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Surprise Medical Bills Are What Americans Fear Most In Paying For Health Care

Kaiser Health News:HealthReform - September 05, 2018

Unexpected medical bills top the list of health care costs Americans are afraid they will not be able to afford, with 4 in 10 people saying they had received a surprisingly large invoice within the past year, according to a new poll.

The Kaiser Family Foundation poll found that 67 percent of people worry about unexpected medical bills, more than they dread insurance deductibles, prescription drug costs or the basic staples of life: rent, food and gas. (Kaiser Health News is an editorially independent program of the foundation.)

Thirty-nine percent of insured adults under age 65 said they had received a medical bill within the previous 12 months that they’d figured would be covered or that was higher than they anticipated. Half of those people said the bill was less than $500, but nearly 1 in 8 said they were on the hook for $2,000 or more.

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A quarter of people who said they received a surprisingly large bill attributed it to a doctor, hospital or other provider that was not in their insurance network. Such providers often will not accept the amount an insurer thinks a procedure or test should cost, and they bill the patient for the difference. That practice, known as balance billing, is one of the most common types of outsize charges that KHN and NPR profile in the “Bill of the Month” series.

Another poll recently conducted by NORC at the University of Chicago, a research group, found similar numbers of people had received a surprise bill. The most common charges were for a physician’s service or a lab test.

Once again, the Kaiser poll found that a majority of the public — regardless of political party — does not want insurers to be allowed to deny coverage or charge higher premiums because of someone’s medical history or health status. Both practices were standard in the health insurance industry until they were outlawed by the Affordable Care Act in 2010.

Those protections would be suspended if a group of Republican attorneys general who assert the law is unconstitutional persuade a federal court judge in Texas this week that the health law be put on hold while their case against the ACA is litigated. The ACA protections are supported by at least 86 percent of Democrats, 71 of independents and 56 percent of Republicans, the poll found.

Americans said there was plenty of blame to go around for the high cost of health care. At the top, 78 percent of the public said excessive drug company profits were a major reason health care costs are rising. That is a 7 percentage point increase from 2011 and more than any other single reason. A majority of the public also blamed waste and fraud, unnecessarily high hospital charges, excessive insurance profits and the cost of new medical technologies.

The poll was conducted Aug. 23-28 among 1,201 adults. The margin of error was +/-3 percent.

As California Hospitals Sweep Up Physician Practices, Patients See Higher Bills

Kaiser Health News:Marketplace - September 04, 2018

Hospitals have gobbled up nearly 40 percent of physician practices in California, leading to higher bills for patients, a new study shows.

Just a quarter of practices were owned by hospitals eight years ago, according to the study published Tuesday in the journal Health Affairs. That type of rapid industry consolidation was associated with higher prices for primary care visits and treatment from specialists.

In areas with both high levels of consolidation among hospitals and between hospitals and physicians, researchers estimated there was a 12 percent increase in premiums on California’s health insurance exchange from fall 2013 through 2016, beyond the general rise in medical costs.

Acquisitions of physician practices by hospitals tend to be small and typically fly under the radar, said Richard Scheffler, the study’s lead author and professor of health economics and public policy at the University of California-Berkeley.

“But when you add them up, they are having an impact on outpatient prices and Affordable Care Act premiums,” he said. “I call it conglomerate care.”

He said the change in California hospital-physician ownership is more recent compared with the earlier consolidation within the hospital industry and among insurance companies, which also pushed up prices.

(Scheffler et al./Health Affairs)

The percentage of California primary care physicians in practices owned by hospitals increased from 26 percent in 2010 to 38 percent in 2016, the study found. For the same period, the percentage of specialists in such practices jumped from 20 percent to 54 percent. For all physicians, the statewide figure grew from 24 percent to 39 percent, according to the study’s authors.

The steady decline of inpatient admissions has upended the normal business model for hospitals, and big systems are seeking more control over where patients get care outside their walls. The general trend toward buying doctors’ practices had been known, but the findings in the Health Affairs study make clear how big a change it is. Until recently, however, consolidation among insurers or hospital systems has attracted more attention from regulators and lawmakers.

A similar wave of hospital-physician consolidation has occurred nationally. From 2010 to 2016, the national share of office-based physicians who worked in hospital-owned organizations has increased from 30 percent to 48 percent, according to Scheffler and his co-authors.

Hospital and physician groups defend these mergers as good for patients, saying they help coordinate care that is often fragmented, duplicative and wasteful. The deals enable them to deliver care that’s less expensive and to negotiate more effectively with giant insurance companies, they say.

Carmela Coyle, chief executive of the California Hospital Association, said the study has serious flaws, drawing conclusions about supposed cost increases due to consolidation that aren’t supported by the data.

“These authors start from a place where consolidation and market concentration is bad,” Coyle said. “Our experience in health care suggests that bringing providers together can be a very good thing for communities and the patients they serve. It often preserves access and allows physicians to stay in the community.”

But critics of consolidation say that as large health systems gain market power, they can dictate where patients go for expensive tests and procedures. Some hospitals tack on “facility fees” for outpatient care, which boosts costs even further.

“These mega-enterprises are buying up everything and when you sit down to contract with them it’s ridiculously expensive,” said Glenn Melnick, a health care economist at the University of Southern California.

For instance, Northern California, where a few large health systems dominate the market and own many physician practices, has become the most expensive place in the country to have a baby.

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Melnick co-authored a separate paper in Health Affairs, also out Tuesday, that described how a steady erosion of competition among hospitals in California has contributed to rising health care costs.

The prices paid by health plans to California hospitals declined by 26 percent from 1995 to 1999, a period when managed care was aggressive at negotiating lower prices. But a consumer backlash against tight controls on care and patient choice ensued, and that trend began to reverse in the early 2000s.

Prices increased by 238 percent from 2001 to 2016 — despite a 10 percent drop in the volume of care for commercially insured patients over that same period.

“Competition was working before, and now that competition has eroded,” Melnick said.

Some health care economists say hospitals and physician groups don’t need to merge in order to collaborate on patient care and that contracting could suffice without diminishing competition through outright acquisitions.

Antitrust enforcers are now giving such consolidation more scrutiny.

In March, California Attorney General Xavier Becerra sued Sutter Health, accusing the health system of overcharging patients for years and illegally driving out competition in Northern California. Part of that case centers on Sutter’s big medical groups, which are a key source for patient referrals and admissions into Sutter facilities. Overall, the nonprofit chain has 24 hospitals, 36 surgery centers and more than 5,500 physicians in its network.

Sutter denies any anticompetitive behavior and touts the benefits of offering patients a broad array of services. “Our integrated network of high-quality doctors and care centers aims to provide better, more efficient care — and has proven to help lower costs,” Sutter said in a recent statement.

Other states have pursued legal action on this front. Last year, for instance, the Washington state attorney general’s office sued Catholic Health Initiatives’ Franciscan Health system to unwind its acquisition of two medical groups, saying those deals violated antitrust law and would harm consumers.

Meantime, California lawmakers have tried to ban certain contracting practices used by large health systems, such as “all or nothing” provisions that force health plans to accept all of their facilities and medical groups systemwide. However, for the second consecutive year, SB 538 failed to advance amid opposition from the hospital industry.

Of course, the doctor’s office — whether it’s owned by a hospital or not — isn’t the only option for many consumers nowadays. Many people visit clinics run by retailers, such as CVS, or talk to a doctor through an app on their smartphone.

Scheffler said his study didn’t examine whether the quality of care had improved under hospital-controlled physician practices. He said, however, that the evidence of any quality improvement is thin so far, and he challenged providers to make their case.

“We want them to integrate care,” Scheffler said. “But if it’s giving them market power and increasing prices, is it worth it?”

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

A Texas Lawsuit Being Heard This Week Could Mean Life Or Death For The ACA

Kaiser Health News:Insurance - September 04, 2018

Wednesday is looking like yet another pivotal day in the life-or-death saga that has marked the history of the Affordable Care Act.

In a Texas courtroom, a group of Republican attorneys general, led by Texas’ Ken Paxton, are set to face off against a group of Democratic attorneys general, led by California’s Xavier Becerra, in a lawsuit aimed at striking down the federal health law. The Republicans say that when Congress eliminated the penalty for not having health insurance as part of last year’s tax bill, lawmakers rendered the entire health law unconstitutional. The Democrats argue that’s not the case.

But first, the sides will argue before U.S. District Judge Reed O’Connor in Fort Worth, Texas, whether the health law should be put on hold while the case is litigated. The GOP plaintiffs are seeking a “preliminary injunction” on the law.

Ending the health law, even temporarily, “would wreak havoc in our health care system,” said Becerra in a call with reporters last week. “And we don’t believe Americans are ready to see that their children are no longer able to see a doctor or that they cannot get treated for a preexisting health condition.”

Here are five questions and answers to help understand the case, Texas v. U.S.

1. What is this suit about?

In February, 18 GOP attorneys general and two GOP governors filed the suit in federal district court in the Northern District of Texas. They argue that because the Supreme Court upheld the ACA in 2012 by saying its requirement to carry insurance was a legitimate use of Congress’ taxing power, eliminating the tax penalty for failure to have health insurance makes the entire law unconstitutional.

“Texans have known all along that Obamacare is unlawful and a divided Supreme Court’s approval rested solely on the flimsy support of Congress’ authority to tax,” Paxton said in a statement when the suit was filed. “Congress has now kicked that flimsy support from beneath the law.”

The lawsuit asks the judge to prohibit the federal government “from implementing, regulating, enforcing, or otherwise acting under the authority of the ACA.”

2. Why are Democratic attorneys general defending the law?

The defendant in the case is technically the Trump administration. But in June, the administration announced it would not fully defend the law in court.

The Justice Department, in its filing in the case, did not agree with the plaintiffs that eliminating the tax penalty should require that the entire law be struck down. But it did say that without the tax, the provisions of the law requiring insurance companies to sell to people with preexisting conditions and not charge them more should fall, beginning Jan. 1, 2019. That is when the tax penalty goes away.

The Republican attorneys general say they still believe the entire law should be invalidated, but if that does not happen, they would accept the elimination of the preexisting condition protections.

The Democratic attorneys general applied to “intervene” in the case to defend the law in its entirety. They say they needed to step forward to protect the health and well-being of their residents. The judge granted them that status on May 16.

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3. What would happen if the judge grants a preliminary injunction?

The GOP plaintiffs say the law needs to be stopped immediately, “both because individuals will make insurance decisions during fall open-enrollment periods and because the States cannot turn their employee insurance plans and Medicaid operations on a dime,” according to their brief.

But setting aside the ACA while the case proceeds “would throw the entire [health] system into chaos,” Becerra said. That’s because the ACA made major changes not just to the insurance market for individuals, but also to Medicare, Medicaid and the employer insurance market.

Even in 2012, when the Supreme Court was considering the constitutionality of the law before much of it had taken effect, some analysts from both parties predicted that finding the law unconstitutional could have serious repercussions for the Medicare program and the rest of the health care system.

In practice, however, even if Judge O’Connor were to rule in favor of the Republicans’ request to stop the law’s enforcement immediately, the decision could be quickly appealed up the line, including, if necessary, before the Supreme Court.

4. Is this case purely Republicans versus Democrats?

The case is largely partisan — with Republicans who oppose the health law arguing for its cancellation and Democrats who support it fighting to keep it in place.

But a friend-of-the-court brief filed by five law professors who disagree on the merits of the ACA said that, regardless, both the GOP states and the Justice Department are wrong to conclude that eliminating the tax penalty should result in the entire law being thrown out.

In this case, “Congress itself has essentially eliminated the provision in question and left the rest of a statute standing,” so courts do not need to guess whether lawmakers intended for the rest of the law to remain, they wrote.

