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Ending Involuntary Commitments Would Shift Burden of Dementia Care to Strapped Communities

Kaiser Health News:States - January 13, 2023

HELENA, Mont. — State lawmakers from both parties have shown support for a plan to stop the practice of committing people with Alzheimer’s disease, other types of dementia, or traumatic brain injuries without their consent to the troubled Montana State Hospital and instead direct them to treatment in their communities.

But a budget estimate attached to the proposed legislation raises questions about whether Montana communities, many of which are still reeling from past budget cuts and insufficient Medicaid reimbursement rates, will have the capacity to care for them by July 2025, when involuntary commitments would cease under the plan.

Health department officials essentially acknowledged as much in the fiscal note accompanying House Bill 29, sponsored by Republican state Rep. Jennifer Carlson. Health officials wrote in the unsigned fiscal note that 24-hour skilled nursing facilities are often the only appropriate settings for such patients, and that few of those facilities “are willing to take these individuals as an alternative placement to the Montana State Hospital.”

As a result, health department officials anticipate having to transfer patients with a diagnosis of Alzheimer’s, other dementia, or a traumatic brain injury from the Montana State Hospital to the state Mental Health Nursing Care Center, a long-term, 117-bed residential facility in Lewistown for people with mental health disorders, if the bill passes. The health department says the facility is for people who “require a level of care not available in the community, but who cannot benefit from the intensive psychiatric treatment available at Montana State Hospital.”

Department officials expect to move 24 patients from the state hospital to the Lewistown facility between fiscal years 2025 and 2027 if the bill passes. The cost of caring for those patients at the Lewistown facility would start at $181,062 per patient, per year, for a total cost of about $10 million over three years. The beds they vacate at Montana State Hospital would likely be immediately filled by other patients, so there would be no expected cost savings there, according to the fiscal note.

Department of Public Health and Human Services spokesperson Jon Ebelt did not immediately comment on the document outlining the expected transfers.

Carlson said she was surprised health department officials expected to relocate patients to another state-run facility when the point of the bill is to facilitate community treatment.

But, she added, that cost would be lowered if the state raised its Medicaid reimbursement rates. If the state raised its reimbursement rates to nursing homes to $300 per patient, per day, from its current $208 rate, those same 24 patients could end up costing the state a lot less, she said.

Carlson said some dementia patients are committed to the state hospital as a last resort because there are no other options for providing the intensive care they need.

“But that excuse is not good enough for me,” Carlson said. “There should be somewhere else for them to go.”

Carlson’s bill is just one of several measures to overhaul operations at the Montana State Hospital.

The Centers for Medicare & Medicaid Services revoked the hospital’s certification after an investigation into a series of deaths and injuries there, leading to the loss of federal funding. The hospital has been strained by high rates of staff vacancies and employee turnover, leading to a reliance on higher-priced temporary staff and contributing to the hospital’s waiting list for admissions.

The bill’s goal of removing patients with dementia or traumatic brain injuries from the Montana State Hospital and into community care has bipartisan support. The Children, Families, Health, and Human Services interim committee voted unanimously last summer to forward the bill to the full legislature. Carlson’s HB 29 was scheduled for its first hearing on Jan. 13 in the House Human Services Committee.

Matt Kuntz, executive director of Montana’s chapter of the National Alliance on Mental Illness, said there is broad agreement that the state hospital isn’t the place for Alzheimer’s patients. The reason the state is in this situation is that community centers don’t have the capacity to care for a growing Alzheimer’s population, he said.

“The positive thing is at least someone’s moving proactively and saying this isn’t right,” Kuntz said of the bill.

Kuntz said the health department is probably right that some patients would end up at the Mental Health Nursing Care Center in Lewistown if the bill passes. But, he added, the bill is meant to reduce institutionalization, not raise the cost of institutionalization.

“Institutionalization of a patient is incredibly expensive and needs to be avoided whenever possible, and that is the crux of Carlson’s bill,” Kuntz said.

Democratic House Minority Leader Kim Abbott said the health and safety of the most vulnerable members of the community is a top priority for the Democratic caucus.

“Community-based care that’s closer to family makes a lot of sense, but we want to make sure that we’re giving it a good vetting,” Abbott said.

Carlson said HB 29 does two things: First, it ends the involuntary commitment of people who shouldn’t be in a mental institution, she said, unless they are an immediate threat to themselves or others. Second, the measure outlines a plan to provide appropriate care within the patients’ communities.

Kuntz said the bill’s 2025 deadline for ending involuntary commitments gives room for officials and legislators to figure out ways to improve it.

The bill would create a transition committee made up of legislators, governor appointees, and state employees with expertise in nursing facilities, Alzheimer’s and other types of dementia, and traumatic brain injuries. The panel would be tasked with finding answers to some big questions, such as where patients can go for care instead of the hospital and figuring out the logistics of relocating patients already in the state hospital. The panel also would track the progress of developing community-based services until involuntary commitments end in 2025.

Gov. Greg Gianforte’s two-year budget proposal, the starting point for legislative budget writers, also includes spending $300 million on behavioral health and improvements to the Montana State Hospital.

Carlson’s bill also directs the health department to give geriatric state hospital residents or those with Alzheimer’s, other forms of dementia, or traumatic brain injuries priority admission to nursing homes.

