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Age-Old Health Care Debate Shifts From Insuring More People To Cutting Costs

In a new article in the BMJ journal, Julie Rovner, chief Washington correspondent for Kaiser Health News, examines the debate over the future of the U.S. health insurance system — a debate that has waxed and waned for the better part of a century. While political parties once argued over whether the government should make sure all residents have coverage, the discussion is changing. As the cost of medical services continues to grow faster than most Americans’ incomes, even people with private insurance coverage — which comes with ever-increasing expenses in the form of deductibles and copayments — are finding the cost of care becoming unaffordable. That’s true for Medicare as well. Read the article here.

Taking The Cops Out Of Mental Health-Related 911 Rescues

Kaiser Health News:States - October 11, 2019

DENVER — Every day that Janet van der Laak drives between car dealerships in her sales job, she keeps size 12 shoes, some clothes and a packed lunch — a PB&J sandwich, fruit and a granola bar — beside her in case she sees her 27-year-old son on the streets.

“’Jito, come home,” she always tells him, using a Spanish endearment. There he can have a bed and food, but her son, Matt Vinnola, rarely returns home. If he does, it is temporary. The streets are easier for him. Home can be too peaceful.

But the same streets that give Vinnola comfort are also unsafe for a man battling dual demons of drug use and chronic paranoid schizophrenia.

Police and criminal courts often intervene before Vinnola gets treatment or care. Since his first diagnosis of severe mental illness in 2014, Vinnola has collected a litany of charges from misdemeanors to felony trespassing and drug offenses. Over the past four years, Vinnola has been charged in four separate Colorado courts and arrested multiple times almost every month either for new offenses or on warrants for failing to appear in court.

But soon, he might encounter mental health professionals on the street instead of cops. Denver is one of at least eight cities considering an Oregon program called Crisis Assistance Helping Out On The Streets to decriminalize and improve the treatment of people with severe mental illness — while saving the city money. The 30-year-old CAHOOTS program diverts nonviolent, often mental health-related 911 calls to a medic and a mental health professional instead of law enforcement.

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Denver police and community service providers visited Eugene, Ore., in May to shadow CAHOOTS teams. Denver police officials said they are considering the model as an option to push beyond their existing co-responder program that sends mental health professionals on about six 911 calls a day.

Over 8 million people struggle with schizophrenia or bipolar disorder in America, and an estimated 40% of people diagnosed with schizophrenia go untreated, according to the Treatment Advocacy Center, a nonprofit focused on mental health. Individuals with those illnesses often lose the ability to realize their deficits, creating a roadblock in accessing care and attending medical or court appointments.

Low-level offenses can land those with paranoia, hallucinations or a reduced ability to communicate, like Vinnola, in the criminal justice system. An estimated 383,000 people with severe mental illness are behind bars nationwide, according to the Treatment Advocacy Center, while only a tenth of that number are in state hospitals.

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The Push To Rethink Safety

Since the 2018 publication of a Wall Street Journal article about CAHOOTS, calls have poured into its organizers from officials in Los Angeles; Oakland, Calif.; New York; Vancouver, Wash.; and Portland, Ore., among others.

The Eugene CAHOOTS team shows up in work boots, jeans and T-shirts — and without police officers — in response to 911 calls diverted to the program.

“That difference in uniforms can assist folks with letting their guard down and being open to accepting the help that is being offered,” said Tim Black, the Eugene CAHOOTS’ operations coordinator.

For people with a history of volatile arrests often while in mental health crisis, this could make treatment more accessible, less traumatic and safer. One in 4 deaths from police shootings represent people with mental illness, according to the Treatment Advocacy Center.

Vinnie Cervantes, the organizing director for Denver Alliance for Street Health Response, believes using medics and mental health professionals as response teams means treating people with dignity.

“There are plenty of fantastic officers, as people, but they have their roles enforcing a system that has been violent, that has been racist, that has been dehumanizing,” Cervantes said.