5. What is Congress doing about this?

Technically, Congress is watching the case just as everyone else is. But Republicans in particular, while they mostly oppose the health law, are aware that the provisions protecting people with preexisting conditions are by far the most popular part of the ACA. And Democrats are already using the issue to hammer opponents in the upcoming midterm elections.

Last month, 10 GOP senators introduced legislation they said would maintain the ACA’s preexisting condition protections in the event the lawsuit succeeds.

“This legislation is a common-sense solution that guarantees Americans with preexisting conditions will have health care coverage, regardless of how our judicial system rules on the future of Obamacare,” said Sen. Thom Tillis (R-N.C.), the bill’s lead sponsor, in a statement.

Critics, however, were quick to point out that the bill doesn’t actually offer the same protections that are embodied in the ACA. While the health law requires coverage for all conditions without extra premiums, the GOP bill would require that insurers sell to people with preexisting conditions, but not that those policies actually cover those conditions.

Democratic, GOP Attorneys General Square Off In Texas Showdown Over Health Law

Kaiser Health News:HealthReform - September 04, 2018

Wednesday is looking like yet another pivotal day in the life-or-death saga that has marked the history of the Affordable Care Act.

In a Texas courtroom, a group of Republican attorneys general, led by Texas’ Ken Paxton, are set to face off against a group of Democratic attorneys general, led by California’s Xavier Becerra, in a lawsuit aimed at striking down the federal health law. The Republicans say that when Congress eliminated the penalty for not having health insurance as part of last year’s tax bill, lawmakers rendered the entire health law unconstitutional. The Democrats argue that’s not the case.

But first, the sides will argue before U.S. District Judge Reed O’Connor in Fort Worth, Texas, whether the health law should be put on hold while the case is litigated. The GOP plaintiffs are seeking a “preliminary injunction” on the law.

Ending the health law, even temporarily, “would wreak havoc in our health care system,” said Becerra in a call with reporters last week. “And we don’t believe Americans are ready to see that their children are no longer able to see a doctor or that they cannot get treated for a preexisting health condition.”

Here are five questions and answers to help understand the case, Texas v. U.S.

1. What is this suit about?

In February, 18 GOP attorneys general and two GOP governors filed the suit in federal district court in the Northern District of Texas. They argue that because the Supreme Court upheld the ACA in 2012 by saying its requirement to carry insurance was a legitimate use of Congress’ taxing power, eliminating the tax penalty for failure to have health insurance makes the entire law unconstitutional.

“Texans have known all along that Obamacare is unlawful and a divided Supreme Court’s approval rested solely on the flimsy support of Congress’ authority to tax,” Paxton said in a statement when the suit was filed. “Congress has now kicked that flimsy support from beneath the law.”

The lawsuit asks the judge to prohibit the federal government “from implementing, regulating, enforcing, or otherwise acting under the authority of the ACA.”

2. Why are Democratic attorneys general defending the law?

The defendant in the case is technically the Trump administration. But in June, the administration announced it would not fully defend the law in court.

The Justice Department, in its filing in the case, did not agree with the plaintiffs that eliminating the tax penalty should require that the entire law be struck down. But it did say that without the tax, the provisions of the law requiring insurance companies to sell to people with preexisting conditions and not charge them more should fall, beginning Jan. 1, 2019. That is when the tax penalty goes away.

The Republican attorneys general say they still believe the entire law should be invalidated, but if that does not happen, they would accept the elimination of the preexisting condition protections.

The Democratic attorneys general applied to “intervene” in the case to defend the law in its entirety. They say they needed to step forward to protect the health and well-being of their residents. The judge granted them that status on May 16.

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3. What would happen if the judge grants a preliminary injunction?

The GOP plaintiffs say the law needs to be stopped immediately, “both because individuals will make insurance decisions during fall open-enrollment periods and because the States cannot turn their employee insurance plans and Medicaid operations on a dime,” according to their brief.

But setting aside the ACA while the case proceeds “would throw the entire [health] system into chaos,” Becerra said. That’s because the ACA made major changes not just to the insurance market for individuals, but also to Medicare, Medicaid and the employer insurance market.

Even in 2012, when the Supreme Court was considering the constitutionality of the law before much of it had taken effect, some analysts from both parties predicted that finding the law unconstitutional could have serious repercussions for the Medicare program and the rest of the health care system.

In practice, however, even if Judge O’Connor were to rule in favor of the Republicans’ request to stop the law’s enforcement immediately, the decision could be quickly appealed up the line, including, if necessary, before the Supreme Court.

4. Is this case purely Republicans versus Democrats?

The case is largely partisan — with Republicans who oppose the health law arguing for its cancellation and Democrats who support it fighting to keep it in place.

But a friend-of-the-court brief filed by five law professors who disagree on the merits of the ACA said that, regardless, both the GOP states and the Justice Department are wrong to conclude that eliminating the tax penalty should result in the entire law being thrown out.

In this case, “Congress itself has essentially eliminated the provision in question and left the rest of a statute standing,” so courts do not need to guess whether lawmakers intended for the rest of the law to remain, they wrote.

5. What is Congress doing about this?

Technically, Congress is watching the case just as everyone else is. But Republicans in particular, while they mostly oppose the health law, are aware that the provisions protecting people with preexisting conditions are by far the most popular part of the ACA. And Democrats are already using the issue to hammer opponents in the upcoming midterm elections.

Last month, 10 GOP senators introduced legislation they said would maintain the ACA’s preexisting condition protections in the event the lawsuit succeeds.

“This legislation is a common-sense solution that guarantees Americans with preexisting conditions will have health care coverage, regardless of how our judicial system rules on the future of Obamacare,” said Sen. Thom Tillis (R-N.C.), the bill’s lead sponsor, in a statement.

Critics, however, were quick to point out that the bill doesn’t actually offer the same protections that are embodied in the ACA. While the health law requires coverage for all conditions without extra premiums, the GOP bill would require that insurers sell to people with preexisting conditions, but not that those policies actually cover those conditions.

Creating Rituals To Honor The Dead At Long-Term-Care Facilities

Kaiser Health News:Marketplace - September 04, 2018

GRAY, Ga. — One by one, their names were recited as family members clutched one another’s hands and silently wept.

Seventeen men and women had died within the past year at Gray Health & Rehabilitation, a 58-bed nursing home. Today, their lives were being honored and the losses experienced by those who cared for them recognized.

Death and its companion, grief, have a profound presence in long-term-care facilities. Residents may wake up one morning to find someone they saw every day in the dining room gone. Nursing aides may arrive at work to find an empty bed, occupied the day before by someone they’d helped for months.

But the tides of emotion that ripple through these institutions are rarely openly acknowledged.

“Long-term care administrators view death as something that might upset residents,” said Dr. Toni Miles, a professor of epidemiology and biostatistics at the University of Georgia. “So, when someone passes away, doors are closed and the body is wheeled discretely out the back on a gurney. It’s like that person never existed.”

At Gray Health’s memorial service on this warm, sunny day, a candle was lit for each person who had died. Their images — young and vibrant, then old and shrunken — flashed by in a video presentation. “Our loved ones continue to live on in the memories in your hearts,” Rev. Steve Johnson, pastor of Bradley Baptist Church, said from a podium.

Dozens of family members gathered outside, each holding a white balloon. At the count of three came the release. Cries of “I love you” echoed as the group turned their faces to the sky.

Sylvia McCoullough wraps her arm around daughter Kim Kohlmayer as they mourn Sylvia’s father, Melvin Henry “Bo” Daniels, at an annual bereavement ceremony at the Gray Health & Rehabilitation in Gray, Ga., on May 14, 2018. (Grant Blankenship for KHN)(Grant Blankenship for KHN)

Those mourning former nursing home residents pray together near the end of an annual bereavement ceremony at Gray Health & Rehabilitation in Gray, Ga., on May 14, 2018.(Grant Blankenship for KHN)

A balloon release concludes the annual bereavement ceremony at Gray Health & Rehabilitation in Gray, Ga.(Grant Blankenship for KHN)

Miles wants to see bereavement openly acknowledged at facilities throughout Georgia to end what she calls “the silence surrounding loss and death in long-term care.” Following in-depth discussions with more than 70 staffers, residents and family members at nine facilities in central Georgia, she has created two handbooks on “best practices in bereavement care” and is gearing up to offer educational seminars and staff training in dozens of nursing homes and assisted living residences across the state.

“Dr. Miles’ work is incredibly important” and has the potential to ease end-of-life suffering, said Amanda Lou Newton, social services team leader at Hospice of Northeast Georgia Medical Center.

Fraught reactions to loss and death are common among nursing assistants and other staff in long-term-care facilities, research shows. When feelings aren’t acknowledged, grief can go underground and lead to a host of physical and psychological symptoms, including depression, distancing and burnout.

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Joanne Braswell, director of social services at Gray Health, remembers a resident with intellectual disabilities who would stay in Braswell’s office much of the day, quietly looking at magazines. Over time, the two women became close and Braswell would buy the resident little gifts and snacks.

“One day, I came in to work and they told me she had died. And I wanted to cry, but I couldn’t,” Braswell recalled, reflecting on her shock, made more painful by memories of her daughter’s untimely death several years earlier. “I promised myself never again to [become] attached to anyone like that.” Since then, when residents are actively dying, “I find myself pulling away,” she said.

Sylvia McCoullough, 56, came to Gray Health’s memorial ceremony for her father, Melvin Daniels, who died on April 19 at age 84.

Two years earlier, not long before her mother passed away, McCoullough had realized that her father had dementia. “He was the strong one in our family. … He always took care of us,” she said, explaining that her father’s confusion and hallucinations shook her to her foundation.

“I cry all the time,” McCoullough continued, looking distressed. “It’s like I’m lost without my mom and dad.” But Gray’s ceremony, she said, brought some comfort.

Edna Williams, 75, was among dozens of residents at the event, sitting quietly in her wheelchair.

“I love to recall all the people that have passed away through the year,” said Williams, who sends sympathy cards to family members every time she learns of a fellow resident’s death. On these occasions, Williams said, she’s deeply affected. “I go to my room” and “shed my own private tears” and feel “sadness for what the family has yet to go through,” she said.

Edna Williams is a resident of the Gray Health & Rehabilitation in Gray, Ga., and a former certified nursing assistant in an assisted living home in her hometown of Statesboro, Ga. When a resident at Gray Health dies, Williams sends their family sympathy cards, which she asks staff and residents to sign — “to let their families know that we really care and understand their feelings," she says.(Grant Blankenship for KHN)

Cathy Bass (left) and granddaughter Heaven Melton attended the bereavement ceremony at Gray Health & Rehabilitation in remembrance of Bass' brother, Timothy Marion Sanders. "I miss him every day," she says.(Grant Blankenship for KHN)

Chap Nelson, Gray Health’s administrator, has instituted several policies that Miles’ bereavement guide recommends as best practices. All staff members are taught what to do when a resident dies. When possible, they’re encouraged to attend the off-site funerals. Every death is acknowledged inside the building, rather than hidden away.

If one of his staff members seems distressed, “I go out and find them and talk to them and ask how I can help them with the feelings they may be having,” Nelson said.

Other best practices include offering support to grieving residents and relatives of the deceased, recognizing residents’ bereavement needs in care plans, and having a protocol to prepare bodies for final viewing.

Some facilities go further and create unique rituals. In one Georgia nursing home, staff members’ hands are rubbed with essential oils after a resident’s death, Miles said. In Ontario, Canada, St. Joseph’s Health Centre Guelph holds a “blessing ritual” in the rooms where people pass away.