“This is a mandate that we improve our community-based systems,” Carlson said.

But those nursing homes face problems of their own, with 11 announcing closures last year amid staffing vacancies and Medicaid reimbursement rates too low to cover the cost of care. A study commissioned by the state government recommended raising those rates to $278.75 per patient, per day. But Gianforte’s budget proposal includes funding for only a portion of that recommended increase: $238.77 per patient, per day, by 2025.

The Montana Health Care Association represents the state’s nursing homes. Executive Director Rose Hughes said nursing homes are probably the places that should be caring for these patients. But there has to be a step between ending involuntary commitment and transitioning all the patients to community centers that can’t yet support them, she said.

“For it to be successful, there really has to be an effort made to support the community providers,” Hughes said.

She doesn’t believe there should be a hard deadline to end involuntary commitments until those community resources are in place. But, she added, there will be another legislative session before the 2025 deadline for lawmakers to extend the process if needed.

“It may not be enough time to solve the problem,” Hughes said. “But I don’t think the problem is going to be worked on unless there is a deadline.”

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


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Ask Voters Directly, and Abortion Rights Wins Most Ballot Fights

Kaiser Health News:States - January 13, 2023

This is shaping up as a critical year in the country’s battle over abortion rights, as both sides struggle to define a new status quo after the Supreme Court struck down the nearly half-century-old constitutional right last year.

It is important not to misread what happened in 2022. After a 6-3 majority of justices overturned Roe v. Wade, voters in six states were asked to choose between preserving or reducing abortion rights. In all six — Kansas, Michigan, California, Kentucky, Montana, and Vermont — voters sided with abortion rights.

Anti-abortion politicians have fared well in recent elections, contributing to a wave of anti-abortion legislation in many statehouses. But when voters are asked to consider a direct ballot question about abortion access — as opposed to weighing in on a candidate, whose anti-abortion position may be one of many stances they hold — voters strongly favor abortion rights.

Many pundits were shocked by last year’s results, particularly in Kansas, where voters have backed the Republican candidate in nearly every presidential election since 1940. Less than six weeks after the court’s decision, Kansas residents — including a large, mostly female contingent of newly registered voters — rejected an amendment to the state constitution that was put on the ballot by anti-abortion state legislators in an effort to overturn a 2019 decision by the Kansas Supreme Court.

It was unquestionably a big deal that the abortion-rights side won by 18 percentage points, particularly since the measure appeared on the ballot during the state’s August primary, when its backers anticipated lower and Republican-leaning voter turnout.

But was the defeat of their effort to limit abortion truly a surprise? Not if you look at the history of state-level ballot measures related to abortion.

According to the website Ballotpedia, there have been 53 abortion-related ballot measures in 24 states since 1970. Of the 43 questions supported or placed by anti-abortion groups or legislators, voters approved 26% and rejected 74%. Of the 10 questions supported by abortion-rights backers, voters approved 70% and rejected 30%.

In other words, the abortion-rights side has won nearly three-quarters of the ballot measures.

More than a few of these ballot questions have been in states where Republicans have even more control than in Kansas. In South Dakota, for example, voters in 2006 overturned a sweeping abortion ban passed by the legislature, which was designed to prompt the Supreme Court to reconsider Roe v. Wade. Two years later, South Dakota voters also rejected a second, slightly less draconian ban.

Even in Mississippi, historically one of the most conservative states, voters in 2011 rejected a “personhood” amendment that would have added language to the state constitution stating that life begins at fertilization. Voters demurred after it was pointed out that such a law could outlaw some common types of birth control and in vitro fertilization.

And many of the anti-abortion ballot measures that were approved dealt with issues that have long enjoyed considerable public support — such as banning public funding of abortion and requiring parents to be involved in a minor’s abortion decision.

That is in stark contrast to the more recent success of candidates who oppose abortion, whose numbers have dramatically increased at both the state and federal levels in recent years. Conservative Republicans won control of so many governorships and state legislatures in 2010 that it led to a landslide of anti-abortion legislation in the following years.

Abortion isn’t the only issue for which voters have split ballots, weighing in on a ballot initiative while backing a candidate with an opposing viewpoint. Expanding Medicaid coverage under the Affordable Care Act is another example. So far, in seven states where Republican governors, lawmakers, or both have refused to extend Medicaid coverage to certain moderate-income residents, voters have approved expansion over those objections.

What explains how some of the same voters who elect and reelect candidates opposed to abortion also support abortion rights in stand-alone ballot questions?

One reason is that until 2022, abortion was not among voters’ top priorities when choosing whom to vote for. As recently as 2016 — when Republican presidential candidate Donald Trump promised to work to ban abortion, while Democrat Hillary Clinton vowed to protect abortion rights — only 45% of voters said abortion was “very important” to their vote, compared with 84% who cited the economy and 80% who said their top issue was terrorism. Out of 14 top issues that year, abortion ranked 13th in the poll from the Pew Research Center.

What does it mean for the future? In 2022, according to an analysis by KFF pollsters, support for abortion rights may have helped Democrats soften their expected midterm losses. As abortion has surfaced more in headlines, the issue has become more salient for voters of both parties.

