to their specialties. Dr. Amarilis Sanchez-Valle, a physician in Tampa, studies metabolic genetic conditions that require a specialized formula for infants to avoid brain damage and other health effects.

Initially, her concern was for her family. “I have a sister in Puerto Rico with multiple sclerosis [who] has only two doses left of her medicine,” she wrote in emails to the American Red Cross and the National MS Society on Sept. 25, five days after Maria made landfall. “Is there a way to get medicine to Puerto Rico in the next few days?”

Representatives from both groups apologized, saying they couldn’t help because all the official channels for delivery had been disrupted.

Sanchez-Valle contacted neurologists in Tampa to get a few samples of the medicine. “The problem was, how to get it there? The airport was closed. FedEx was closed.”

A friend put her in touch with a person who works for American Airlines. The airline employee agreed to put the medication in the cargo hold of a relief flight. Sanchez-Valle said her sister is “lucky she’s got me. But what about all the other patients out there? What about my [infant] patient population?” she asked.

Sanchez-Valle contacted former colleagues in Puerto Rico and the formula suppliers she works with. Several companies agreed to donate a few hundred pounds of formula.

The formula reached the island thanks to Dr. Elimarys Perez-Colon and her colleague Dr. Asa Oxner, two internal medicine specialists in Tampa. The women took a commercial flight to San Juan in the beginning of October, each carrying five suitcases with 800 pounds of supplies, everything from syringes to water filters to donations they received from manufacturers and doctors like Sanchez-Valle. When they arrived in San Juan, the airport appeared to be almost fully functional. And the capital and other coastal towns seemed to be receiving adequate help from the Federal Emergency Management Agency and the military, the women say.

Dr. Asa Oxner, an internal medicine physician in Tampa, Fla., uses a headlamp to count pills while working in an area of Puerto Rico without power. (Courtesy of Dr. Asa Oxner)

But as they traveled to inland towns like Villalba, where they delivered supplies, they found incredible needs.

The hospitals and clinics they reached were running on diesel generators. Asthma medication was in short supply, Perez-Colon noted. People in small towns were drinking untreated water, a major risk for infection. “Clean water is one of the biggest issues,” she said.

For some residents who already had health problems, their conditions worsened in the heat, with no power and limited access to water. Some reported being visited by FEMA once; others, not at all.

“The help is not getting to the small towns. It’s not getting to the middle of the island,” Perez-Colon said.

Hospice Workers Who Care For The Dying Don’t Plan Ahead Themselves

November 07, 2017

Hospice workers may witness terminal illness and death almost daily, but that doesn’t mean they’ve documented their own end-of-life wishes, a new report finds.

A survey of nearly 900 health care workers at a nonprofit Florida hospice found that fewer than half — just 44 percent — had completed advance directives. Of the rest, 52 percent said they had not filled out the forms that specify choices about medical care. Nearly 4 percent said they weren’t sure if they had or not.

That surprised Dr. George Luck, a palliative medicine expert at the Charles E. Schmidt College of Medicine at Florida Atlantic University, who led the research.

Although the proportion is higher than the roughly one-third of Americans overall who have advance directives in place, Luck expected more from those who work with the dying.

“I expected people who work in a hospice setting, who see what happens when someone doesn’t have an advance directive, how that can be a struggle for the family, a bigger burden,” to be better prepared, said Luck. The report was published last month in the American Journal of Medicine.

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

Equally surprising was that about 10 percent of hospice workers without directives said they didn’t know where to obtain the forms — which are widely available online. Another nearly 6 percent said cost was a barrier, even though the documents can be completed for free, without an attorney’s help.

“I don’t expect everybody to have an advance directive, but at least know the basics,” Luck said. “Basically, you could write it on a napkin if you wanted to.”

About 7 percent of workers said fear of the subject kept them from completing directives, he said.

Luck and his colleagues sent surveys last year to nearly 2,100 workers at Trustbridge, a hospice in Boca Raton, Fla., that serves about 2,000 patients. The 890 people who responded included doctors, nurses, clergy, office staff, volunteers and others.

Whether they had completed advance directives varied by ethnicity and age. Nearly 60 percent of white employees had filled out the documents, compared with about 30 percent of Hispanics, 22 percent of African-Americans and 14 percent of Asians, the study showed.