Fifteen miles away from Gray, in Macon, Ga., Tom Rockenbach runs Carlyle Place, an upscale facility with four levels of care: independent living, assisted living, memory care and skilled nursing services. Altogether, about 325 seniors live there. Last year, 40 died.

“We don’t talk about it enough when someone passes here; we don’t have a formal way of expressing grief as a community,” Rockenbach said, discussing what he learned after Miles organized listening sessions for staff and residents. “There are things I think we could do better.”

When a death occurs at this continuing care retirement community, an electric candle is lit in the parlor, where people go to pick up their mail. If there’s an obituary, it’s placed in a meditation room, often with a sign-in book in which people can write comments.

Since working with Miles, Rockenbach has a keener appreciation for the impact of death and loss. He’s now considering starting a support group for staff and hosting a death cafe for residents where “people could come and hear what other people have gone through and how they got through it.”

Tom Rockenbach (center) is executive director of the Carlyle Place senior living facility in Macon, Ga. Rockenbach is considering starting a support group for staff and hosting a death cafe for residents where “people could come and hear what other people have gone through and how they got through it.”(Grant Blankenship for KHN)

Tameka Jackson, a licensed practical nurse who has worked at Carlyle Place for eight years, became distraught after the death of one resident, in his 90s, with whom she had grown close.

“Me and him, we were two peas in a pod,” she said, recalling the man’s warmth and sense of humor.

Over time, the old man confided in the nurse that he was tired of living but holding on because he didn’t want family members to suffer. “He would tell me all kinds of things he didn’t want his family to worry about,” Jackson said. “In a way, I became his friend, his nurse and his confidante, all in one.”

One morning, she found his room was bare: He’d died the night before, but no one had thought to call her. Jackson’s eyes filled with tears as she recalled her hurt. “I’m a praying person, and I had to ask God to see me through it,” she said. “I found comfort in knowing he knew I genuinely loved him.”

Jan Peak, 81, was dealing with grief of a different sort in mid-May: Her husband, David Reed, who had rapidly advancing Parkinson’s disease, had recently moved to Carlyle Place’s assisted living section from their independent-living apartment— signaling the end of their time living together.

Like other people at Carlyle Place, Peak had a lot of adjusting to do when she moved into the facility five years ago after her first husband had died. “Lots of people here have come here from somewhere else and given up their homes, their friends and their communities, often after the death of a spouse,” Peak said. “Once you’re here, loss — either your own or someone else’s — is around you continually.”

She found herself turning to David, whose first wife had died of a brain tumor and whom she describes as a “soft, sweet, wise man.” Before they married, they talked openly about what lay ahead, and Peak promised she would carry on.

“No one can stop the heartache that accompanies loss,” but “my friends and family still need me,” she said.

In late May, David sustained a severe head injury after falling and died. “I miss him greatly as we were very happy together,” Peak wrote in an email. “I am doing as well as I can.”

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

Lawmakers Push To Protect Patients And Counter Trump

Kaiser Health News:HealthReform - September 04, 2018

California lawmakers this year played offense and defense on health care, adopting bills to give patients more access to care and medications, while defending Californians against Trump administration attacks on the Affordable Care Act.

As they raced toward their Friday deadline to pass bills, legislators voted to make the abortion pill available to students on public college campuses, and to stop hospitals from discharging homeless patients onto the streets.

State lawmakers also countered some Trump administration regulations that health advocates say could have foiled California’s ongoing efforts to reduce its uninsured population. For example, they banned what they call “junk” plans, endorsed by President Donald Trump, that don’t meet ACA requirements.

“California has been extremely successful at implementing the Affordable Care Act,” said Deborah Kelch, executive director of the Insure the Uninsured Project, which advocates for expanded health care access. “The state of California has a very compelling reason to make sure we don’t lose those gains.”

While they blocked some Trump administration policies from taking effect in California, lawmakers’ attempts to expand coverage to more Californians were quashed by Democratic Gov. Jerry Brown’s fiscal conservatism. Single-payer health care wasn’t even on the table this year, despite the outsize role it has played in the 2018 political campaign season. And measures that would have expanded Medicaid to some of California’s low-income, undocumented immigrants failed — as did bills to create state-funded insurance subsidies for some residents. Instead, lawmakers passed a bill that calls for a study of a “public option” that would create a government-run health care program open to anyone.

“What we didn’t get this year, we’re getting ready for in the next governor,” said Jen Flory, a policy advocate at the Western Center on Law & Poverty, a nonprofit that advocates for low-income Californians.

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Here’s a look at some of the major health care bills that California lawmakers have sent to Brown’s desk. He has until Sept. 30 to sign or veto them.

Defending the Affordable Care Act

Association Health Plans

The Trump administration earlier this year issued regulations that allow individuals to buy coverage through “association health plans,” which employers and associations can create to offer group health insurance. The bill, SB 1375, would bar individuals from such plans, which its author, state Sen. Ed Hernandez (D-West Covina), described as “junk insurance.”

Short-Term Health Plans

Parting ways again with the Trump administration, California lawmakers adopted SB 910 — also introduced by Hernandez — which would ban short-term health insurance policies. The plans, which can last up to 12 months, aren’t required to include key consumer protections guaranteed under the ACA, such as coverage for preexisting conditions.

Medical Loss Ratio

Lawmakers made clear they don’t want California to lower the amount insurers must spend on medical care after the Trump administration this spring gave states permission to modify what is known as the “medical loss ratio.” The Affordable Care Act required insurance companies to spend at least 80 percent of their premium income on health claims and quality improvement instead of administrative costs and profit. AB 2499, by Assemblyman Joaquin Arambula (D-Fresno), requires California insurers to maintain the 80 percent threshold.

Medi-Cal Work Requirements

Lawmakers approved legislation that would prevent California from imposing work requirements on its Medicaid recipients — or any other requirement that would make it harder for low-income families to get or use their health coverage, according to the bill’s proponents. Hernandez introduced the bill, SB 1108, after the Trump administration informed states they could implement work requirements, a change that critics say could kick people off the program.

Consumer Protection

Unloading Homeless Patients 

Appalled by reports of homeless patients discharged from hospitals right onto the streets or into crammed shelters, lawmakers approved legislation intended to get these vulnerable patients to a safe location after they have received medical care. SB 1152, again by Hernandez, would require hospitals to develop a discharge plan for homeless patients.

Health Care Providers

Concerned that some patients with kidney disease and substance abuse addictions are being scammed, California lawmakers clamped down on for-profit, third-party health providers that enroll patients into private plans that reimburse providers more money, even though the patients might be eligible for Medicare or Medi-Cal. This can result in higher out-of-pocket costs and a disruption in care for the patients. Sen. Connie Leyva (D-Chino) has described her bill, SB 1156, as one that would end such insurance schemes and protect patients. Critics, including some dialysis patients, say the measure would limit the charitable financial assistance patients receive and prevent them from affording treatment.

Abortion Pills On Campus

Lawmakers want students at all 34 California State University and University of California campuses to have access to the abortion pill at student health centers. In some cases, pregnant students must now travel far for medical care, and that can delay their treatment, said Leyva, the bill’s co-author. SB 320 would require public universities to provide medical abortion services on campus by Jan. 1, 2022, to be paid for by private funds.

Rape Kit Testing

Angered by reports of untested rape kits, California lawmakers approved a pair of bills intended to audit the state’s backlog and require all new kits be tested going forward. AB 3118, by Assemblyman David Chiu (D-San Francisco), would require California’s first official statewide count of untested kits. Under SB 1449, co-authored by Leyva, law enforcement agencies would be required to submit evidence to a laboratory within 20 days, and those laboratories would need to process the kits within 120 days.

Medication Disposal

California lawmakers want the medical/pharmaceutical industry to take responsibility for unused prescriptions, used needles and other medical waste. SB 212, introduced by Sen. Hannah-Beth Jackson (D-Santa Barbara), would require manufacturers and distributors to create an industry-run and -funded program for Californians to dispose of medical waste. It would be implemented no later than 2022.

Hospital Nurse-Patient Ratios

The California Department of Public Health would be obliged to inspect hospitals periodically to ensure they’re complying with nurse-to-patient staffing ratios under another bill introduced by Leyva, SB 1288. Hospitals found to be violating those ratios could be fined. Ratios vary by ward — from 1:1 for trauma patients in the emergency room to 1:4 for pediatric patients.

Health Care Mergers

The legislature, concerned that consumers are facing restricted choice and paying higher prices as a result of consolidation, is demanding stronger state oversight of proposed health plan mergers. AB 595, by Assemblyman Jim Wood (D-Santa Rosa), would authorize the state Department of Managed Health Care to approve or block merger applications depending on their impacts on consumers.

Drug Prices

California lawmakers want to regulate pharmacy benefit managers, which negotiate drug prices for patients, saying their dealings with drugmakers and insurance companies should be more transparent. AB 315, co-authored by Wood, would require these entities to be licensed by the Department of Managed Health Care and reveal certain cost information that could shed light on whether the savings they negotiate are passed on to consumers.

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

Over Past 20 Years, The Percentage Of Children With ADHD Nearly Doubles

Kaiser Health News:Marketplace - August 31, 2018

The number of children diagnosed with attention deficit hyperactivity disorder (ADHD) has reached more than 10 percent, a significant increase during the past 20 years, according to a study released Friday.

The rise was most pronounced in minority groups, suggesting that better access to health insurance and mental health treatment through the Affordable Care Act might have played some role in the increase. The rate of diagnosis during that time period doubled in girls, although it was still much lower than in boys.

But the researchers say they found no evidence confirming frequent complaints that the condition is overdiagnosed or misdiagnosed.

The U.S. has significantly more instances of ADHD than other developed countries, which researchers said has led some to think Americans are overdiagnosing children. Dr. Wei Bao, the lead author of the study, said in an interview that a review of studies around the world doesn’t support that.

”I don’t think overdiagnosis is the main issue,” he said.

Nonetheless, those doubts persist. Dr. Stephen Hinshaw, who co-authored a 2014 book called “The ADHD Explosion: Myths, Medication, Money, and Today’s Push for Performance,” compared ADHD to depression. He said in an interview that neither condition has unequivocal biological markers, so it makes it hard to determine if a patient truly has the condition without lengthy psychological evaluations. Symptoms of ADHD can include inattention, fidgety behavior and impulsivity.

“It’s probably not a true epidemic of ADHD,” said Hinshaw, a professor of psychology at the University of California-Berkeley and a professor of psychiatry at UC-San Francisco. “It might be an epidemic of diagnosing it.”

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In interpreting their results, however, the study’s authors tied the higher numbers to better understanding of the condition by doctors and the public, new standards for diagnosis and an increase in access to health insurance through the ACA.

Because of the ACA, “some low-income families have improved access to services and referrals,” said Bao, an assistant professor of epidemiology at the University of Iowa College of Public Health.

The study, published in JAMA Pediatrics, used data from the National Health Interview Survey, an annual federal survey of about 35,000 households. It found a steady increase in diagnoses among children from about 6 percent of children between 1997 and 1998 to more than 10 percent between 2015 and 2016.

Advances in medical technology also may have contributed to the increase, according to the research. Twenty years ago, preterm or low-weight babies had a harder time surviving. Those factors increase the risk of being diagnosed with ADHD.

The study also suggests that fewer stigmas about mental health care in minority communities may also lead to more people receiving an ADHD diagnosis.

In the late 1990s, 7.2 percent of non-Hispanic white children, 4.7 percent of non-Hispanic black children and 3.6 of Hispanic children were diagnosed with ADHD, according to the study.

By 2016, it was 12 percent of white kids, 12.8 percent of blacks and 6.1 percent of Hispanics.