State and federal lawmakers, emboldened by the court’s decision, may need to be more careful in deciding how to legislate on abortion-related matters in 2023. The voters are watching.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


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California Attorney General Sues Drugmakers Over Inflated Insulin Prices

Kaiser Health News:States - January 12, 2023

[UPDATED on Jan. 13]

California Attorney General Rob Bonta on Thursday sued the six major companies that dominate the U.S. insulin market, ratcheting up the state’s assault on a profitable industry for artificially jacking up prices and making the indispensable drug less accessible for diabetes patients. 

The 47-page civil complaint alleges three pharmaceutical companies that control the insulin market — Eli Lilly and Co., Sanofi, and Novo Nordisk — are violating California law by unfairly and illegally driving up the cost of the drug. It also targets three distribution middlemen known as pharmacy benefit managers: CVS Caremark, Express Scripts, and OptumRx. 

“We’re going to level the playing field and make this life-saving drug more affordable for all who need it, by putting an end to Big Pharma’s big profit scheme,” Bonta said at a news conference after filing the lawsuit in a state court in Los Angeles. “These six companies are complicit in aggressively hiking the list price of insulin, at the expense of patients.” 

In the lawsuit, Bonta argued that prices have skyrocketed and that some patients have been forced to ration their medicine or forgo buying insulin altogether. The attorney general said a vial of insulin, which diabetics rely on to control blood sugar, cost $25 a couple of decades ago but now costs about $300. 

A 2021 U.S. Senate investigation found that the price of a long-acting insulin pen made by Novo Nordisk jumped 52% from 2014 to 2019 and that the price of a rapid-acting pen from Sanofi shot up about 70%. From 2013 to 2017, Eli Lilly had a 64% increase on a rapid-acting pen. The investigation implicated drug manufacturers and pharmacy benefit managers in the increases, saying they perpetuated artificially high insulin prices. 

“California diabetics who require insulin to survive and who are exposed to insulin’s full price, such as uninsured consumers and consumers with high deductible insurance plans, pay thousands of dollars per year for insulin,” according to the complaint. 

Eli Lilly spokesperson Daphne Dorsey said the company is “disappointed by the California attorney general’s false allegations,” arguing that the average monthly out-of-pocket cost of insulin has fallen 44% over the past five years, and the drug is available to anyone “for $35 or less.” 

Mike DeAngelis, a spokesperson for CVS, said it would vigorously defend itself, saying that pharmaceutical companies alone set list prices. “Nothing in our agreements prevents drug manufacturers from lowering the prices of their insulin products, and we would welcome such action. Allegations that we play any role in determining the prices charged by manufacturers are false,” he said.

OptumRx, a division of UnitedHealthcare, said it welcomes the opportunity to show California “how we work every day to provide people with access to affordable drugs, including insulin.” And company spokesperson Isaac Sorensen said it has eliminated out-of-pocket costs for insulin. 

Other companies targeted in the suit, and the trade associations that represent them, did not immediately respond to inquiries seeking comment, or declined to comment on the lawsuit. Instead, they either blamed one another for price increases or outlined their efforts to lower costs. Costs for consumers vary widely depending on insurance coverage and severity of illness. 

California follows other states, including Arkansas, Kansas, and Illinois, in going after insulin companies and pharmaceutical middlemen, but Bonta said California is taking an aggressive approach by charging the companies with violating the state’s Unfair Competition Law, which could carry significant civil penalties and potentially lead to millions of dollars in restitution for Californians. 

If the state prevails in court, the cost of insulin could be “massively decreased” because the companies would no longer be allowed to spike prices, Bonta said. 

Bonta joins fellow Democratic leaders in targeting the pharmaceutical industry. Gov. Gavin Newsom has launched an ambitious plan to put the nation’s most populous state in the business of making its own brand of insulin as a way to bring down prices for roughly 3.2 million diabetic Californians who rely on the drug. 

“Big Pharma continues to put profits over people — driving up drug prices and restricting access to this vital medicine,” Newsom spokesperson Brandon Richards told KHN. “That is why California is moving towards manufacturing our own affordable insulin.” 

California is going to make its own insulin. It’s simple. People should not go into debt to get life-saving medication.

— Gavin Newsom (@GavinNewsom) July 7, 2022

By launching an aggressive attack against the pharmaceutical industry, California is also wading into a popular political fight. Many Americans express outrage at drug costs while manufacturers blame pharmacy middlemen and health insurers. Meanwhile, the middlemen point the finger back at drugmakers. 

Edwin Park, a California-based research professor with Georgetown University’s Center for Children and Families, said California’s push to enter the generic drug business, while also suing the pharmaceutical industry, could ultimately lead to lower patient costs at the pharmacy counter. 

“It can put downward pressure on list prices,” Park said, referring to the sticker price of drugs. “And that can lead to lower out-of-pocket costs.” 

There isn’t much transparency in how drug prices are set in the U.S. Manufacturers are predominantly to blame for high drug costs, because they set the list prices, Park said. A growing body of research also indicates that the pharmaceutical middlemen are a prime driver of high patient drug costs. To lower prices, it’s critical to target the entire supply chain, experts say. 

“The list price has definitely gone up,” said Dr. Neeraj Sood, a professor of health policy, medicine, and business at the University of Southern California who has studied drivers of high insulin costs. “But over time a larger share of the money is going to the middlemen rather than the manufacturers.” 