Doctors and volunteers were most likely to have advance directives, with almost 60 percent saying they had documents in place, compared with about 20 percent of certified nursing assistants.

That was probably related to age, Luck said. Doctors and volunteers tended to be older than the CNAs. Nearly 80 percent of workers older than 65 had filled out the forms, compared with about 25 percent of those 40 and younger.

It didn’t appear to matter whether workers cared directly for dying patients. About 46 percent of those who spent more than 75 percent of their time in hands-on care had directives, about the same as those with no patient interaction.

Although the proportion of Americans overall who put their wishes in writing is low, it’s getting better. In 1990, just 16 percent of those who responded to a Pew Research Center study had completed directives. By 2013, that figure rose to 35 percent.

Still, the new report underscores the reluctance of many people to address their own mortality, said Jon Radulovic, a spokesman for the National Hospice and Palliative Care Organization (NHPCO).

“It’s a reminder that hospice professionals, despite the fact that they deal with death and dying among the patients and families they care for, are still people who don’t really think their deaths might be imminent,” Radulovic said in an email.

Anyone can fill out an advance directive, said Luck. Once completed, the forms can be shared with caregivers and kept with important documents. An NHPCO program called, offers free, state-specific advance directive forms, plus a guide for having end-of-life conversations.

Better education is the key, Luck said. And it’s possible that hospice workers may just need a nudge. After the Florida staff members took his survey, 43 percent of those without documents said they intended to fill out the forms.

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation and its coverage related to aging; improving care of older adults is supported by The John A. Hartford Foundation.

Liquid Gold: Pain Doctors Soak Up Profits By Screening Urine For Drugs

November 06, 2017

The cups of urine travel by express mail to the Comprehensive Pain Specialists lab in an industrial park in Brentwood, Tenn., not far from Nashville. Most days bring more than 700 of the little sealed cups from clinics across 10 states, wrapped in red-tagged waste bags. The network treats about 48,000 people each month, and many will be tested for drugs.

Gloved lab techs keep busy inside the cavernous facility, piping smaller urine samples into tubes. First there are tests to detect opiates that patients have been prescribed by CPS doctors. A second set identifies a wide range of drugs, both legal and illegal, in the urine. The doctors’ orders are displayed on computer screens and tracked by electronic medical records. Test results go back to the clinics in four to five days. The urine ends up stored for a month inside a massive walk-in refrigerator.

The high-tech testing lab’s raw material has become liquid gold for the doctors who own Comprehensive Pain Specialists. This testing process, driven by the nation’s epidemic of painkiller addiction, generates profits across the doctor-owned network of 54 clinics, the largest pain-treatment practice in the Southeast. Medicare paid the company at least $11 million for urine and related tests in 2014, when five of its professionals stood among the nation’s top billers. One nurse practitioner at the company’s clinic in Cleveland, Tenn., single-handedly generated $1.1 million in Medicare billings for urine tests that year, according to Medicare records.

Dr. Peter Kroll, one of the founders of CPS and its medical director, billed Medicare $1.8 million for these drug tests in 2015. He said the costly tests are medically justified to monitor patients on pain pills against risks of addiction or even selling of pills on the black market. “I have to know the medicine is safe and you’re taking it,” Kroll, 46, said in an interview. Kroll said that several states in which CPS is active have high rates of opioid use, which requires more urine testing.

A sign hangs in the lobby of the Comprehensive Pain Specialists clinic in Hendersonville, Tenn., advising patients about urine drug screening. (Heidi de Marco/KHN)

Urine drug testing has become particularly lucrative for doctors who operate their own labs. (Heidi de Marco/KHN)

Kaiser Health News, with assistance from researchers at the Mayo Clinic, analyzed available billing data from Medicare and private insurance billing nationwide, and found that spending on urine screens and related genetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year — more than the entire budget of the Environmental Protection Agency. The federal government paid providers more to conduct urine drug tests in 2014 than it spent on the four most recommended cancer screenings combined.

Yet there are virtually no national standards regarding who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to detect drugs that presented minimal abuse danger for most patients, according to arguments made by government lawyers in court cases that challenge the standing orders to test patients for drugs. Payments have surged for urine tests for street drugs such as cocaine, PCP and ecstasy, which seldom have been detected in tests done on pain patients. In fact, court records show some of those tests showed up positive just 1 percent of the time.