Over the past several decades, Hinshaw said, there’s been an expanded view of who can develop ADHD. It’s no longer viewed as a disease that affects only white middle-class boys, as eating disorders are no longer seen as afflicting only white middle-class girls.

Still, he cautioned against overdiagnosing ADHD in communities where behavioral issues could be the result of social or environmental factors such as overcrowded classrooms.

The study found rates of ADHD among girls rose from 3 to more than 6 percent over the study period. It said that was partly a result of a change in how the condition is classified. For years, ADHD pertained to children who were hyperactive. But in recent years, the American Psychiatric Association added to its guide of mental health conditions that diagnosis should also include some children who are inattentive, Bao said. That raised the number of girls, he explained, because it seems they are more likely to be in that second subtype.

“If we compare these two, you can easily imagine people will easily recognize hyperactivity,” he said.

That rang true for Ruth Hay, a 25-year-old student and cook from New York who now lives in Jerusalem. She was diagnosed with what was then called ADD the summer between second and third grade.

Hay said her hyperactive tendencies aren’t as “loud” as some people’s. She’s less likely to bounce around a room than she is to bounce in her chair, she said.

Yet despite her early diagnosis, Hay said, no one ever told her about other symptoms. For example, she said, she suffers from executive dysfunction, which leaves her feeling unable to accomplish tasks, no matter how much she wanted to or tried.

“I grew up being called lazy in periods of time when I wasn’t,” Hay said. “If you look at a list of all the various ADHD symptoms, I have all of them to one degree or another, but the only ones ever discussed with me was you might be less focused and more fidgety.”

“I don’t know how my brain would be if I didn’t have it,” she added. “I don’t know if I’d still be me, but all it has been for me is a disability.”

KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

The $109K Heart Attack Bill Is Down To $332. What About Other Surprise Bills?

Kaiser Health News:Marketplace - August 31, 2018

A Texas hospital that charged a teacher $108,951 for care after a heart attack slashed the bill to $332.29 Thursday — but not before the huge charge sparked a national conversation over what should be done to combat surprise medical bills that afflict a growing number of Americans.

The story of Drew Calver was first reported by Kaiser Health News and NPR on Monday as part of the “Bill of the Month” series, which examines U.S. health care prices and the troubles patients run up against in the $3.5 trillion industry.

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In Calver’s case, the 44-year-old father of two had suffered a heart attack in April 2017 and a neighbor rushed him to the nearest emergency room, which was an out-of-network hospital under his school district health plan. His insurance paid the hospital nearly $56,000 for his four-day hospitalization and procedures to clear his blocked “widow-maker” artery.

But the hospital, St. David’s Medical Center in Austin, wasn’t satisfied with that amount and went after the high school history teacher and swim coach for an additional $109,000 in a practice known as “balance billing.”

Within hours of the story publishing, the hospital offered to waive nearly the entire bill and charge him $782.29 instead. By Thursday, St. David’s lowered the amount even further. Calver said he paid it off over the phone, eager to put this stressful saga behind him.

Calver said it’s a relief that his family doesn’t face a six-figure bill and threatening letters from the hospital’s debt collector. But he said he worries about other patients hit with unjust medical bills of $10,000 or $20,000 who don’t catch the media’s attention.

“It feels great that this is over for me and my family. But this isn’t just about my bill,” Calver said in an interview. “I don’t feel any consumer should have to go through this.”

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Calver and his wife, Erin, said they were encouraged by the outpouring of support and attention they received. Drew Calver gave local TV interviews after teaching class and his story was featured on CBS This Morning. The couple said they’re hopeful the national conversation that ensued will lead to changes that help other consumers across the country.

Just after paying off his hospital bill, Calver walked to the school cafeteria Thursday to grab lunch. One of the cafeteria workers approached him and shared that she, too, was facing a huge medical bill from the same Austin hospital. Calver said he plans to follow up with the woman and assist in any way he can.

“This is the next way I can be of help to others,” he said.

Calver says it’s a relief that his family doesn’t face a six-figure bill and threatening letters from the hospital’s debt collector.(Callie Richmond for KHN)

The hospital system, St. David’s HealthCare, continues to defend its handling of Calver’s bill, saying it “did everything right in this particular situation.” It also pointed out that it informed the family on several occasions that they could apply for a discount through a financial assistance program, based on their household income.

Calver said he didn’t fill out the financial assistance paperwork earlier because he didn’t feel he owed the $108,951 — and had been contesting the validity of the charges all along.

His health plan said the $55,840 it paid the hospital should have satisfied the hospital’s claim. And Calver was already paying $1,400 as coinsurance, which was the out-of-pocket amount calculated by his health plan.

HCA Healthcare, the largest for-profit hospital chain in the country, and two nonprofit foundations own St. David’s.

The chief executive of St. David’s HealthCare, C. David Huffstutler, wrote a memo Monday addressed to his board of governors about Calver’s story. A St. David’s employee shared the memo with Kaiser Health News, and the hospital didn’t dispute its accuracy.

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Submit Your Bill

“I realize this is not the type of coverage any of us want for St. David’s HealthCare,” Huffstutler wrote in his Aug. 27 memo. “With this story, we had a number of circumstances that made it difficult to neutralize the coverage — a monthly news segment that seeks to empower patients to challenge their medical bills; a gap in the system that is affecting patients … and, a compelling patient story.”

Huffstutler also wrote that the hospital’s charges of $165,000 were “reasonable and customary.” He said that the school district and its health plan administrator, Aetna, chose to offer a narrow network plan that “can potentially place a heavy financial burden on the patient.”

Consumer advocates said the hospital should have erased the bill completely after putting the family through so much stress for months.

The drastic reduction in the bill “shows that these hospital numbers are just made up,” said Bonnie Sheeren, who runs Houston Health Advocacy and assists consumers with their medical bills. “It should be a zero balance, and the hospital should pay for therapy sessions to help this family recover from the billing ordeal.”

Several states have passed laws or introduced programs to help shield patients from surprise medical bills, particularly those stemming from emergencies.

But those state rules don’t apply to most U.S. workers because they get their health coverage from employers that are self-insured, meaning the companies pay claims out of their own funds. Federal law governs most of those health plans, and it does not include such protections.

Rep. Lloyd Doggett (D-Texas) heard Calver’s story on the radio while driving Monday and immediately wrote the family a letter offering his support. Calver teaches at the high school that Doggett attended.

The lawmaker proposed legislation last year aimed at limiting surprise billing for patients, but he said it hasn’t received a hearing in the current Congress.

“This is a nationwide problem, and we need a nationwide solution,” Doggett said in an interview. “We have a system where the patient, the most vulnerable person of all those involved, is caught between the insurer and the health care provider. … These problems are solvable.”

Zack Cooper, an associate professor of public health and economics at Yale University, has studied hospital billing practices extensively and said the nearly $109,000 bill was no accident.

He noted that St. David’s, like other hospitals, advertises short wait times for its emergency rooms in order to attract out-of-network patients like Calver. Cooper said his case illustrates the need for better regulation of out-of-network billing at the state or federal level.

“The idea that a hospital would send a bill that will probably bankrupt an individual boggles the mind. For me, that is emblematic of a fairly toxic culture,” Cooper said.

“This was a remarkable story, and it has done remarkable good for him,” Cooper added. “But we shouldn’t be in a world where to avoid financial ruin you have to hope your story is featured in the popular press. We can do better than this.”

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills.

Ashley Lopez of member station KUT in Austin contributed audio reporting. “CBS This Morning” featured it on Wednesday.

Do you have a bill you would like us to examine? Submit it here.

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

Podcast: KHN’s ‘What The Health?’ Ask Us Anything!

This week, KHN’s “What the Health?” panelists answered questions submitted by listeners.

Among the topics covered were the origins of coverage in Medicare and Medicaid, telehealth, wellness plans and why doctors get paid the way they do.

This week’s panelists are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Margot Sanger-Katz of The New York Times and Joanne Kenen of Politico. Kaiser Health News will post a transcript of the podcast later.

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

Julie Rovner: The New York Times’ “Scotland to Provide Free Sanitary Products to Students,” by Ceylan Yeginsu

Joanne Kenen: The Virginian-Pilot’s “Horrific Deaths, Brutal Treatment: Mental Illness in America’s Jails,” by Gary A. Harki

Margot Sanger-Katz: The New York Times’ “Study Causes Splash But Here’s Why You Should Stay Calm on Alcohol’s Risks,” by Aaron Carroll

Anna Edney: Vox.com’s “Republicans Claimed Medicaid Made the Opioid Epidemic Worse. A New Study Proves Them Wrong,” by German Lopez

To hear all our podcasts, click here.

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

HHS Watchdog To Probe Enforcement Of Nursing Home Staffing Standards

Kaiser Health News:Marketplace - August 30, 2018

The inspector general at the Department of Health and Human Services this month launched an examination into federal oversight of skilled nursing facilities amid signs some homes aren’t meeting Medicare’s minimum staffing requirements.

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The review comes on the heels of a Kaiser Health News and New York Times investigation that found nearly 1,400 nursing homes  report having fewer registered nurses on duty than the Centers for Medicare & Medicaid Services (CMS) requires or failed to provide reliable staffing information to the government.

The Office of Inspector General said it would examine the staffing data nursing homes submit to the government through CMS’ new system that uses payroll records. That system gives a more accurate view of staffing than the self-reported numbers facilities had provided for nearly a decade.

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The IG said it would also look into how CMS ensured accuracy of the records, enforced minimum staffing requirements and rewarded facilities that exceeded those standards.

Donald White, a spokesman for the inspector general, said the project was “part of our ongoing review of programs at the department.” The report is likely to be issued in the federal fiscal year that begins in October 2019.

KHN’s analysis of the payroll records found thousands of nursing homes had one or more days where the facilities did not report a registered nurse on duty for at least eight hours, as required by Medicare.

KHN also found great volatility in the staffing of certified nursing assistants day to day, with particularly low numbers on weekends. Those aides are crucial to daily care, helping residents eat, bathe and complete other basic activities.

Neglect Unchecked

Skilled nursing homes are among the most regulated types of medical providers, yet they remain dangerous places for frail residents.

This KHN series examines the reasons that nursing homes, their owners and the government fail to protect people.

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In July, Medicare assigned its lowest staffing rating of one star to nursing homes that did not meet the registered nurse standard, as published on the Nursing Home Compare website. Still, only about half of those homes saw their overall star rating — the most important consumer guide — drop.

CMS declined to comment about the new examination.

Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, said she hoped the probe would spur CMS to take action against facilities where payroll records show they are leaving residents with insufficient nursing coverage.

“We know registered nurses are critical, and they are finding that they’re not there on weekends,” Edelman said.

Earlier this month, Sen. Ron Wyden (D-Ore.), citing the KHN reporting, asked CMS to explain how it is addressing the issue of nursing homes’ inadequate staffing data or understaffing.

LeadingAge, an association of nonprofit providers of aging services including nearly 2,000 nursing homes, said in response to Wyden’s letter that facilities have complained their data is not showing up correctly on the website and that “kinks” in the new system need to be worked out.

“Even if the report results from a mistake that is immediately corrected, the star is not restored until the next quarterly reporting period,” the group wrote.

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

The Pluses And Minuses Of Allowing Medical Marijuana At School

Kaiser Health News:States - August 30, 2018

Every school day at noon, Karina Garcia drives to her son’s South San Francisco high school to give him a dose of cannabis oil to prevent potentially life-threatening seizures.

But she can’t do it on campus. She has to take Jojo, a 19-year-old with severe epilepsy, off school grounds to squirt the drug into his mouth, then bring him back for his special education classes.