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

GOP House Opens With Abortion Agenda

The Host Julie Rovner KHN @jrovner Read Julie's stories. Julie Rovner is Chief Washington Correspondent and host of KHN’s weekly health policy news podcast, “What the Health?” A noted expert on health policy issues, Julie is the author of the critically praised reference book “Health Care Politics and Policy A-Z,” now in its third edition.

Having spent its entire first week choosing a speaker, the Republican-led U.S. House finally got down to legislative business, including passing two bills backed by anti-abortion groups. Neither is likely to become law, because they won’t pass the Senate nor be signed by President Joe Biden. But the move highlights how abortion is sure to remain a high-visibility issue in the nation’s capital.

Meanwhile, as open enrollment for the Affordable Care Act nears its Jan. 15 close, a record number of people have signed up, taking advantage of renewed subsidies and other help with medical costs.

This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico, and Sarah Karlin-Smith of the Pink Sheet.

Panelists Sarah Karlin-Smith Pink Sheet @SarahKarlin Read Sarah's stories Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories Margot Sanger-Katz The New York Times @sangerkatz

Among the takeaways from this week’s episode:

  • The House now has a speaker after 15 rounds of full-chamber roll call votes. That paved the way for members to be sworn in, committee assignments to be made, and new committee chairs to be named. Cathy McMorris Rodgers (R-Wash.) and Jason Smith (R-Mo.) will be taking the helm of major health committees.
  • McMorris Rodgers will lead the House Energy and Commerce Committee; Smith will be the chairman of Ways and Means. Unlike McMorris Rodgers, Smith has little background in health issues and has mostly focused on tax issues in his public talking points. But Medicare is likely to be on the agenda, which will require the input of the chairs of both committees.
  • One thing is certain: The new GOP-controlled House will do a lot of investigations. Republicans have already reconstituted a committee to investigate covid-19, although, unlike the Democrats’ panel, this one is likely to spend time trying to find the origin of the virus and track where federal dollars may have been misspent.
  • The House this week began considering a series of abortion-related bills — “statement” or “messaging” bills — that are unlikely to see the light of day in the Senate. However, some in the caucus question the wisdom of holding votes on issues like these that could make their more moderate members more vulnerable. So far, bills have had mostly unanimous support from the GOP. Divisions are more likely to emerge on topics like a national abortion ban. Meanwhile, the Title X program, which pays for things like contraception and testing for sexually transmitted infections, is becoming a hot topic at the state level and in some lawsuits. A case in Texas would restrict contraception availability for minors through this program.
  • It’s increasingly clear that abortion pills are going to become an even bigger part of the abortion debate. On one hand, the FDA has relaxed some of the risk evaluation and mitigation strategies (REMS) from the prescribing rules surrounding abortion pills. The FDA puts these extra restrictions or safeguards in place for certain drugs to add additional protection. Some advocates say these pills simply do not bring that level or risk.
  • Anti-abortion groups are planning protests in early February at large pharmacies such as CVS and Walgreens to try to get them to walk back plans to distribute abortion pills in states where they are legal.
  • A growing number of states are pressuring the Department of Health and Human Services to allow them to import cheaper prescription drugs from Canada — or, more accurately, importing Canada’s price controls. While this has long been a bipartisan issue, it has also long been controversial. Officials at the FDA remain concerned about breaking the closed supply chain between drugs being manufactured and delivered to approved U.S. buyers. The policy is popular, however, because it promises lower prices on at least some drugs.
  • Also in the news from the FDA: The agency granted accelerated approval for Leqembi for the treatment of Alzheimer’s disease. Leqembi is another expensive drug that appears to work, but also carries big risks. However, it is generally viewed as an improvement over the even more controversial Alzheimer’s drug Aduhelm. Still to be determined is whether Medicare — which provides insurance to most people with Alzheimer’s — will cover the drug.
  • As the Affordable Care Act enrolls a record number of Americans, it is notable that repealing the law has not been mentioned as a priority for the new GOP majority in the House. Rather, the top health issue is likely to be how to reduce the price of Medicare and other health “entitlement” programs.

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

Julie Rovner: The Washington Post’s “Social Security Denies Disability Benefits Based on List With Jobs From 1977,” by Lisa Rein

Margot Sanger-Katz: Roll Call’s “Providers Say Medicare Advantage Hinders New Methadone Benefit,” by Jessie Hellmann

Alice Miranda Ollstein: The New York Times’ “Grant Wahl Was a Loving Husband. I Will Always Protect His Legacy.” By Céline Gounder

Sarah Karlin-Smith: KHN’s “Hospitals’ Use of Volunteer Staff Runs Risk of Skirting Labor Laws, Experts Say,” by Lauren Sausser

Also mentioned in this week’s podcast:

Credits Francis Ying Audio Producer Stephanie Stapleton Editor

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on SpotifyApple PodcastsStitcherPocket Casts, or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


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Biden-Harris Administration Proposes Restoring Protections for Beneficiaries of Federally Funded Social Services

HHS Gov News - January 12, 2023
Nine federal agencies proposed rules that would provide important protections for Americans who rely on federally funded social service programs.

Bleeding and in Pain, a Pregnant Woman in Louisiana Couldn’t Get Answers

Kaiser Health News:States - January 12, 2023

BATON ROUGE, La. — When Kaitlyn Joshua found out she was pregnant in mid-August, she and her husband, Landon Joshua, were excited to have a second baby on the way. They have a 4-year-old daughter and thought that was just the right age to help with a younger sibling.