This KHN story also ran on Bloomberg. It can be republished for free.

Urine testing has become particularly lucrative for doctors who operate their own labs. In 2014 and 2015, Medicare paid $1 million or more for drug-related tests billed by health professionals at more than 50 pain management practices across the U.S. At a dozen practices, Medicare billings were twice that high.

Thirty-one pain practitioners received 80 percent or more of their Medicare income just from urine testing, which a federal official called a “red flag” that may signal overuse and could lead to a federal investigation.

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

‘It Was Almost A License To Steal’

As alarm spread about opioid deaths and overdoses in the past decade, doctors who prescribed the pills were looking for ways to prevent abuse and avert liability. Entrepreneurs saw a lucrative business model: persuade doctors that testing would keep them out of trouble with licensing boards or law enforcement and protect their patients from harm. Some companies offered doctors technical help opening up their own labs.

A 2011 whistleblower lawsuit against one of the nation’s top billers for urine tests, a San Diego-based laboratory owned by Millennium Health LLC, underscores the potential for profit. “Doctor,” one lab representative said during sales calls, according to an affidavit, “drug testing is not about medicine but about making money, and I am going to show you how to make a lot of money.”

Millennium Health, billing records show, took in more than $166 million from Medicare in 2014 despite being the target of at least eight whistleblower cases alleging fraud over the past decade. A Millennium sales manager involved in a 2012 case in Massachusetts reported earning $700,000 in salary and sales commissions in the previous year.

Millennium encouraged doctors to order more tests both as a way to lower patients’ risks and to shield the physicians against possible investigations by law enforcement or medical licensing boards, according to court filings. Millennium denied the allegations in the whistleblower suits and settled all of them with the Justice Department in 2015 by agreeing to pay $256 million; its parent company, Millennium Lab Holdings II, declared bankruptcy.

(Garth Superville for KHN)

Tests to detect drugs in urine can be basic and cheap. Doctors have long used testing cups with strips that change color when drugs are present. The cups cost less than $10 each, and a strip can detect 10 types of drugs or more at once and display the results in minutes.

After noticing that some labs were levying huge charges for these simple urine screens, the Centers for Medicare & Medicaid Services moved in April 2010 to limit these billings. To circumvent the new rules, some doctors scrapped cup testing in favor of specialized — and much costlier — tests performed on machines they installed in their facilities. These machines had one major advantage over the cups: Each test for each drug could be billed individually under Medicare rules.

“It was almost a license to steal. You had such a lucrative possibility, it was very tempting to sell as many [tests] as you can,” said Charles Root, a longtime lab industry consultant whose company, CodeMap, has tracked the rise of testing labs in doctors’ offices.

Voluminous Drug Tests 

The CPS testing lab in Tennessee opened in 2013, not long before a pain specialist named William Wagner moved from New Mexico to open a CPS clinic in Anderson, S.C. He was lured by the promise of $30,000 a month in salary, which would grow as the clinic added patients and revenue, along with other benefits. His contract said he could be on-site for as little as 20 percent of the clinic’s operating hours.

A sign for responsible opioid treatment is displayed in an exam room of the Comprehensive Pain Specialists clinic in Hendersonville, Tenn. (Heidi de Marco/KHN)

When the company recruited him, Wagner said, he was told the job offered “potential to earn a great deal of money” from bonuses he would receive from services he generated, including a share of collections from lab services for urine tests done at the new Tennessee facility.

That did not happen, according to Wagner. He is suing CPS, saying that it failed to collect bills for services he rendered and then closed the clinic. CPS refutes Wagner’s claims and says it fulfilled its obligations under the contract. In a counterclaim, CPS argues that Wagner owes it $190,000.

“All of their money was being made off of urine drug screens. They weren’t doing anything else properly,” Wagner said. The lawsuit is pending in federal court in Nashville.

Former CPS chief executive John Davis, in an interview, described the urine-testing lab as part of a “strategic expansion initiative” in which the company invested $6 million to $10 million in computerized equipment and swiftly acquired new clinics. Kroll, one of the owners of CPS, said the idea was to “take the company to the next level.”