Van der Laak said she thinks her son would be more willing to accept treatment if police were not part of the intervention in his mental health crises. She worries that his delayed responses to commands and difficulty answering cops will be perceived as defiance and escalate into an arrest — or worse.

Giving Voice To Her Son

After van der Laak’s son was diagnosed with paranoid schizophrenia in 2014, her everyday gaze shifted from the city skyscrapers and Colorado blue sky to the people living on Denver’s streets. It’s hard for her to pretend they don’t exist. That would mean her son doesn’t exist.

She doesn’t understand how people do it — walk by her son as if he’s just a tree, or nothing, even when his bare feet are bloody, his clothes torn and his face visibly dehydrated, all visible signs of Vinnola fighting his internal battle with schizophrenia.

“His brain just doesn’t work like yours and mine,” she said.

Janet van der Laak walks on Federal Boulevard in Denver looking for her son, Matt Vinnola, on July 19, 2019. Van der Laak tries to make contact with business owners and employees along this stretch of road, giving them her phone number to call instead of the police if they see her son.(LJ Dawson for KHN)

Vinnola’s mother said her son is not a danger to anyone other than himself, but many people associate mental illness with violence. People with severe mental illness are more than 10 times more likely to be victims of a violent crime than the general population, according to the U.S. Department of Health and Human Services.

Vinnola agreed to be interviewed for this article but was unable to answer questions for more than a few minutes. His answers were fragmented and short. He struggled to understand the questions. Van der Laak said he answers the same way in the courtroom.

Van der Laak is outspoken for her son, calling herself his advocate and voice. She attends his court dates, toting legal and medical paperwork in a thick manila folder. He might not attend, but she won’t miss a chance to speak up against a justice system she sees as incapable of being responsible for her son’s treatment.

“It’s critical that I’m there. Because if I am not, they will railroad him and he will end up in jail for long periods of time,” she said. “And that’s not where he needs to be.”

Dr. Sasha Rai, director of behavioral health at the Denver County Jail, said a person in a mental health crisis needs to be in a more therapeutic place for treatment than jail. To him, the biggest obstacles to care for the people he treats in jail are a lack of stable housing and the stigma of mental illness.

“If you were sick with cancer, they’re not going to stick you in jail for 84 days until they find a place to get you care,” van der Laak added, referring to when her son spent over two months in jail in 2017 awaiting one of the 455 beds in the state’s mental health hospital after being arrested for violating probation.

A Burden Lifted

The Eugene Police Department uses its CAHOOTS staff for more than mental health calls. They deliver death notices across the city, hand out water bottles and socks to people living on the streets, and take after-hours community medical referrals. The staff offers those services to the city for half the cost of a police officer.

Nationally, police officers carry the brunt of responding to mental health issues. In 2017, law enforcement agencies spent $918 million transporting people with severe mental illness, according to a 2019 survey from the Treatment Advocacy Center. It also estimated that officers spend 21% of their time responding to and transferring people for mental health issues.

“Our police officers try the best they can, but they are not mental health professionals,” said Eugene Police Lt. Ron Tinseth.

In 2017, Eugene diverted 17% of an estimated 130,000 calls to its CAHOOTS teams. This freed up Eugene police officers to respond to higher-level emergencies.

Like many police departments, Denver is feeling the pressure of mental health issues. From July 2018 to July 2019, the department said, it received 15,915 mental health-related calls, almost a 9% increase from its annual average over three years.

To enact a program like CAHOOTS, the Denver Police Department would have to iron out details such as insurance to cover responders and partnerships with local nonprofits that offer services like sobering-up shelters, medical care and substance-abuse counseling.

Lisa Raville, executive director of Denver’s Harm Reduction Action Center, a Denver nonprofit focused on helping those who use drugs, asserts that the power of a CAHOOTS program lies in its community relationships and the ability of first responders to simply ask, “How can I support you today?”

“And then you can do it. Maybe it can be possible. Maybe this person can find some sort of safety,” she said. “We all deserve that.”