At about six weeks pregnant, Joshua, 30, called a physician group in Baton Rouge. She wanted to make her first prenatal appointment there for around the eight-week mark, as she had in her first pregnancy. But Joshua said the woman on the line told her she was going to have to wait over a month.

“They specifically said, ‘We now no longer see women until they’re at least 12 weeks,'” Joshua recalled. “And I said, ‘Oh, Lord. Is this because of what I think?’ And they said, ‘Yes.'”

Louisiana has a near-total abortion ban, which took effect Aug. 1, that has raised fears among physicians that they could be investigated for treating a miscarriage, since the same treatments are also used for abortion.

Joshua recalled the woman on the phone saying that since the U.S. Supreme Court decision overturned Roe v. Wade, there was what the woman called a gray area in Louisiana’s law. The medical practice was delaying the first prenatal appointment with patients.

Joshua remembered her saying that many women miscarry in the first 12 weeks of pregnancy, and they didn’t want to be liable for an investigation. For anyone convicted of providing an abortion, the law carries stiff penalties of 10 to 15 years in prison, up to $200,000 in fines and the loss of a physician’s license.

Since Louisiana’s ban took effect, some doctors have warned that the law’s language is vague, and that fear and confusion over the law would lead to delays in pregnancy care. And fear and confusion are precisely what Joshua and her husband experienced.

During those early weeks of pregnancy, Joshua felt symptoms she hadn’t dealt with in her first pregnancy: mild cramping and spotting. Without access to a doctor, though, Joshua felt she had nowhere to go for answers.

“How in the world can we have a viable health care system for women, especially women of color, when they won’t even see you for 12 weeks?” she said.

Joshua, who works as a community organizer, knew pregnancy can be dangerous, especially for Black women like herself. She also knew about Louisiana’s dismal maternal health statistics: The state has one of the highest maternal death rates in the country, and Black women are at higher risk than white women, according to reports from the state’s health department.

So Joshua booked an appointment weeks away with one of the few OB-GYNs she could find who was a woman of color. Then, when she was between 10 and 11 weeks pregnant, she started bleeding heavily, passing clots and tissue. She said the pain was worse than when she’d given birth.

Her husband was at work, so Joshua drove herself to the emergency room at Woman’s Hospital in Baton Rouge. There the staff gave her an ultrasound, which they said showed that her fetus had stopped growing, she recalled. It was measuring seven or eight weeks gestation, not 10 or 11 weeks. Her medical records show her pregnancy hormone levels were abnormally low.

She was told her fetus had only a faint heartbeat. Joshua understood she was miscarrying. But hospital staffers wouldn’t definitively confirm it and didn’t explain what treatment options she’d have if she was having a miscarriage.

Joshua said a nurse told her: “‘It appears that you could be having one. But we don’t want to say that’s what it is. So let’s just keep watching it. You can continue to come back. Of course, we’re praying for you.'”

Joshua is Christian. She spends Sunday mornings at church. But she said the comment felt like an insult. “Folks need answers, not prayers. And that’s exactly what I was looking for in that moment,” she said.

The next day, her bleeding and pain were worse. Landon, her husband, was afraid for her life.

By the evening, Joshua was pacing her bathroom floor, bleeding and cramping, when she felt more blood and tissue come out of her body.

“It literally felt like I had almost birthed a child,” she said. “And so I was like, ‘No, I have to go somewhere, like, now.'”

She didn’t want to return to the first ER, so she called her mother and husband and told them to meet her at Baton Rouge General in nearby Prairieville. There, a security guard put her in a wheelchair. Her jeans were soaked through with blood. Staffers gave her another ultrasound, and the technician told her she’d lost a lot of blood.

A doctor came in to talk about the ultrasound results. She told Joshua it looked like a cyst, not a pregnancy, and asked if she was positive she’d been pregnant — a question that made Joshua angry.

Joshua remembers the doctor then said that if she was indeed miscarrying, she should go back home and wait, then follow up with her OB-GYN in two or three days.

Joshua asked the doctor for treatment to alleviate her pain and speed up the process. There are two standard options for managing a confirmed miscarriage, other than letting it pass on its own: a procedure called dilation and curettage, to remove pregnancy tissue; or medication, which can help clear the uterus more quickly. Both of the latter treatments are also used for abortions.

The doctor told her, “‘We’re not going to do that,'” Joshua recalled. “I just remember her saying, ‘We’re not doing that now.'”

The doctor also said she wouldn’t refer Joshua somewhere else for miscarriage treatment, Joshua recalled, or give her discharge papers stating she was having a miscarriage, known in medical terminology as a spontaneous abortion.

“She stated that they’re not going to put anywhere ‘spontaneous abortion’ because that would then flag an investigation on them,” Joshua said.

Landon Joshua said he had the impression that the doctor was afraid to confirm his wife’s miscarriage.

“She would not look me in the eye to tell me what was happening,” Kaitlyn said.

Frustrated and scared, the Joshuas went home.

Both Woman’s Hospital and Baton Rouge General said in statements to NPR that their pregnancy care has not changed since Louisiana’s abortion ban passed. Baton Rouge General said its care of Kaitlyn Joshua was appropriate. NPR contacted the provider whom Joshua originally called for a prenatal appointment, and it denied that it had changed the timing of first appointments.