It doesn’t matter that Jojo has a doctor’s note to take the drug, nor that the medication is legal for both medicinal and recreational purposes in California. Marijuana use is strictly forbidden on school sites because it violates federal law.

“To go into the classroom every day and have to grab your child, walk down the block, give them a dose and return them, it’s so disruptive,” said Garcia, 38, who explained that prescription drugs didn’t stop Jojo’s seizures and left him in a zombie-like state. Jojo can’t administer the drug himself because he has developmental disabilities and uses a wheelchair, she said.

Karina Garcia prepares to administer medical marijuana to her son, JoJo. Prescription drugs didn’t stop his seizures and left him in a zombie-like state, she explains.(Scott Strazzante/The Chronicle)

A growing number of parents and school districts across the country face similar problems as more people turn to medical marijuana to treat their sick children, often after pharmaceutical remedies have failed.

Now, California Gov. Jerry Brown must decide whether to approve a law that would allow parents to administer medical marijuana to their kids at school, setting up a potential showdown with the federal government.

Of the 31 states and Washington, D.C., that have legalized medical marijuana, at least seven have enacted laws or regulations that allow students to use it on school grounds, in part because doing so could risk their federal funding. So far, the federal government has not penalized any of the seven states.

New Jersey, Illinois, Delaware and Colorado permit parents to give their child non-smokable medicinal pot products at school. This summer, Colorado expanded its law to allow school staff to administer the medication. Washington and Florida allow school districts to decide for themselves whether to allow the drug on campuses. And Maine expanded state regulations to permit medical marijuana use at school, according to the Education Commission of the States.

California’s legislation would let school boards decide whether to allow medical cannabis at schools if a child has a doctor’s note. The drug cannot be prescribed because, with limited exceptions, it is illegal under federal law — classified as one that has “no accepted medical use.”

“More lawmakers are acknowledging this is an issue their constituents care about … [and] are trying to address this inherent conflict” between federal and state law, said Paul Armentano, deputy director of NORML, a national marijuana advocacy group.

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State Sen. Jerry Hill (D-San Mateo), who wrote the California bill, named it Jojo’s Act after Garcia’s son, who suffers from the severe seizure disorder known as Lennox-Gastaut syndrome. The oil Jojo takes contains the chemical cannabidiol, or CBD, and a trace amount of tetrahydrocannabinol, or THC, both extracted from the marijuana plant.

It’s unclear how many kids use medical marijuana, which is most commonly given to children with autism, seizures or cancer, said Dr. Frank Lucido, a Berkeley doctor who has treated more than 200 kids who suffer from seizures or severe autism.

Some school officials in California say the mere possibility of sanctions is enough to oppose opening up schools to medical pot. At risk are federal funds, including money for school breakfasts and lunches for low-income students, that are contingent on schools being drug-free zones, according to the Association of California School Administrators.

The California bill, SB 1127, which was approved by both houses of the state legislature, landed on Brown’s desk this week for his signature — or veto. It would require that parents or legal guardians administer the medical marijuana, which couldn’t be ingested via smoking or vaping. Nor could it be kept on school grounds; parents would still have to bring the drug to school every day. Traditional prescription drugs, by contrast, are often stored at a school nurse’s office and given by a school employee.

The school administrators’ association argues that staffers would be put in an impossible position if the bill became law.

“We’re asking school administrators and other employees to comply with state and federal laws for everything, except this one time we’re going to turn a blind eye,” Laura Preston, legislative advocate for the school administrators, told lawmakers at a hearing earlier this year.

A different school group, however, is asking lawmakers to back the measure as a way to ensure more kids stay in school.

“As more students have started using it to address their medical issues, it becomes a larger issue for schools,” said Erika Hoffman, legislative advocate for the California School Board Association. “We see this as a step in trying to provide an accessible education for a child who unfortunately has severe medical issues.”

Neurologists and pediatricians say success stories from parents offer patients hope, but they warn that much more research is needed to prove the benefits of medical marijuana.

Karina Garcia feeds JoJo at home.(Scott Strazzante/The Chronicle)

The Food and Drug Administration in June approved the first prescription drug that contains marijuana compounds after studies showed a reduction in the frequency of seizures. The medicine, called Epidiolex, contains cannabidiol, or CBD, and is intended to treat Dravet syndrome and Lennox-Gastaut syndrome.

But Epidiolex is not expected to replace other cannabis products, which are not approved by the FDA. Jojo, for instance, continues to use another formulation of cannabis oil, his mother said.

Lucido, the Berkeley doctor, says his patients often need different combinations of CBD and THC for the treatment to be effective. Children with seizures may require multiple doses of CBD oil a day at regular intervals, he said, and allowing children to take it at school could result in better outcomes.

Medical cannabis, he added, doesn’t make kids intoxicated or sleepy as can many prescription anti-seizure drugs, allowing kids to be more alert in class. In many cases, the marijuana product that kids receive, such as CBD oil, isn’t the kind that gives users of recreational marijuana, which contains significant amounts of THC, a euphoric high.

Critics warn that children might be harmed by drugs that haven’t passed federal health and safety standards. For example, researchers at the University of California-Davis found potentially lethal bacteria and mold on samples of marijuana from 20 Northern California dispensaries two years ago.

“Our concern is the exposure to children of potentially contaminated products,” said Sue Rusche, president of the Atlanta-based National Families in Action, an anti-drug group that says any drug given as medicine ought to be approved by the federal government. “We don’t think they ought to be available to the public.”

Hill, the state senator who introduced California’s bill, said the decision should be left up to state residents.

“The people of California have made it very clear what they want,” he said. “We’re looking at the appropriate balance of that.”

Karina Garcia and her son, JoJo. Jojo can’t administer the medical marijuana himself because of his developmental disabilities, she says.(Scott Strazzante/The Chronicle)

For Garcia, all she wants is the freedom for herself and other parents to come out of the shadows and treat their kids no matter where they are — especially at school.

“When I first started giving him cannabis, I was scared to tell anybody,” Garcia said of Jojo, who as a special needs student can stay in high school until he is 22. “I kept it on the hush-hush. But then, he started improving, and I realized I had to tell people. And my story is not unique.”

KHN’s coverage of these topics is supported by California Health Care Foundation and Heising-Simons Foundation

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

Watch: What Happened To That $109,000 Heart Attack

Kaiser Health News:Insurance - August 29, 2018

Kaiser Health News editor-in-chief Elisabeth Rosenthal discusses the latest Bill of the Month installment on “CBS This Morning” on Wednesday.  The story of a high school teacher who faced an outrageous hospital bill is part of an ongoing crowdsourced investigation by KHN and NPR.

For Nursing Home Patients, Breast Cancer Surgery May Do More Harm Than Good

Kaiser Health News:Marketplace - August 29, 2018

Surgery is a mainstay of breast cancer treatment, offering most women a good chance of cure.

For frail nursing home residents, however, breast cancer surgery can harm their health and even hasten death, according to a study published Wednesday in JAMA Surgery.

The results have led some experts to question why patients who are fragile and advanced in years are screened for breast cancer, let alone given aggressive treatment.

The study examined the records of nearly 6,000 nursing home residents who had inpatient breast cancer surgery the past decade. It found that 31 to 42 percent died within a year of the procedure. That’s significantly higher than the 25 percent of nursing home residents who die in a typical year, said Dr. Victoria Tang, lead author and an assistant professor of geriatrics and hospital medicine at the University of California-San Francisco.

Although her study doesn’t include information about the cause of death, Tang said she suspects that many of the women died of underlying health problems or complications related to surgery, which can further weaken older patients. Patients who were the least able to take care of themselves before surgery, for example, were the most likely to die within the following year. Dementia also increased the risk of death.

It’s unlikely that many of the deaths were due to breast cancer, which often grows slowly in the elderly, Tang said. Breast cancers often take a decade to turn fatal.

“When someone gets breast cancer in a nursing home, it’s very unlikely to kill them,” said study co-author Dr. Laura Esserman, director of the UCSF

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breast cancer center. “They are more likely to die from their underlying condition.”

Yet most patients in the study got sicker and less independent in the year following breast surgery.

Among patients who survived at least one year, 58 percent suffered a serious downturn in their ability to perform “activities of daily living,” such as dressing, bathing, eating, using the bathroom or walking across the room.

Women in the study, who were on average 82 years old, suffered from a variety of life-threatening health problems even before being diagnosed with breast cancer. About 57 percent suffered from cognitive decline, 36 percent had diabetes, 22 percent had heart failure, 17 percent had chronic lung disease, and 12 percent had survived a heart attack.

The high mortality rate in the study is striking because breast surgery is typically considered a low-risk procedure, said Dr. Deborah Korenstein, chief of general internal medicine at New York’s Memorial Sloan Kettering Cancer Center.

The paper provided an example of how sick, elderly people can suffer from surgery. An 89-year-old woman with dementia who underwent a mastectomy became confused after surgery and pulled off all her bandages. Health care workers had to restrain her in bed to prevent her from pulling off the bandages again. The woman died 15 months later of a heart attack.

Surgery late in life is more common than many realize. One-third of Medicare patients undergo surgery in the year before they die, according to a 2011 study in The Lancet. Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week.

Nearly 1 in 5 women with severe cognitive impairment, such as Alzheimer’s disease, get regular mammograms, according to a study in the American Journal of Public Health.

The new study leaves some important questions unanswered.

The paper didn’t include healthier nursing home residents who are strong enough to undergo outpatient surgery, said Dr. Heather Neuman, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health. These women may fare better than those who are very ill.

Esserman and Tang said their findings suggest doctors need to treat breast cancer differently in very frail patients.

“People think, ‘Oh, a lumpectomy is nothing,’” Esserman said. “But it’s not nothing in someone who is old and frail.”

In recent years, doctors have tried to scale back breast cancer therapy to help women avoid serious side effects. In June, for example, researchers announced that sophisticated genetic tests can help predict which breast cancers are less aggressive, a finding that could allow 70 percent of patients to avoid chemotherapy.

The Medicare database used in this study didn’t mention whether any of the patients had chemotherapy, radiation or other outpatient care. So the UCSF researchers acknowledged that they can’t rule out the possibility that some of the women suffered complications due to these other therapies. In general, however, authors noted that only 6 percent of nursing home residents with cancer are treated with chemotherapy or radiation.

The authors said doctors should give very frail patients the option of undergoing less aggressive therapy, such as hormonal treatments. In other cases, doctors could offer to simply treat symptoms as they appear.

The new study raises questions about the value of screening nursing home residents for breast cancer, Korenstein said. Although the American Cancer Society hasn’t set an upper age limit for breast cancer screening, it advises women to be screened as long as they’re in good health and expected to live at least another decade.

Residents of nursing homes generally can’t expect to live long enough to benefit from breast screening, Korenstein said.

“It makes no sense to screen people in nursing homes,” Korenstein said. “The harms of doing anything about what you find are far going to outweigh the benefits.”

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

Wisconsin Reinstates Coverage Of Transgender Treatment For State Workers

Kaiser Health News:Insurance - August 29, 2018

In a surprising reversal, a Wisconsin board has voted to again offer insurance coverage to transgender state employees seeking hormone therapy and gender confirmation surgery.

Members of the Group Insurance Board, which manages the insurance program for Wisconsin’s public workers and retirees, last week voted 5-4 to overturn its current policy barring treatments and procedures “related to gender reassignment or sexual transformation.”

The change will take effect Jan. 1, allowing insurance to defray the cost of care deemed medically necessary.

“This was an empowering moment, offering up hope things can get better,” Wren Logan, a trans woman and psychiatry resident at UW Health who fought the policy, wrote in an email to Kaiser Health News.