Until then, when van der Laak’s son is on the streets, she uses Facebook and her neighbors to keep track of him. She gives store clerks near the streets he chooses to live on her phone number in the hope they will call her to pick up her son during a crisis, not 911.

KHN’s ‘What The Health?’: Trump Merges Health And Immigration

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Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Julie Appleby

Kaiser Health News

@Julie_Appleby

Read Julie's Stories Alice Miranda Ollstein

Politico

@AliceOllstein

Read Alice's Stories Paige Winfield Cunningham

The Washington Post

@pw_cunningham

Read Paige's Stories

President Donald Trump has merged two of his favorite hot-button topics by requiring new immigrants to either purchase health insurance within 30 days of arrival or prove they can pay for medical expenses on their own.

Meanwhile, the Supreme Court has agreed to hear an abortion case out of Louisiana and could soon take another from Indiana. Either or both could be used to weaken or possibly roll back Roe v. Wade, the 1973 ruling that legalized abortion nationwide.

And on the Democratic presidential campaign trail, Vermont Sen. Bernie Sanders has a heart attack and South Bend, Ind., Mayor Pete Buttigieg has a drug plan. Also, Republicans have a unified message: They say Democrats are pushing socialism.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Julie Appleby of Kaiser Health News and Paige Winfield Cunningham of The Washington Post.

Among the takeaways from this week’s podcast:

  • In his surprise announcement last week setting requirements for legal immigrants to have health insurance, Trump based the new policy on concerns about the burden uninsured people put on the health system. That is an argument often used by supporters of the Affordable Care Act, which Trump strongly criticizes.
  • The Supreme Court likely has four options in the Louisiana abortion case it accepted last week. The state law in question requires that doctors performing abortions be accredited at local hospitals ― an issue at the heart of a Texas law that the justices rejected several years ago. The court could say the Louisiana law is much like Texas’ and strike it down; use the new law to overturn abortion rights; say the Texas decision was not correct and let stand the Louisiana law; or say the facts are different in Louisiana and its law can stand.
  • Somewhat overlooked in the court’s acceptance of the case is that it will also rule on another abortion issue: whether health care providers can sue to stop restrictive state laws. If the court says they can’t and instead the burden is on women seeking an abortion, it will make challenging state statutes much more difficult.
  • The executive order signed by Trump last week could result in significant changes to Medicare, allowing doctors to opt out of the program and set up private contracts with patients.
  • Sen. Bernie Sanders’ heart attack has raised questions ― again ― about how transparent presidential candidates should be about their health.
  • As both Republican critics of the ACA and its supporters await a decision by the 5th Circuit Court of Appeals on a Texas lawsuit that could strike down the federal health law, GOP officials are growing nervous about timing. The case will be appealed to the Supreme Court, but some administration officials would like that to not hit the court during the 2020 presidential campaign and are considering ways to prolong the appeal process.

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

Julie Rovner: Kaiser Health News’ “Why Hospitals Are Getting Into The Housing Business,” by Markian Hawryluk

Alice Miranda Ollstein: The New York Times’ “Sexually Transmitted Disease Cases Rise to Record High, C.D.C. Says,” by Liam Stack

Paige Winfield Cunningham: Bloomberg’s “AbbVie, Bristol-Myers Among Patient Advocacy Groups’ Big Backers,” by Alex Ruoff. Also, Kaiser Health News’ database of pharma contributions to patient advocacy groups can be found here.

Julie Appleby: Kaiser Health News’ “They Enrolled In Medical School To Practice Rural Medicine. What Happened?” by Lauren Weber

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

HHS Announces Guide for Appropriate Tapering or Discontinuation of Long-Term Opioid Use

HHS Gov News - October 10, 2019

Today, the U.S. Department of Health and Human Services published a new Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. Individual patients, as well as the health of the public, benefit when opioids are prescribed only when the benefit of using opioids outweighs the risks.  But once a patient is on opioids for a prolonged duration, any abrupt change in the patient’s regimen may put the patient at risk of harm and should include a thorough, deliberative case review and discussion with the patient. The HHS Guide provides advice to clinicians who are contemplating or initiating a change in opioid dosage.