Both ERs Joshua visited deny that they have changed care because of Louisiana’s ban.

In a statement, Dr. R. Cliff Moore, the chief medical officer and a maternal-fetal medicine specialist at Woman’s Hospital — the first hospital Joshua visited — said bleeding during the first trimester is common and doesn’t necessarily mean a patient is miscarrying. He added that diagnosing a miscarriage “requires complex medical analysis” that can take days or weeks. “Our hearts go out” to those who’ve experienced miscarriages, he added.

Baton Rouge General, the second ER, said it has not changed the way it manages miscarriage or the options provided to patients. In a statement, Dr. Kathleen Varnes, an ER doctor, said that the hospital “sympathizes with the pain and anxiety” Joshua experienced but that it believes her care was “appropriate.” Every patient is different, she said, adding that “there are times when waiting and observing is the right approach, and other times when medication or a procedure may be necessary.”

According to Joshua’s discharge papers from Baton Rouge General, she was suffering from vaginal bleeding, which can, but doesn’t always, lead to miscarriage. But in her medical charts, which Joshua later obtained from the hospital, staff wrote “it appears that she is having a miscarriage,” and diagnosed her as having a “complete or unspecified spontaneous abortion without complication.” Her medical records also note that Joshua’s pregnancy hormone levels, called HCG, had declined from her previous ER visit, when they should have been increasing if her pregnancy was proceeding normally.

After Joshua signed forms allowing the hospital to comment on her care, Baton Rouge General said that because of Joshua’s symptoms, “her discharge papers and treatment plan provided instructions on how to manage bleeding and when to follow up with a physician.”

Other doctors and lawyers in the state are concerned that the abortion ban is affecting some health care decision-making. They point to the fact that even after a state court briefly blocked Louisiana’s ban last summer, Louisiana Attorney General Jeff Landry threatened the medical licenses of physicians, claiming they could still be prosecuted.

In September, at a Louisiana Department of Health meeting, Dr. Joey Biggio, the chair of maternal and fetal medicine with Ochsner Health, Louisiana’s largest health system, said some OB-GYN doctors were afraid to provide routine care.

“There has now been such a level of concern created from the attorney general’s office about the threat to them both criminally and civilly and professionally, that many people are not going to provide the care that is needed for patients, whether it’s ectopic pregnancies, miscarriages, ruptured membranes, you know, hemorrhage,” Biggio said. “And we need to figure out a way to be able to provide some clear, unequivocal guidance to providers, or we’re going to see some unintended consequences of all of this.”

The Policy Debate

The author of Louisiana’s abortion ban, Sen. Katrina Jackson, is a Democrat who opposes abortion. She maintains that the law is clear about miscarriages, saying in an emailed statement that “it does not prohibit medical treatment regarding miscarriages.”

Sarah Zagorski, communications director for Louisiana Right to Life, which helped draft the ban, said no part of Louisiana’s law requires a physician to delay prenatal care until 12 weeks of pregnancy. And she said the law specifically differentiates miscarriage care from abortion.

“It looks like the fault is not with the law, but with a misinterpretation of the law,” Zagorski said.

Ellie Schilling, a lawyer with Lift Louisiana, a reproductive justice organization that challenged Louisiana’s law in state court, said that while the law allows for miscarriages to be treated, it is written in legal language that doesn’t translate easily into medicine or necessarily line up with an individual patient’s set of circumstances. And this puts doctors in a very difficult situation.

“They’re trying to interpret specific language and pair it up to specific patients to do some sort of calculation about, you know, have we reached this threshold yet? Or have we not?” she said.

Doctors also must consider whether someone else might later disagree with their decision, she added. “How is somebody else going to interpret that later? How is law enforcement or a prosecutor potentially going to interpret that later?”

She argued that the law needs to be clarified. “It puts providers and patients in a really dangerous situation,” she said. “And to abdicate all responsibility for making the laws, before drafting the laws in a way that will work for physicians on the ground, is just irresponsible.”

The Patient’s Perspective

In the week after Joshua’s last ER visit, the heavy bleeding and piercing pains continued. While mourning the loss of what would have been her new baby, she remained worried about her own health. She feared getting worse and wondered how bad she would need to get to get treatment.

Joshua blames Louisiana’s anti-abortion law for the care she received. “For me to have to navigate so many different channels to get health care should not be happening,” she said. “This has to change. There needs to be clarity within the abortion ban” so that physicians are not confused or afraid to provide care and support.

It took weeks, but Joshua was able to pass the pregnancy at home. If she had been given a choice, she would have chosen care that made the experience faster, less painful, less scary, and less risky, especially as a Black woman.

“This experience has made me see how Black women die. Like, this is how Black women are dying,” she said.

It also has made Kaitlyn and Landon Joshua rethink their plans for more children.

“I love my kid. And so, she constantly makes me want another her. But in this moment, it’s just too dangerous to get pregnant in the state of Louisiana,” Kaitlyn said. “I don’t think it’s worth risking your life for a baby right now.”