Davis, who led the initiative before leaving the company in June, would not discuss the private company’s finances other than to say CPS is profitable and that lab profits “to a great degree” drove the expansion. “Urine screening isn’t the reason why we decided to grow our company. We wanted to help people in need,” Davis said.

Kroll acknowledged that urine tests are profit-makers, but stressed that verifying that patients aren’t abusing drugs gives him a “whole different level of confidence that I’m doing something right for the patients’ condition.”

He said his doctors try to be “judicious” in ordering urine tests. Kroll said some of his doctors and nurses treat “high-risk” patients who require more frequent testing. The company said that its Medicare billing practices, including urine screens, had withstood a “very in-depth” government audit.  The audit initially called for repayment of $25 million but was settled in 2016 for less than $7,000, according to the company. Medicare officials had no comment.

Kroll’s orthopedic career took a sharp turn more than a decade ago after watching his brother suffer through multiple surgeries for muscular dystrophy, along with bone fractures, stiffness and pain. His brother died at age 25, and Kroll decided to switch to anesthesiology and become a pain specialist.

“It sensitized me to the plight of people with chronic conditions that we have no medical answer for,” Kroll said. His brother “battled for his whole life.”

Kroll’s career change coincided with a national movement to establish pain management as a vital medical specialty, with its own accrediting societies and lobbying and political arm to advance its interests and those of patients.

Joined by three other doctors, he formed Comprehensive Pain Specialists at a storefront in suburban Hendersonville, Tenn. It quickly gained a foothold on referrals from local doctors unsure, or uneasy, about treating unyielding pain with heavy narcotics such as oxycodone, morphine and methadone.

In 2014, when CPS was among Medicare’s major urine-test billers, Tennessee led the nation in Medicare spending on urine drug tests run by doctors with in-house labs, according to federal billing records.

A urine specimen is prepared for shipment to the CPS lab to be tested. (Heidi de Marco/KHN)

How Much Is Too Much?

There is wide disagreement among legislators, medical trade associations and the state boards that license doctors over the best approach to urine testing. One association of pain specialists argued in 2008 that urine testing could be done as often as weekly, while others have balked at that frequency.

Indiana’s medical board ordered mandatory urine tests for all pain patients in late 2013, only to face a lawsuit from the American Civil Liberties Union, which argued that the policy was unconstitutional and an unlawful search. Officials backed down the next year, and current policy states that testing can be done “at any time the physician determines that it is medically necessary.”

The federal Centers for Disease Control and Prevention, wary of both cost and privacy concerns, declined to set a definitive national standard despite years of debate. In long-awaited guidelines issued in March 2016, the CDC called for testing at the start of opioid therapy and once a year for long-term users. Beyond that, it said, testing should be “left up to the discretion” of the medical professional.

Doctors who receive the lion’s share of their Medicare funds from urine drug testing would certainly raise a red flag.

Donald White, spokesman for the Department of Health and Human Services’ Office of the Inspector General

There is likewise little scientific justification for many of these new types of drug testing that have made their way onto doctors’ order sheets and laboratory menus.

Many pain patients on opioids are routinely tested for phencyclidine, an illegal, hallucinogenic drug also known as PCP, or angel dust, Medicare records show. Yet urine tests have rarely detected the drug. Millennium, the San Diego-based company that once topped Medicare billings for urine tests, found PCP in fewer than 1 percent of all patient samples, according to federal court filings.

In a tour of the CPS lab, Chief Operations Officer Jeff Hurst, who has more than two decades of experience working for commercial labs, rattled off a list of drugs ranging from cocaine to heroin and methamphetamine, which he said was “really big in East Tennessee.”

How often urine tests reveal serious drug abuse — or suggest patients might be selling some of their medications instead of taking them — is tough to pin down. Asked during a tour of the laboratory in Tennessee if CPS could provide such data, Hurst said he did not have it; Kroll said he didn’t either.

Hurst said the lab often ends up doing a “long list of tests” because CPS doctors are prescribing dangerous drugs that may be deadly if abused and “need to know what patients are taking.” Prescribed drugs, such as opiates and tranquilizers, are also measured at the CPS lab.

Government officials have criticized the explosive growth in testing for some prescription drugs, notably a class of tranquilizers known as tricyclic antidepressants. Medicare paid more than $45 million in 2014 for more than 200,000 people to be tested for tricyclic drugs, often multiple times. Medicare was billed for 644,495 tests for one tricyclic drug, amitriptyline, up from 6,173 tests five years earlier.