“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, M.D., assistant secretary for health. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”

Clinicians have a responsibility to coordinate patients’ pain treatment and opioid-related problems. In certain situations, a reduced opioid dosage may be indicated, in joint consultation with the care team and the patient. HHS does not recommend opioids be tapered rapidly or discontinued suddenly due to the significant risks of opioid withdrawal, unless there is a life-threatening issue confronting the individual patient.

Compiled from published guidelines and practices endorsed in the peer-reviewed literature, the Guide covers important issues to consider when changing a patient’s chronic pain therapy. It lists issues to consider prior to making a change, which include shared decision-making with the patient; issues to consider when initiating the change; and issues to consider as a patient’s dosage is being tapered, including the need to treat symptoms of opioid withdrawal and provide behavioral health support. For more information, go to: www.hhs.gov/opioids.

About the Office of the Assistant Secretary for Health

The Office of the Assistant Secretary for Health (OASH) oversees the U.S. Department of Health and Human Services’ key public health offices and programs, a number of Presidential and Secretarial advisory committees, 10 regional health offices across the nation, and the Office of the Surgeon General and the U.S. Public Health Service Commissioned Corps. OASH is committed to leading America to healthier lives.

Follow the Assistant Secretary for Health on Twitter @HHS_ASH, and sign up for HHS Email Updates.

‘We Vape, We Vote’: How Vaping Crackdowns Are Politicizing Vapers

Kaiser Health News:States - October 10, 2019

Vapers across the country are swarming Twitter, the White House comment line and statehouse steps with the message “We Vape, We Vote.”

They’re speaking out after a slew of attacks on their way of life. President Donald Trump announced his support for a vaping flavor ban in September. Some states temporarily banned the sales of vaping tools or flavors. And the Centers for Disease Control and Prevention has warned people to stop vaping until public health experts can find the cause of more than a thousand cases of lung injuries nationwide.

The backlash from vapers and vape shop owners is getting louder as they argue their small businesses and their rights to what some see as a smoking cessation tool are being trampled.

“Rather than just vote a party ticket, they may in fact change their vote for anybody who comes out and wants to have a critical conversation about vaping,” warned Alex Clark, the CEO of the Consumer Advocates for Smoke-Free Alternatives Association, a self-described tobacco harm-reduction nonprofit in Plattsburgh, N.Y.

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Political groups are noticing that vaping is an identity, not just a hobby. Conservative powerhouse Grover Norquist, whose Americans for Tax Reform group hosted over 200 vaping advocates last month in Washington, D.C., cautions this is an electorate Trump should not ignore for 2020.

Vaping activists have already claimed success in a handful of races. Now some advocates say this burgeoning anger could shape the votes of the nation’s more than 10 million adult vapers and 20,000 vape shop owners.

“Are there enough vapers to swing states like Michigan?” added YouTube vaping influencer Matt Culley. “Absolutely.”

The Vaping Electorate

Jason Volpe has owned a vape shop in Caledonia, Mich., for six years. He supports raising the age to buy tobacco to 21 and encourages young customers to use products with lower levels of nicotine.

Volpe, who voted for both President Barack Obama and Trump, is not afraid to talk about politics in his shop. He gives discounts on Election Day to customers with an “I voted” sticker.

Lately, he said, his customers come in angry at what they call government overreach. They are unhappy with Democratic Gov. Gretchen Whitmer, who temporarily banned the sale of nearly all flavors of vaping liquid.

“That’s not supposed to happen in America,” Volpe said. “Are they going to come after our guns next?”

He said his customers — from the liberal to the “very red farmers” — feel under attack. It’s a common grievance in a community that sees itself as continually marginalized by the government even after some vapers used the devices to quit smoking.

There’s a strong libertarian and conservative streak in the movement that the Libertarian Party has capitalized on, selling “I Vape I Vote” T-shirts online alongside a pledge to “vote for candidates who support vaping.” Issues surrounding vaping, like supporting small businesses and promoting personal liberty, are a natural fit for this segment of the right.