This story was produced in partnership with WWNO and KHN. It was edited by Carrie Feibel, Jane Greenhalgh, Diane Webber, and Carmel Wroth. Meredith Rizzo and Max Posner handled art direction and design. Photographs by Claire Bangser.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Despite Doctors’ Concerns, University of California Renews Ties With Religious Affiliates

As the University of California’s health system renews contracts with hundreds of outside hospitals and clinics — many with religious affiliations — some of its doctors and faculty want stronger language to ensure that physicians can perform the treatments they deem appropriate, including abortions for women or hysterectomies for transgender patients.

University of California Health is in the middle of a two-year process to renew contracts with affiliate hospitals and clinics that help the university deliver care in underserved parts of the state. Many of the agreements are with faith-based facilities, including prominent hospitals operated by Dignity Health, Providence, or Adventist Health. Such arrangements generate more than $20 million a year for the UC system and help the public university approach its goal of improving public health.

The current policy, adopted in 2021, states that UC physicians have the freedom to advise, refer, prescribe, or provide emergency care, covering cases in which moving a patient “would risk material deterioration to the patient’s condition.” But some UC doctors and faculty worry that physicians would be allowed to perform certain surgeries only in an emergency.

They want to add a clause stating that physicians have the right to perform procedures in a manner they deem advisable or necessary without waiting for the patient’s condition to get worse.

Others have gone so far as to urge the university to reject partnerships with hospitals that have ethical and religious directives against sterilization, abortion, some miscarriage management procedures, and some gender-affirming treatments. The Academic Senate, a faculty body that helps the university set academic policies, and other faculty councils urged the university’s president to avoid working with health care facilities because many have restrictions that “have the potential for discriminatory impact on patients.”

In response, university leaders have pledged publicly to ensure that doctors and trainees can provide whatever care they deem necessary at affiliated facilities but haven’t made changes to the policy language.

“We’ve made it clear that the treating provider is the one to decide if an emergency exists and when to act,” said Dr. Carrie Byington, executive vice president for University of California Health, at a fall meeting of the UC Board of Regents, the governing board of the university system.

UC Health has given itself until the end of this year to make contracts conform to its new policy. During the October board meeting, staffers estimated that one-third of the contracts had been evaluated. Administrators haven’t said whether the current policy thwarted any contracts.

Back in June 2021, the regents approved the policy governing how its doctors practice at outside hospitals and clinics with religious or ethical restrictions. Regent John Pérez made significant amendments to a staff proposal. At the time, it was celebrated as a win by those advocating for the university to push back on religious directives from affiliates.

Pérez noted at the time that his amendments were aimed at “making clear that it’s the regents’ expectation in policy that nothing that is not based on science or [the] best practice of medicine should limit the ability of our practitioners to practice medicine in the interest of the patients.”

But some doctors and faculty said Pérez’s proposal was then wordsmithed as it was converted from the regents’ vote into a formal policy months later. Some questioned whether the policy could be interpreted as restricting services unless there is an emergency, and said it does not go far enough to define an emergency.

“It sounds pretty good,” Dr. Tabetha Harken, director of the Complex Family Planning, Obstetrics & Gynecology division at the UC Irvine School of Medicine, testified before the board. “It passes the commonsense test, but in reality, this is just the federal minimum requirement of care.”

Pérez declined to comment to KHN.

At the regents’ meetings, concerned doctors offered examples of pregnancy and gender-affirming care they believe would be at risk in some hospitals.

One was tubal ligation or sterilization procedures immediately after birth to prevent future pregnancies that may put the woman at risk. It’s a simpler procedure if done postpartum because the uterus is larger than normal and it eliminates the need for additional surgery, said Dr. Jennifer Kerns, an associate professor at UC-San Francisco and director of the school’s Complex Family Planning Fellowship.

Dr. Mya Zapata of UCLA Health described cases of two patients who might not be able to get the same care at a religiously restricted hospital: a trans male who seeks out a hysterectomy based on a mental health referral for gender-affirming surgery, and a cisgender female who seeks out the same procedure for uterine fibroids.

In a hospital with restrictions, Zapata said, the cisgender patient would be able to get the surgery but the trans patient would not, despite both being considered nonemergency cases.

But it’s unclear if physicians are running into problems. UC Health leaders said there have been no formal complaints from university doctors or trainees practicing at affiliate medical centers about being blocked from providing care.

Critics said the lack of complaints may not reflect reality since physicians may find workarounds by transferring or referring patients elsewhere. One researcher, Lori Freedman, who works at UCSF, has spoken to dozens of doctors working at religious-affiliated hospitals across the country. Many have not filed complaints about care restrictions out of fear they’d put their job at risk, she said.

The debate stems from a partnership with Dignity Health, a Catholic-affiliated hospital system. In 2019, UCSF Medical Center leaders considered a controversial plan to create a formal affiliation with Dignity. Critics voiced opposition in heated public meetings, and the plan drew condemnation from dozens of reproductive justice advocates and the gay and transgender communities. UCSF ultimately backed off the plan.

When it became clear that UC medical centers across the state had similar affiliation contracts, faculty members raised additional concerns. Janet Napolitano, then president of the UC system, convened a working group to evaluate the consequences of ending all agreements with organizations that have religious restrictions. Ultimately, the group stressed the importance of maintaining partnerships to provide care to medically underserved populations.

“With 1 in 7 patients in the U.S. being cared for in a Catholic hospital,” the group wrote in its report, “UC’s isolating itself from major participants in the health care system would undermine our mission.”