The Department of Justice argued in a 2012 whistleblower case that these tests often couldn’t be justified because of “low abuse potential” of the drugs and a “lack of abuse history for the vast majority of patients.”

Income Breakdown Raises ‘Red Flag’

When told that drug screens accounted for most of the Medicare income for dozens of pain doctors, federal officials said that was troubling.

“Doctors who receive the lion’s share of their Medicare funds from urine drug testing would certainly raise a red flag,” said Donald White, a spokesman for the Department of Health and Human Services’ Office of the Inspector General. “Confirmation of fraud would require federal investigation and a formal judicial proceeding.”

In a report released last fall, the watchdog office said some uptick in testing might be justified by the drug abuse epidemic, but noted that the situation also “could provide cover for labs that might seek to fraudulently bill Medicare for unnecessary drug testing.”

(Heidi de Marco/KHN)

Medicare pays only for services it considers “medically necessary.” While that sometimes can be a judgment call, pain clinics that adopt a “one-size-fits-all” approach to urine testing may find themselves under suspicion, said Mehta, the assistant U.S. attorney in Florida.

Mehta’s office investigated a network of Florida clinics called Coastal Spine & Pain Center for alleged over-testing, including routinely billing for a second round of expensive tests simply to confirm earlier findings. In a press release in August 2016, the government argued that these tests were “medically unnecessary.” The company paid $7.4 million last year to settle the False Claims Act case. Coastal Spine & Pain, which did not admit fault, had no comment.

Four Coastal Spine & Pain doctors were among the top 50 Medicare billers during 2014, when they charged nearly $6 million for drug tests, according to Medicare billing data analyzed by KHN.

Starting in 2016, Medicare began to crack down on urine billings as part of a federal law that is supposed to reset lab fees for the first time in three decades. Now tougher scrutiny of urine testing, and cuts in reimbursements, may be threatening CPS — or at least its profits.

CPS closed nine clinics last year and told its doctors that urine-testing revenue had dropped off 32 percent in the first quarter of the year, according to a letter then-CEO Davis sent its physician partners.

Davis said the company had to “make some changes” because of cuts in Medicare reimbursements for urine tests and other medical services. A company spokeswoman told KHN that the drop in urine revenue worsened through 2016 but has bounced back somewhat this year.

Despite the cuts, privately held CPS plans to open new clinics this year. Urine testing will remain a key service — for keeping patients safe, it said. CPS is just playing by the rules of the game. “Tell us how often to test,” said Hurst, the operations officer, “and we’ll be happy to follow it.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

‘Liquid Gold’ Investigation: Sifting Through The Data

Kaiser Health News relied on payment data from Medicare’s fee-for-service program, available from the Centers for Medicare & Medicaid Services to analyze the prevalence and cost of urine drug testing and related genetic testing. Doctors and laboratories bill Medicare using standard codes. KHN consulted with several billing experts in the field and used government documents to identify relevant billing codes for this analysis.

Medicare reimburses providers for each code they bill based on a standard amount that allows for some geographic variation. Each code represents a type of test, and multiple tests can be done on a single urine sample; therefore, the amount that providers bill for a single sample of urine varies greatly.

Medicare’s Part B payment data is publicly available only for the years 2012 through 2015. KHN acquired historical data from the consulting firm CodeMap going back to 2005 to analyze trends in billing.

KHN also teamed up with researchers at the Mayo Clinic to analyze claims data for private insurers and Medicare Advantage to estimate the total cost per year, which in 2014 was roughly $8.5 billion for private plus government payers. Mayo Clinic researchers accessed data from the OptumLabs Data Warehouse, which includes health insurance claims that cover about 20 million patients per year. The analysis included claims from physicians and independent labs, and excluded any facility (hospital or outpatient) fees. To estimate the yearly cost, KHN took the total cost per enrollee from the Mayo Clinic data analysis and applied it to the estimated populations for both private insurance (from the Current Population Survey) and Medicare Advantage (from CMS’ Beneficiary Public Use File). This is a rough estimate because the OptumLabs claims might not reflect some variations in medical care costs and health conditions across the country.