Clark, the “smoke-free” advocate, is a registered Democrat who is disappointed that the left isn’t embracing vaping. He considers it hypocritical for them to back marijuana legalization but not vaping.

Volpe just wants his shop to stay open. He feels betrayed that people with heroin addictions can have a safe place to use drugs and that flavored alcohol is still on the market, but not the blueberry maple syrup-flavored vape juice he uses. The stress around the flavor ban sent him to the emergency room last month. What he thought was a heart attack turned out to be anxiety.

A Vaper Voting Block?

Vocal vapers point to Wisconsin Republican Sen. Ron Johnson’s shocking election victory in 2016 as proof of their power.

Johnson became a folk hero on vaping websites after pushing back on proposed Food and Drug Administration vaping regulations. But early in fall 2016, the incumbent was down in the polls and not expected to recover.

Then Mark Block got involved. He’s the former chief of staff for Republican Herman Cain’s 2012 presidential campaign and owned an online vape store at the time. Block said he met with at least a hundred vape shop workers across the state and leveraged their networks to contact what he estimates was upward of 200,000 voters. Some shops registered people to vote. He also started a political action committee, Vape PAC, which raised over $3,000 and distributed some 400,000 postcards.

After Johnson’s victory, the senator specifically thanked vapers: “You made tonight possible; I truly appreciate it. I will be on your side.”

But Tom Russell, campaign manager for Johnson’s opponent, former Sen. Russ Feingold, doesn’t buy the idea that vapers swung the election, saying he didn’t see any money or data to that effect.

“The reality is to the extent there was a Tea Party, previously unmotivated voting bloc, they were motivated by Donald Trump,” he said. “I’m pretty sure it wasn’t ‘Vape Nation.’”

Vaping advocates also point to a 2014 state election in New Mexico as an early victory for their growing cause. That year, state Rep. Liz Thomson, a Democrat, lost her reelection bid to Republican Conrad James, a pro-vaping candidate who got a last-minute boost from Clark’s CASAA and vaping groups. The American Vaping Association put out a celebratory press release, and Americans for Tax Reform called Thomson vaping’s “first victim.”

Thomson, though, considers the loss a fluke, not the work of vapers. “I do not believe they had any effect in my race,” said the legislator, who later won back her seat. “It was a confluence of factors that was bigger than their group.”

In 2018, Block joined the late stages of the California race of embattled U.S. Rep. Duncan Hunter. Known as the vaping congressman, the Republican has helped create pro-vaping legislation.

But he was indicted for campaign finance violations in 2018.

Reusing the 2016 playbook, Block went to vape store after vape store in the last three weeks of Hunter’s race, handing out postcards with an illustration of the congressman vaping that say “Blaze your own trail.”

Hunter narrowly won.

What’s Next

Those races were almost like a practice run. Right now, vaping activists are scrambling to create the framework for a broader political campaign.

Clark said CASAA feels pressure to make a voting guide, but it doesn’t have the resources to figure out which candidates are truly pro-vaping. The group’s first attempt at a guide in 2016 involved surveys sent to some 900 candidates, but Clark said only 200 or so of the “most fringe” candidates responded.

The American Vaping Association, a nonprofit advocacy organization in Stratford, Conn., is training vapers on the basics of politics — how to speak at local government meetings, register people to vote and talk to the press and elected officials without getting worked up, said its president, Gregory Conley. He also is focused on targeting primaries, where he said it’s a lot easier and less expensive to have impact.

The seeds of a grassroots movement seem to be in place. The organizing and get-out-the-vote work is happening online and in vape shops, which Norquist calls the “megachurches” of this community.

The Vapor Technology Association, a trade group that represents e-liquid manufacturers, vape shops and other vaping professionals, said state and local associations are ahead of the national organization when it comes to voter mobilization.

“We haven’t really had to move them because they’re doing it already,” said Chris Howard, the association’s board treasurer.