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The board’s decision comes less than a month after Kaiser Health News, in partnership with NPR, published a project as part of its Bill of the Month series about a 24-year-old trans woman, Wren Vetens, who fought to get her gender confirmation surgery covered after the Group Insurance Board’s initial decision left her without insurance coverage.

It has been two years since the board first opted to pay for such expenses. That decision came shortly after the Obama administration unveiled a rule in May 2016 prohibiting discrimination based on gender identity, and the board was advised that refusing to cover certain treatments for trans patients could run afoul of that rule. Members voted unanimously in July 2016 for the change.

State officials soon began pressuring the board to not cover these services, despite the Obama administration’s directive.  About the same time, Wisconsin’s justice department joined a lawsuit challenging the anti-discrimination rule.

The board voted to reinstate the restrictive policy should a handful of conditions be met — one of which was a court decision to halt the rule. By coincidence, that ruling came the following day. A month later, in February 2017, the restrictions took effect once more, again barring trans patients from obtaining coverage.

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In a recent memo to the board, a state health policy adviser noted the “legal landscape” had changed, broadening protections for the transgender community. Last month, a federal judge ordered Wisconsin to pay for gender confirmation surgery for two individuals on Medicaid, who sought coverage to treat their gender dysphoria.

Gender dysphoria is the diagnosis for those with “significant distress” due to the difference between their gender and sex, according to the American Psychiatric Association.

In another case, two transgender women employed by the University of Wisconsin and covered by the state insurance program have sued the Group Insurance Board and the university’s board of regents, among others, accusing them of discrimination based on their inability to get coverage for gender confirmation surgery. The case is scheduled to go to trial in October, before the same judge who ruled in favor of the patients on Medicaid.

Officials from the University of Wisconsin — as well as UnitedHealthcare, which is opening a Medicare Advantage program for Wisconsin’s public employees and retirees — have also raised concerns about the policy.

The decision comes amid speculation that the Trump administration will soon unveil a new rule formally overturning the Obama-era anti-discrimination rule.

Earwax, Of All Things, Poses Unrecognized Risk In Long-Term Care

Kaiser Health News:Marketplace - August 29, 2018

Of all the indignities that come with aging, excessive earwax may be the most insidious.

Don’t laugh.

That greasy, often gross, buildup occurs more often in older ears than those of the young, experts say. And when it goes unrecognized, it can pose serious problems, especially for the 2.2 million people who live in U.S. nursing homes and assisted living centers.

“The excessive amount [of earwax] can cause hearing loss or ringing in your ears. Some people experience vertigo, which increases the risk of falling,” said Jackie Clark, a board-certified audiologist who is president of the American Academy of Audiology. “Right now, we see some correlation between hearing loss and cognitive decline.”

Earwax — which is not really wax at all, but a substance called cerumen that binds with dirt, dust and debris — is normally produced by the body as a way to clean and protect the ears. In most people, the self-cleaning process works fine.

But in others — including about 10 percent of young children, 20 percent of adults and more than 30 percent of elderly and developmentally disabled people — the wax collects to the point where it can completely block the ear canal.

Up to two-thirds of people in nursing homes may suffer from that condition, known as impaction, according to 2017 guidelines for removal of impacted earwax issued by the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

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In 2016, federal Medicare recipients logged nearly 1.7 million earwax removal services at a cost of more than $51 million, according to payment records analyzed by Kaiser Health News.

“In elderly patients, it’s fairly common,” said Dr. Seth Schwartz, a Seattle otolaryngologist who led the most recent update of the guidelines. “It seems like such a basic thing, but it’s one of the most common reasons people present for hearing-related problems.”

It’s so bad that Janie York, of Omaha, Neb., started Hear Now mobile hearing solutions, one of a growing number of businesses devoted to cleaning hearing aids and checking the ears of elderly people living in residential care settings.

“It’s epidemic,” said York, whose clients now include 10 local centers. “About 3 in 5 people I see have some degree of impaction and most are completely impacted.”

York runs Hear Now mobile hearing solutions, a business aimed at cleaning hearing aids and checking the ears of older people living in residential care settings.(Chris Machian for KHN)

York cleans Martin's hearing aid. (Chris Machian for KHN)

Julie Brown, assistant director of nursing in the memory support unit at SilverRidge Assisted Living in Gretna, Neb., said impacted earwax can be a particular problem for patients with dementia. It exacerbates hearing loss, which can impede communication and worsen aggression and other difficult behaviors.

“As soon as the earwax is cleared up, even their behavior has calmed down,” Brown said.

Excessive earwax sends about 12 million people to see health workers every year, including about eight million who require wax removal, according to the otolaryngology association.

That’s not counting the people who try DIY treatments to get rid of earwax, nearly all of which are frowned on by the professionals.

“People put everything in their ears: Q-tips, bobby pins, pencils, fingernails,” Schwartz said.

Usually, the best way to control earwax is to leave it alone, Schwartz said. But that advice can backfire when families or caregivers neglect to check the ears of elderly people in residential care.

In about 10 percent of young children, 20 percent of adults and more than 30 percent of elderly and developmentally disabled people, earwax collects to the point where it can completely block the ear canal.(Chris Machian for KHN)

Hearing-aid users should have regular ear checks every three to six months, the guidelines suggest. People with dementia should also have earwax removed regularly.

It can take a professional with an otoscope — a device that can look deep inside the ear — to tell if cerumen is blocking the ear canal. Usually, earwax can be safely removed by softening it with water, saline or commercial ear drops and then through gentle syringing or manual extraction with a device called a curette.

The effects in the elderly can be immediate. A small 2014 study by Japanese researchers found significant improvements in hearing and cognitive performance in elderly patients with memory disorders when impacted cerumen was removed.

Too often, though, earwax in the elderly goes unnoticed.

“I’m seeing 15 people here, but what about the other hundred?” York said. “Nobody’s looking. I don’t know why it’s been neglected for so long.”

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

Shifting Gears: Insuring Your Health Column — Born With The ACA — Draws To A Close

Until I started writing the Insuring Your Health column eight years ago, I had no idea what a medical loss ratio was, and I’d surely never used the words “benchmark silver plan” in a story. If asked, I would have guessed that “ACA” stood for the American Canoe Association (which is actually a thing, by the way).

Now I know better. Way better, having written once or twice a week for several years about how the Affordable Care Act has affected consumers’ health care coverage and costs.

I’ve delved into other coverage issues along the way as well, but the huge changes brought about by the 2010 health law have been a constant focus.

Now it’s time to shift gears. This is the last Insuring Your Health column. But it isn’t the last time you’ll hear from me at Kaiser Health News. I’ll continue writing regularly about consumer health care for KHN, just not every Tuesday. With the added flexibility I want to be able to now and then take a broader look at some of the consumer health areas I’ve been writing about over the years. I hope you will keep reading and giving me feedback.

I couldn’t do this work without a lot of help. Thanks to the many, many smart and thoughtful pros who’ve carved out time to talk with me again and again to help me understand the devil-in-the-details of medicine, health law and policy. I expect I’ll be calling on some of you this week to chat.

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Thanks also to the amazing team of committed journalists at KHN who produce such great work day in and day out. They are an inspiration.

Most of all, I’d like to thank the many people who’ve shared their stories with me over the years and allowed me to write about them. People like Kristen Catton, who faced thousands of dollars in bills when her health plan changed how it covered her multiple sclerosis drug. Or Phyllis Petruzzelli, who avoided a hospital stay for pneumonia by being “admitted” to her living room through a hospital-at-home program. Those experiences explain health policy in personal terms for readers, and I’m so grateful to the many people who’ve trusted me to tell their stories.

And I hope you’ll keep on doing so! Hearing from real readers about their boots-on-the-ground experiences in the health care trenches, as it were, is invaluable.

Please let me know what’s on your mind and how the system is working for you. You can reach me at Andrews.KHN@gmail.com. I look forward to hearing your thoughts and ideas.

A Jolt To The Jugular! You’re Insured But Still Owe $109K For Your Heart Attack

Kaiser Health News:Insurance - August 27, 2018

Drew Calver took out his trash cans and then waved goodbye to his wife, Erin, as she left for the grocery store the morning that upended his picture-perfect life.

Minutes later, the popular high school history teacher and swim coach in Austin, Texas, collapsed in his bedroom from a heart attack. He pounded his fist on the bed frame, violent chest pains pinning him to the floor.

“I thought I was dying,” the 44-year-old father recalled. He called out to the only other person in the house, his oldest daughter, Eleanor, now 7. Using his voice, he texted his wife, who was at the store with their youngest, Emory, now 6. A neighbor rushed him to the nearby emergency room at St. David’s Medical Center on April 2, 2017.

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The ER doctors confirmed the trauma to Calver’s heart and admitted him to the hospital’s cardiac unit. The next day, doctors implanted stents in his clogged “widow-maker” artery.

The heart attack was a shock for Calver, an avid swimmer who had competed in an Ironman triathlon just five months before.

Despite the surprise, even from his hospital bed, Calver asked whether his health insurance would cover all of this, a financial worry that accompanies nearly every American hospital stay. He was concerned because St. David’s is out-of-network on his school district health plan. The hospital told him not to worry and that they would accept his insurance, Calver said.

The hospital charged $164,941 for his surgery and four days in the hospital. Aetna, which administers health benefits for the Austin Independent School District, paid the hospital $55,840, records show. Despite the difference of more than $100,000, with the hospital’s prior assurance, Calver believed he would not bear much, if any, out-of-pocket payment for his life-threatening emergency and the surgery that saved him.

And then the bills came.

Patient: Drew Calver, 44, a high school history teacher and father of two in Austin, Texas.

Total Bill: $164,941 for a four-day hospital stay, including $42,944 for four stents and $10,920 for room charges. Calver’s insurer paid $55,840. The hospital billed Calver for the unpaid balance of $108,951.31.

Service Provider: St. David’s HealthCare, a large hospital system in central Texas. It’s run by HCA Healthcare, the nation’s largest for-profit hospital chain, and two nonprofit foundations.

Medical Treatment: Emergency room treatment followed by four days in the hospital, most of it spent in the cardiac unit. During surgery, four stents were implanted to clear a blockage in his left anterior descending artery, the source of so-called widow-maker heart attacks, because they are so frequently deadly.

What Gives: St. David’s Medical Center is billing Calver for the $109,000 balance — an amount nearly twice his annual pay as a teacher.

The hospital’s billing company sent a notice June 26, urging him to take advantage of this “FINAL opportunity to settle your balance.

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“They’re going to give me another heart attack stressing over this bill,” Calver said. “I can’t pay this bill on my teacher salary, and I don’t want this to go to a debt collector.”

In the wake of his heart attack, Calver fell victim to twin medical billing practices that increasingly bedevil many Americans, even as legislators have tried to protect them: surprise bills and balance billing.

Surprise bills occur when a patient goes to a hospital in his insurance network but receives treatment from a doctor that does not participate in the network, resulting in a direct bill to the patient. They can also occur in cases like Calver’s, where insurers will pay for needed emergency care at the closest hospital — even if it is out-of-network — but the hospital and the insurer may not agree on a reasonable price. The hospital then demands that patients pay the difference, in a practice called balance billing.

The total bill for Drew Calver’s four-day hospital stay at St. David’s Medical Center in April 2017 was $164,941.(Callie Richmond for KHN)

His insurer paid $55,840, leaving Calver responsible for the unpaid balance of $108,951.31.(Callie Richmond for KHN)

Several states, including Texas (as well as New York, California and New Jersey) have passed laws to help shield consumers from surprise bills and balance billing, particularly for emergency care.