Vapers are terrified they’re about to lose what they say is the only tool that saved them from smoking — and saved their lives. That’s a powerful motivating force, Culley said. Plus, all the jobs lost from a potential flavor ban — which Trump had announced his support for on Sept. 11 — wouldn’t be a good look for the president, he said.

Trump followed that announcement with a tweet two days later that was more ambiguous about his intentions for a ban: “While I like the Vaping alternative to Cigarettes, we need to make sure this alternative is SAFE for ALL! Let’s get counterfeits off the market, and keep young children from Vaping!”

The damage was already done, according to vape shop owner Mike Moran, who offers customers voter registration paperwork in his two stores in New Jersey. He blames Trump’s initial tweet for kicking off the wave of state bans.

“If Donald Trump lets this go down because of his misstatement, I’ll vote against him,” Moran said. “His words caused this.”

VCU Health Will Halt Patient Lawsuits, Boost Aid In Wake Of KHN Investigation

Kaiser Health News:Insurance - October 09, 2019

VCU Health, the major Richmond medical system that includes the state’s largest teaching hospital, said it will no longer file lawsuits against its patients, ending a practice that has affected tens of thousands of people over the years.

VCU’s in-house physician group filed more than 56,000 lawsuits against patients for $81 million over the seven years ending in 2018, according to a Kaiser Health News analysis of district court data. Those suits will end and VCU will increase financial assistance for lower-income families treated at the $2.16 billion system, according to Melinda Hancock, VCU’s chief administrative and financial officer.

Melinda Hancock, CFO, VCU Health System(Courtesy of VCU Health)

Kaiser Health News recently reported that UVA Health, the University of Virginia system, had filed more than 36,000 suits over six years against patients who could not pay their bills. That revelation, published last month in The Washington Post, led UVA to pledge to “positively, drastically” reduce patient lawsuits.

VCU’s new stance on lawsuits goes beyond UVA’s, which promised to stop suing only patients whose income is below 400% of poverty guidelines. UVA officials did not respond to requests for comment.

VCU’s flagship hospital, VCU Medical Center, hasn’t filed patient suits in at least seven years, Hancock said in an interview this week. But its in-house physician group continued to sue patients and families for overdue bills.

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That approach stopped as of last month, she said. VCU Health, a state-operated system including Richmond’s VCU School of Medicine and Community Memorial Hospital in South Hill, Va., will stop suing patients “as part of normal debt collection,” she said. It is also ending garnishment of patient wages and attaching liens to patient homes, she said.

Hancock said VCU has been considering changing its policies since last year but recent revelations about UVA “expedited” the decision. Starting in June, KHN had requested comment from VCU officials about the health system’s financial assistance and lawsuits.

Read Stories From This Investigation

“We don’t want to be part of that,” she said about patient lawsuits, which are a standard tool for many hospitals seeking to maximize revenue. “We feel that taking care of the patient’s financial health is taking care of their holistic health.”

The system, affiliated with Virginia Commonwealth University, is also considering “how we should address pending lawsuits and retrospective cases,” said spokeswoman Laura Rossacher.

VCU Health will continue to send unpaid debts to collections and report patients with overdue bills to credit agencies.

“We still need to get our bills paid,” Hancock said. “We do need to deploy reasonable collection efforts.”

Policy scholars said the new guidelines, which would make VCU’s collection and billing practices among the most liberal for Virginia hospitals, would still leave many patients vulnerable to credit downgrades, financial hardship and bankruptcy.

“This certainly seems like progress,” said Sara Rosenbaum, a health law professor at George Washington University. But even if no lawsuit is filed, “being an apparent deadbeat on a bill written off as bad debt has terrible and enduring consequences on folks.”

Negative credit reports from a hospital, even without a court case, can send families into a downward spiral, said Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance and Management.

“If they send you to a collection agency, you’re not able to borrow any money because that’s going to put you in such a poor credit rating,” he said. “You cannot expect somebody to pay a $10,000 or $20,000 bill if they don’t have insurance.”

Analysts also criticized as inadequate VCU’s new discounts to the uninsured. Last year, the system started reducing list prices by 45% for those lacking coverage. The previous discount was 25%. Almost nobody pays list charges, which hospitals typically use as a starting point for negotiations with insurers.

But VCU’s average cost of care is 77% below list charges, according to 2017 government filings. That means the uninsured are still paying a big markup under the new policy.

“Most uninsured have very little income, and asking them to pay twice as much as it costs to deliver care is not appropriate,” Anderson said. “It is no wonder why so many cannot pay the bills.”

Uninsured patients paying promptly can receive discounts of up to 55%, Rossacher said. But few are able to do that.

Like UVA, VCU is raising the income threshold for patients seeking financial assistance ― in its case, awarding aid to families with income up to 300% above the federal poverty level, or $77,000 for a family of four. For most patients, the previous cutoff was 200%, or $52,000, for a family of four.

That aid threshold takes effect in November. VCU officials declined to give an estimate of what the new policies would cost the system.

KHN analyzed lawsuits filed by VCU and other hospitals using civil court data collected by Code for Hampton Roads, a nonprofit focusing on improving government technology.

“VCU Health System and its affiliated physicians are making important policy changes that are long overdue,” said Jill Hanken, a health care attorney for the Virginia Poverty Law Center. She urged “further and ongoing oversight” from lawmakers to ensure appropriate indigent care policies.

Virginia Gov. Ralph Northam, a physician, has said little publicly about the state hospitals and doctors under his leadership that often pursue patients for all they are worth.

“No one should go bankrupt because they get sick,” said Northam spokeswoman Alena Yarmosky. “Gov. Northam is glad to see health systems taking real steps to put Virginians first and address aggressive bill collection practices.”

VCU will continue reviewing its collections and assistance policies, Hancock said. “This is an ongoing process,” she said. “It doesn’t’ stop here.”

One impetus to dropping lawsuits was an increasing number of patients with health insurance who still have trouble paying, she said.

“With the rise of high-deductible plans,” in which patients pay thousands before insurance kicks in, she said, “we just felt that there are other collection efforts that were more suitable now.”

Methodology
KHN analyzed civil case records from the Virginia district courts from 2012 to 2018, based on the date the case was filed. The case records were part of a dataset KHN acquired from Ben Schoenfeld, a volunteer for Code for Hampton Roads, a nonprofit focused on improving government technology. Schoenfeld compiled court records available directly from Virginia’s court system (from both circuit and district courts) and posted them on the website VirginiaCourtData.org. The analysis included all “warrant in debt” cases where the plaintiff was listed as MCV Physicians.

HHS Proposes Stark Law and Anti-Kickback Statute Reforms to Support Value-Based and Coordinated Care

HHS Gov News - October 09, 2019

Today, the Department of Health and Human Services (HHS) announced proposed changes to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the “Stark Law”) and the Federal Anti-Kickback Statute.

The proposed rules provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients. The proposals would ease the compliance burden for healthcare providers across the industry, while maintaining strong safeguards to protect patients and programs from fraud and abuse.

The proposed rules are part of HHS’s Regulatory Sprint to Coordinated Care, which seeks to promote value-based care by examining federal regulations that impede efforts among providers to better coordinate care for patients.

“President Trump has promised American patients a healthcare system with affordable, personalized care, a system that puts you in control, provides peace of mind, and treats you like a human being, not a number. But too often, government regulations have stood in the way of delivering that kind of care,” said HHS Secretary Alex Azar. “Regulatory reform has been a key piece of President Trump’s agenda not just for faster innovation and economic growth, but also better, higher-value healthcare. Our proposed rules would be an unprecedented opportunity for providers to work together to deliver the kind of high-value, coordinated care that patients deserve.”

“These proposed rules would be a historic reform of how healthcare is regulated in America,” said HHS Deputy Secretary Eric Hargan. “They are part of a much broader effort to update, reform, and cut back our regulations to allow innovation toward a more affordable, higher quality, value-based healthcare system, while maintaining the important protections patients need. Here at HHS, CMS and the Office of Inspector General recognized the need for reform and have acted to produce serious and thoughtful sets of proposals.”