But there’s a huge loophole: Those state-mandated protections don’t apply to people, like the Calver family, who get their health coverage from employers that are self-insured, meaning the companies or public employers pay claims out of their own funds.  Federal law governs those health plans — and it does not include such protections.

About 60 percent of people with employer health benefits are covered by self-insured plans, but many don’t even know it, since employers typically hire an insurer to administer the plan and employees carry a card bearing the name of Blue Cross Blue Shield or another major insurer.

Drew Calver sits with his wife, Erin, and daughters Eleanor (left) and Emory (middle) in their Austin, Texas, home where he had a heart attack on April 2, 2017.(Callie Richmond for KHN)

This case “illustrates the dangers that even insured people face,” said Carol Lucas, an attorney in Los Angeles with experience in health care payment disputes. “The unfairness is especially acute when there is an emergency and the patient, who might ordinarily be completely compliant, has no say about the facility he winds up in.”

In a statement, St. David’s HealthCare defended its handling of Calver’s bill and sought to blame the school district and Aetna for offering such a narrow network.

“While we did everything right in this particular situation, the structure of the patient’s insurance plan as a narrow network product placed a large portion of the financial responsibility directly on the patient because our hospital was not in-network,” the hospital said.

Patients experiencing an emergency are particularly at risk of landing at an out-of-network hospital. St. David’s said once ER patients are deemed stable, it tries to transfer them to an in-network facility. “However, this is not always possible because the patient’s health must come first,” the hospital said.

This case also raises questions about the validity of the hospital’s charges.

Industry analysts and consumer advocates say St. David’s has a reputation for exorbitant billing and for trying to collect big payouts as an out-of-network provider. “This is a well-known, problematic provider. We’ve seen multiple bills from them and they are always highly inflated,” said Dr. Merrit Quarum, chief executive of WellRithms, which scrutinizes medical bills for self-funded employers and other clients nationwide.

WellRithms reviewed Calver’s bill in detail at the request of Kaiser Health News and determined that a reasonable reimbursement would have been $26,985. That’s less than half what Aetna paid.

Healthcare Bluebook, which offers cost estimates for medical tests and treatments, arrived at a similar conclusion. It said a fair price for a hospitalization in Austin involving four heart stents would be about $36,800. St. David’s Medical Center charged four times that amount.

Quarum and other analysts who reviewed the bill said several charges stood out, especially on the four stents, which were billed at $42,944. Coronary stents are typically metal mesh tubes implanted in arteries to improve blood flow. Most are coated with drugs to assist in healing.

St. David’s charged $19,708 apiece for two Synergy stents made by device giant Boston Scientific. Two other stents used were far cheaper.

The $20,000 price tag represents a significant markup of what U.S. hospitals typically pay themselves for stents. The median price paid by hospitals for the Synergy stent was $1,153 over the past year, according to the nonprofit research firm ECRI Institute.

“St. David’s charge of over $19,000 for those stents is absolutely outrageous,” Quarum said.

St. David’s declined to comment on its markup for the stents or what it actually paid the manufacturer.

Resolution: For now, Calver still faces a bill for $108,951.31, with none of the parties involved in his treatment or coverage providing significant redress.

In fact, the hospital’s debt collector sent the Calvers a letter Aug. 3 demanding payment in full.

After a reporter made inquiries, St. David’s said collection efforts were put on hold, and a hospital representative called Calver, offering to help him apply for a discount based on his income.

In a statement, St. David’s said “we work with all patients needing financial assistance to help determine their eligibility for this discount.”

Calver said that approach doesn’t address the balance billing or whether the charges were appropriate.

A spokeswoman for Aetna said “we are actively working to rectify the situation on behalf of the member.” But the health plan hasn’t shared any further details. The Austin school district declined to discuss this specific case.

Calver said the whole ordeal has been incredibly stressful for him and his wife.

“I am stuck in the middle of this convoluted, flawed system,” he said. “I’ve never owed a large amount like this or had credit card debt. What does it mean if this goes on my credit report?”

Drew Calver’s daughters visit him at the hospital in April 2017 after his heart attack and resulting emergency surgery.(Courtesy of the Calver family)

The Takeaway: Faced with a surprise bill or a balance-billing situation, don’t rush to pay any medical bills you receive. First, let the insurance process play out completely so you’re sure what the health plan is paying the hospital and doctors — and what you ultimately might be responsible for, in terms of coinsurance or copayments.

Ask for an itemized bill. Review the charges carefully and talk to your insurer, your employer and the hospital if the prices seem out of line. Arm yourself with estimates you can find online of the average prices charged in your area as you negotiate with all the players.

If the bills keep coming, talk to your employer’s benefits department or the state insurance department about your legal protections. The situation will vary depending on the type of health insurance you have and the state you live in. Tell any debt collection agencies that may contact you that you are contesting the bill.

With any of these entities, you can always appeal to reason, with this argument: You had no choice but to go to an out-of-network hospital in the case of a life-threatening emergency, so the insurer and the hospital should work out payment and hold you harmless from financially crippling bills.

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

The Doctors Want In: Democratic Docs Talk Health Care On The Campaign Trail

Dr. Rob Davidson, an emergency physician from western Michigan, had never considered running for Congress. Then came February 2017. The 46-year-old Democrat found himself at a local town-hall meeting going toe-to-toe with Rep. Bill Huizenga, his Republican congressman of the previous six years.

“I told him about my patients,” Davidson recalled. “I see, every shift, some impact of not having adequate health care, not having dental insurance or a doctor at all.”

His comments triggered cheers from the audience but didn’t seem to register with Huizenga, a vocal Obamacare critic. And that got Davidson thinking.

Dr. Rob Davidson (Courtesy of Rob Davidson’s campaign)

“I’ve always been very upset … about patients who can’t get health care,” he said. But it never inspired him to act. Until this June, that is, when the political novice joined what is now at least eight other Democratic physicians running in races across the country as first-time candidates for Congress.

Democrats hope to gain control of Congress by harnessing what polls show to be voters’ dissatisfaction with both Capitol Hill and President Donald Trump. The president maintains Republican support but registers low approval ratings among Americans overall, according to news organization FiveThirtyEight. Democrats also see promise in candidates such as Davidson, a left-leaning physician who may have a special advantage: firsthand health system experience.

Polls by Quinnipiac University, The Wall Street Journal and the Kaiser Family Foundation suggest health care is among voters’ top concerns as midterm elections approach. (Kaiser Health News is an editorially independent project of the foundation.)

Of the Democratic doctors running for office, all but one are seeking House seats. In addition to the nine newcomers, there are two incumbents up for re-election. Each candidate is campaigning hard on the need to reform the health care system.

And they present a stark contrast to Congress’ current physician makeup.

Twelve of the 14 doctors now in Congress are Republicans. Three are senators. Half of the 14 practice in high-paying specialties such as orthopedic surgery, urology and anesthesiology.

By contrast, these stumping Democratic physicians hail predominantly from specialties such as emergency medicine, pediatrics and internal medicine, though one is a radiologist. They’re fighting to represent a mix of rural, urban and suburban districts.

(Story continues below.)

 

“Electing Democratic doctors would certainly change the face of medicine in Congress, and perhaps lend more credence in that body to more liberal health care policies,” said Dr. Matthew Goldenberg, a psychiatrist at Yale School of Medicine who has researched political behavior and advocacy among doctors.

Physicians once trended Republican. The infusion of female and minority doctors, experts said, has changed this. Now, more than 50 percent of party-affiliated doctors are Democrats, and the medical establishment has — following Republican efforts to undo Obamacare — emerged as a staunch defender of the law.

Indeed, many doctor-candidates point to the GOP’s repeal-and-replace efforts as their motivation.

“It’s at a boiling point for many of these physicians,” said Jim Duffett, executive director of the left-leaning Doctors for America, which supports universal health care.

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While health care consistently emerges as a top issue, Democrats are more likely to rank it No. 1. For independents and Republicans, though, it’s neck and neck with the economy — and some political analysts question how effective it will be in flipping conservative districts.

“Democrat voters blame Republicans for the problems with health care right now. Republicans blame Democrats. Independents say, ‘A pox on both your houses,’” argued Jim McLaughlin, a Republican pollster working on several 2018 races who has previously worked with Trump. “They’re making a big mistake thinking they can run on [health care].”

That said, doctors can be effective messengers, especially in their communities.

Research suggests Americans hold their own physicians in high regard.

“Voters listen carefully to what physicians have to say about health policy,” said Jonathan Oberlander, a professor of social medicine and health policy at the University of North Carolina. “In a district that’s not so one-sided red or blue, there’s no question that the white coat confers prestige. It’s something physician candidates can speak to with authority.”

Dr. Kyle Horton (Courtesy of Kyle Horton’s campaign)

Davidson, for instance, supports a “Medicare-for-all”-style overhaul, an approach that involves expanding the federal insurance program for seniors and disabled people to all Americans. If elected, he said, he intends to join Democrats’ burgeoning support for a single-payer system, in which the government runs the sole health insurance program, guaranteeing universal coverage. He did not have a primary challenge and is running against Huizenga, the Republican incumbent, in the general election for Michigan’s 2nd Congressional District.

Or there’s Dr. Kyle Horton, an internist running in the North Carolina 7th District. She supports expanding Medicare, by lowering the eligibility age from 65 to 50. She also supports a “public option” health insurance plan sold by the government.

Dr. Hiral Tipirneni (Courtesy of Hiral Tipirneni’s campaign)

Dr. Hiral Tipirneni, an emergency physician in Arizona’s 8th Congressional District, asserts all Americans should be able to buy in to Medicare.

Physicians can have an advantage on other controversial topics, by casting them as public health issues, said Howard Rosenthal, a political scientist at New York University.

Davidson’s campaign, for instance, posts videos on Facebook in which he talks about topics such as health care access and gun violence. One — filmed after an overnight ER shift — has gotten 41,000 views so far.

Also spurring physicians: concerns about abortion access.

Dr. Cathleen London (Courtesy of Kathleen London’s campaign)

Dr. Cathleen London, a Maine doctor, launched her campaign against four-term incumbent GOP Sen. Susan Collins for the 2020 election. She said she had been considering a run, but the upcoming vote for a justice to replace Anthony Kennedy on the Supreme Court — which could have sweeping implications for reproductive health law — pushed her to declare.

“Doctors are really frustrated with Washington, frustrated with the lack of listening to us,” London said.

Many of these Democrats face steep climbs.

Dr. Kim Schrier (Courtesy of Kim Schrier’s campaign)

Of races featuring newcomer physicians, the Cook Political Report, which analyzes elections, rates only Arizona’s 2nd Congressional District as leaning Democratic, and the doctor in that race is just one of seven candidates in the primary. The outcome for Washington’s 8th District, where Dr. Kim Schrier, a pediatrician, is a candidate, is considered a toss-up and a Democratic pickup target.

Tipirneni is the only non-incumbent doctor to have a fundraising advantage so far, according to data from Open Secrets, a nonpartisan, nonprofit project tracking campaign-finance records.

Regardless of electoral results, many observers say the potential implications are sizable — even if few doctors go to Washington.

“They are planting a flag, and they’re going to be raising some important issues — not just health care, but health care is going to be front and center,” said Duffett, from Doctors for America. “That will help change the political debate and political landscape.”

Pediatricians Put It Bluntly: Motherhood And Marijuana Don’t Mix

Kaiser Health News:States - August 27, 2018

More and more people consider smoking marijuana harmless or even beneficial, but mounting research suggests women who are pregnant or breastfeeding should avoid it altogether.

That’s according to new recommendations from the American Academy of Pediatrics, which cites growing evidence of marijuana’s potential harm to children’s long-term development.