The Stark Law’s new value-based exceptions, under the proposed rule issued by the Centers for Medicare & Medicaid Services (CMS), acknowledge that incentives are different in a healthcare system that pays for value, rather than the volume, of services provided. They include proper safeguards that ensure the Stark Law will continue to provide meaningful protection against overutilization and other harms, while giving physicians and other healthcare providers added flexibility to improve the quality of care for their patients.

“We serve patients poorly when government regulations gather dust in the attic: they become ever more stale and liable to wreak havoc throughout the healthcare system,” said CMS Administrator Seema Verma. “Administrative costs are driving up the cost of healthcare in America – to the tune of hundreds of billions of dollars. The Stark proposed rule is an important next step in President Trump’s healthcare agenda for Americans. We are updating our antiquated regulations to decrease burden for providers and helping bring down these increasingly escalating costs.”

The proposed changes to the regulations related to the Federal Anti-Kickback Statute and the Civil Monetary Penalties Law issued by the Office of Inspector General (OIG) would, if finalized, address the longstanding concern these laws unnecessarily limit the ways in which healthcare providers can coordinate care for patients. The changes would offer flexibility for beneficial innovation and improved coordinated care through, for example, outcome-based payment arrangements that reward improvements in patient health. The changes would also make it easier for physicians and other healthcare providers to ensure they are complying with the law by offering specific safe harbors for these arrangements.

“Any patient can tell you how difficult it is to coordinate their own care. This proposed rule would help patients to focus on their health, enable providers to better coordinate high-quality healthcare, and empower both to achieve improved health outcomes,” said Acting Inspector General Joanne M. Chiedi. “We are proposing strong safeguards to protect patients from fraud and abuse by bad actors who might seek to misuse the new flexibilities.”

Below are examples involving coordinated care, value-based care, data sharing, and patient engagement activities that, depending on the facts, could currently be difficult to fit under existing protections and could potentially be protected by the Stark Law, Anti-Kickback Statute, or Civil Monetary Penalties Law proposals if all applicable conditions are met:

  • In an effort to coordinate care and better manage the care of their shared patients, a specialty physician practice could share data analytics services with a primary care physician practice.
  • Hospitals and physicians could work together in new ways to coordinate care for patients being discharged from the hospital. The hospital might provide the discharged patients’ physicians with care coordinators to ensure patients receive appropriate follow up care, data analytics systems to help physicians ensure that their patients are achieving better health outcomes, and remote monitoring technology to alert physicians or caregivers when a patient needs healthcare intervention to prevent unnecessary ER visits and readmissions.
  • A physician practice could provide smart pillboxes to patients without charge to help them remember to take their medications on time.  The practice could also provide a home health aide to teach the patient and the patient’s caregiver how to use the pillbox.  The pillbox could automatically alert the physician practice and caregiver when a patient misses a dose so they could follow up promptly with the patient.  
  • A local hospital could improve its cybersecurity and the cybersecurity of nearby providers that it works with frequently.  To do so, it could donate, for free, cybersecurity software to each physician that refers patients to its hospital.  The hospital and the physicians often share information about their patients, so it is important that there are no weak links that might compromise everyone else.  The software would help ensure that hackers cannot attack the physician’s computers.  Improving each physician’s cybersecurity would help prevent hackers from spreading the attack to other physicians and the hospital.
  • To improve health outcomes for patients with end-stage kidney disease, a nephrologist, dialysis facility, or other provider could furnish the patients with technology that is capable of monitoring the patient’s health and two-way, real-time interactive communication between the patient, facility, and physician.  In addition, the facility could equip the physicians with data analytics software to help them monitor patients’ health outcomes. 

Read OIG’s proposed rule.*

Read CMS’s proposed rule.*

More on the changes to the Stark Law.

More on the changes to the Federal Anti-Kickback Statute.

* People using assistive technology may not be able to fully access information in this file. For assistance, contact digital@hhs.gov.

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