The strong direction to women and pediatricians comes as more than half of states, including California, have legalized marijuana for medical or recreational use, and studies show that a growing number of babies are being exposed to the drug.

The march toward marijuana legalization has outpaced scientific research about its effects. Because marijuana is a Schedule 1 drug — by definition, one with potential for abuse and no approved medical use — federal law has limited research on it. But in a detailed review of the existing safety data published Monday in the journal Pediatrics, researchers concluded that enough concerns exist about both short-term growth and long-term neurological consequences for children to recommend against it.

“Women should definitely be counseled that it’s not a good idea to use marijuana while pregnant. If you’re breastfeeding, we would encourage you to cut back or quit,” said Seth Ammerman, a co-author of the report and professor of pediatrics at Stanford.

If a breastfeeding mother does not stop using, however, “the benefits of breastfeeding would outweigh the potential exposure to the infant,” he added.

A second study, also published in Pediatrics, found that THC, the molecule that gives marijuana most of its psychoactive effects, accumulates in breast milk, even up to six days after the mother’s last use.

The findings come as marijuana use among pregnant women is rising. From 2002 to 2014, self-reported use of marijuana in the past month increased by 62 percent to 3.85 percent. Since then, a growing number of states have legalized marijuana for recreational use, so this is likely an underestimate of current rates. In studies of urban, young and socioeconomically disadvantaged pregnant women, 15 to 28 percent of women reported using the drug.

California legalized use of recreational marijuana among adults 21 and older beginning in January.

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Unlike for alcohol and cigarettes, even legally sold marijuana may not carry a safety warning for pregnant women, depending on the state. California and Colorado do require safety warnings.

“There’s a myth out there that it’s benign. And for many adults who are sporadic users, that’s probably true. But in these circumstances it may be harmful,” said Ammerman.

Of particular concern, he added, is that the potency of THC in marijuana has more than quadrupled since 1983. Several of the largest studies were conducted when potency was much lower, according to the report.

Research has found that THC can easily cross the placenta and accumulate in the brain and fat of the growing fetus. Studies, while limited, suggest that prenatal exposure to marijuana could cause harm to children’s executive functioning, including concentration, attention, impulse control and problem-solving.

Nonetheless, mothers groups online are filled with women touting the benefits of marijuana during pregnancy, citing the drug as a remedy for the nausea of morning sickness.

“A lot of women may be getting the info from online media and from marijuana dispensaries. As health professionals, we need to educate women that there are a lot of concerns both for the fetus and for later development,” said Kelly Young-Wolff, a research scientist at the Kaiser Permanente Northern California Division of Research, who was not involved in the Pediatrics studies. (Kaiser Health News is not affiliated with Kaiser Permanente.)

A recent study in the journal Obstetrics and Gynecology, for example, found that 70 percent of cannabis dispensaries in Colorado recommended marijuana to treat morning sickness during the first trimester. No evidence suggests that marijuana use is safe or indicated for morning sickness, said Young-Wolff, though there are plenty of other options that a health professional can recommend. And the worst nausea happens in the first trimester, when the developing fetus might be the most vulnerable to substances like marijuana.

But convincing women of the dangers of cannabis use during pregnancy can be challenging. “A lot of the public equates legalization with some kind of endorsement of safety. Of course, that’s not true,” said Dana Gossett, a professor of obstetrics and gynecology at the University of California-San Francisco.

When she counsels patients to avoid marijuana, Gossett said, she runs into a “fair amount of indifference.”

Pregnancy is often a time when women are receptive to changing their habits to protect their growing baby. But while they generally accept that smoking cigarettes is bad — that’s been clear since the 1960s — they often view marijuana as safe and natural, and therefore harmless.

“Just because something is plant-based or natural doesn’t make it safe.” Arsenic, added Gossett, is also a natural substance.

So far, the news of the dangers of marijuana during pregnancy and breastfeeding does not appear to be reaching its target audience.

On Facebook, the group “Stoner Moms” has more than 22,000 followers. And the Glow Nurture pregnancy app has several community groups devoted to users, including “420 Friendly,” “Ganja Mommies,” “CannaMoms” and “Stoners.”

The chats are filled with women asking not whether marijuana could be harmful, but rather whether smoking marijuana could put them at risk of involvement from Child Protective Services.

“I live in Georgia. … I’m only 5 weeks but I plan to keep smoking since there’s no evidence of it being harmful. Has anyone given birth here without being tested?” asked one user on the “Moms for Marijuana” group on the popular BabyCenter app.

A user in Wisconsin wrote: “Did you have any issues with being tested at delivery or having CPS getting involved while on Medicaid? Thanks in advance!!”

“I wonder if moms that smoke cigarettes have to go through the same worries that moms that smoke weed do?” asked a third poster in North Carolina. “I stopped smoking at 24 weeks and it just sucks that we have to live in fear of our babies being taken away! Even though there’s no evidence of weed being harmful!”

Screening rules vary by hospital, but 24 states and the District of Columbia require health care professionals to report suspected prenatal drug use, according to the Guttmacher Institute. In many states, drug use can be used as evidence of child neglect or abuse in a civil case.

According to Young-Wolff, although pregnant and breastfeeding women should certainly be educated about the risks of marijuana, “none of this research should be used to penalize or stigmatize women.”

Correction: An earlier version of this story incorrectly reported that no states require safety warnings for pregnant women on legally sold marijuana. At least six states do require labeling.

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

McCain’s Complicated Health Care Legacy: He Hated the ACA. He Also Saved It.

There are many lawmakers who made their names in health care, seeking to usher through historic changes to a broken system.

John McCain was not one of them.

And yet, the six-term senator from Arizona and decorated military veteran leaves behind his own health care legacy, seemingly driven less by his interest in health care policy than his disdain for bullies trampling the “little guy.”

He was not always successful. While McCain was instrumental in the passage of the Americans with Disabilities Act in 1990, most of the health initiatives he undertook failed after running afoul of traditional Republican priorities. His prescriptions often involved more government regulation and increased taxes.

In 2008, as the Republican nominee for president, he ran on a health care platform that dumbfounded many in his party who worried it would raise taxes on top of overhauling the U.S. tradition of workplace insurance.

Many will remember McCain as the incidental savior of the Affordable Care Act, whose late-night thumbs-down vote halted his party’s most promising effort to overturn a major Democratic achievement — the signature achievement, in fact, of the Democrat who beat him to become president. It was a vote that earned him regular — and biting — admonishments from President Donald Trump.

McCain died Saturday, following a battle with brain cancer. He was 81. Coincidentally, his Senate colleague and good friend Ted Kennedy died on the same date, Aug. 25, nine years ago, succumbing to the same type of rare brain tumor.

Whether indulging in conspiracy theories or wishful thinking, some have attributed McCain’s vote on the ACA in July 2017 to a change of heart shortly after his terminal cancer diagnosis.

But McCain spent much of his 35 years in Congress fighting a never-ending supply of goliaths, among them health insurance companies, the tobacco industry and, in his estimation, the Affordable Care Act, a law that extended insurance coverage to millions of Americans but did not solve the system’s ballooning costs.

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His prey were the sort of boogeymen that made for compelling campaign ads in a career stacked with campaigns. But McCain was “always for the little guy,” said Douglas Holtz-Eakin, the chief domestic policy adviser on McCain’s 2008 presidential campaign.

“John’s idea of empathy is saying to you, ‘I’ll punch the bully for you,’” he said in an interview before McCain’s death.

McCain’s distaste for President Barack Obama’s health care law was no secret. While he agreed that the health care system was broken, he did not think more government involvement would fix it. Like most Republicans, he campaigned in his last Senate race on a promise to repeal and replace the law with something better.

After Republicans spent months bickering amongst themselves about what was better, McCain was disappointed in the option presented to senators hours before their vote: hobble the ACA and trust that a handful of lawmakers would be able to craft an alternative behind closed doors, despite failing to accomplish that very thing after years of trying.

What bothered McCain more, though, was his party’s strategy to pass their so-called skinny repeal measure, skipping committee consideration and delivering it straight to the floor. They also rejected any input from the opposing party, a tactic for which he had slammed Democrats when the ACA passed in 2010 without a single GOP vote. He lamented that Republican leaders had cast aside compromise-nurturing Senate procedures in pursuit of political victory.

In his 2018 memoirs, “The Restless Wave,” McCain said even Obama called to express gratitude for McCain’s vote against the Republican repeal bill.

“I was thanked for my vote by Democratic friends more profusely than I should have been for helping save Obamacare,” McCain wrote. “That had not been my goal.”

Better known for his work on campaign finance reform and the military, McCain did have a hand in one landmark health bill — the Americans with Disabilities Act of 1990, the country’s first comprehensive civil rights law that addressed the needs of those with disabilities. An early co-sponsor of the legislation, he championed the rights of the disabled, speaking of the service members and civilians he met in his travels who had become disabled during military conflict.

McCain himself had limited use of his arms due to injuries inflicted while he was a prisoner of war in Vietnam, though he was quicker to talk about the troubles of others than his own when advocating policy.

Yet two of his biggest bills on health care ended in defeat.

In 1998, McCain introduced a sweeping bill that would regulate the tobacco industry and increase taxes on cigarettes, hoping to discourage teenagers from smoking and raise money for research and related health care costs. It faltered under opposition from his fellow Republicans.

McCain also joined an effort with two Democratic senators, Kennedy of Massachusetts and John Edwards of North Carolina, to pass a patients’ bill of rights in 2001. He resisted at first, concerned in particular about the right it gave patients to sue health care companies, said Sonya Elling, who served as a health care aide in McCain’s office for about a decade. But he came around.

“It was the human, the personal aspect of it, basically,” said Elling, now senior director of federal affairs at Eli Lilly. “It was providing him some of the real stories about how people were being hurt and some of the barriers that existed for people in the current system.”

The legislation would have granted patients with private insurance the right to emergency and specialist care in addition to the right to seek redress for being wrongly denied care. But President George W. Bush threatened to veto the measure, claiming it would fuel frivolous lawsuits. The bill failed.

McCain’s health care efforts bolstered his reputation as a lawmaker willing to work across the aisle. Sen. Chuck Schumer of New York, now the Senate’s Democratic leader, sought his help on legislation in 2001 to expand access to generic drugs. In 2015, McCain led a bipartisan coalition to pass a law that would strengthen mental health and suicide prevention programs for veterans, among other veterans’ care measures he undertook.

It was McCain’s relationship with Kennedy that stood out, inspiring eerie comparisons when McCain was diagnosed last year with glioblastoma — a form of brain cancer — shortly before his vote saved the Affordable Care Act.

That same aggressive brain cancer killed Kennedy in 2009, months before the passage of the law that helped realize his work to secure better access for Americans to health care.

“I had strenuously opposed it, but I was very sorry that Ted had not lived to see his long crusade come to a successful end,” McCain wrote in his 2018 book.

While some of his biggest health care measures failed, the experiences helped burnish McCain’s résumé for his 2000 and 2008 presidential campaigns.

In 2007, trailing other favored Republicans, such as former New York City mayor Rudy Giuliani in early polling and fundraising, McCain asked his advisers to craft a health care proposal, said Holtz-Eakin. It was an unusual move for a Republican presidential primary.

The result was a remarkable plan that would eliminate the tax break employers get for providing health benefits to workers, known as the employer exclusion, and replace it with refundable tax credits to help people — not just those working in firms that supplied coverage — buy insurance individually. He argued employer-provided plans were driving up costs, as well as keeping salaries lower.

The plan was controversial, triggering “a total freakout” when McCain gained more prominence and scrutiny, Holtz-Eakin said. But McCain stood by it.

“He might not have been a health guy, but he knew how important that was,” he said. “And he was relentless about getting it done.”

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