Dignity Health, which merged in 2019 with Catholic Health Initiatives to form CommonSpirit Health, has already reached a new contract that adopts the updated UC policy. Chad Burns, a spokesperson for Dignity, said the hospital system values working with UC Health for its expertise in specialties, such as pediatric trauma, cancer, HIV, and mental health. He added that the updated agreement reflects “the shared values of UC and Dignity Health.”

Some UC doctors point out that they have not only public support, but legal standing to perform a variety of reproductive and contraceptive treatments. After California voters passed Proposition 1, the state constitution was officially changed in December to affirm that people have a right to choose to have an abortion or use contraceptives. Unlike health systems in other states, some faculty say UC Health can assert reproductive rights.

“We have a lot of latitude, being in California, to be able to make these decisions and stand in our power,” Kerns said. “I think it’s our responsibility to do so.”

Other doctors say the university system should prioritize public service. Dr. Tamera Hatfield, a maternal-fetal medicine specialist at UC-Irvine, testified at a regents’ meeting that she had never been asked to modify care for patients based on religious restrictions since her department formed an affiliation with Providence St. Joseph Hospital-Orange about a decade ago.

“Partnering with faith-based institutions dedicated to serving vulnerable populations affords opportunities to patients who are least able to navigate our complex health systems,” she said.

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Listen: Who Investigates Suspicious Deaths in Your Community — And Why It Matters

Each state has its own laws governing the investigation of violent and unexplained deaths, and the expertise and training of those in charge of such investigations vary widely across the nation. The job can be held by an elected coroner as young as 18 or a highly trained physician appointed as medical examiner.

Rulings on causes of death are often not cut-and-dried and can be controversial. In a recent California case, the Sacramento County coroner’s office ruled that Lori McClintock, the wife of U.S. congressman Tom McClintock, died from dehydration and gastroenteritis in December 2021 after ingesting white mulberry leaf, a plant not considered toxic to humans. The ruling triggered questions by doctors and pathologists about the decision to link the plant to her cause of death. When asked to explain how he made the connection, Dr. Jason Tovar, the chief forensic pathologist who reports to the coroner, said he reviewed literature about the plant online using WebMD and Verywell Health.

KHN senior correspondent Samantha Young appeared this month on the “Apple News Today” podcast and KOA, a public radio station in Denver, to discuss the difference between coroners and medical examiners and why it matters who holds the job. Her segment on Apple News starts at the 5-minute mark.

You can read Young’s coverage of the issue here.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Hospitals’ Use of Volunteer Staff Runs Risk of Skirting Labor Laws, Experts Say

MOUNT PLEASANT, S.C. — Most of the 30 volunteers who work at the 130-bed, for-profit East Cooper Medical Center spend their days assisting surgical patients — the scope of their duties extending far beyond those of candy stripers, baby cuddlers, and gift shop clerks.

In fact, one-third of the volunteers at the Tenet Healthcare-owned hospital are retired nurses who check people in for surgery or escort patients to a preoperative room, said Jan Ledbetter, president of the hospital’s nonprofit Volunteer Services Organization. Others relay important information from hospital staffers to expectant families. “They’re kept extremely busy,” Ledbetter said. “We need to have four of those volunteers a day.”

At hospitals across the U.S., volunteers play an integral role. So much so that when volunteers were barred from East Cooper at the beginning of the covid-19 pandemic, staff nurses assumed the volunteers’ duties in the surgical waiting room. Like paid employees, hospital volunteers typically face mandatory vaccine requirements, background checks, and patient privacy training. And their duties often entail working in regular shifts.

At HCA Healthcare, the world’s largest for-profit hospital system, volunteers include aspiring medical providers who work in patient rooms, in labs, and in wound care units, according to the company’s magazine.

Over centuries, leaning on volunteers in medicine has become so embedded in hospital culture that studies show they yield meaningful cost savings and can improve patient satisfaction — seemingly a win-win for hospital systems and the public.

Except, there’s a catch.

The U.S. health system benefits from potentially more than $5 billion in free volunteer labor annually, a KHN analysis of data from the Bureau of Labor Statistics and the Independent Sector found. Yet some labor experts argue that using hospital volunteers, particularly at for-profit institutions, provides an opportunity for facilities to run afoul of federal rules, create exploitative arrangements, and deprive employees of paid work amid a larger fight for fair wages.

The federal government instructs that any person performing a task of “consequential economic benefit” for a for-profit entity is entitled to wages and overtime pay. That means profit-generating businesses, like banks and grocery stores, must pay for labor. A Chick-fil-A franchise in North Carolina was recently found guilty of violating minimum wage laws after paying people in meal vouchers instead of wages to direct traffic, according to a Department of Labor citation.

Still, volunteer labor at for-profit hospitals is commonplace and unchecked.

“The rules are pretty clear, and yet it happens all the time,” said Marcia McCormick, a lawyer who co-directs the Wefel Center for Employment Law at Saint Louis University. “It’s a confusing state of affairs.”

In a statement, HCA spokesperson Harlow Sumerford said coordinators oversee hospital volunteers to ensure they are participating in appropriate activities, such as greeting and assisting visitors. Tenet Health spokesperson Valerie Burrow did not respond to a question about how the company ensures that its volunteer activities comply with federal labor laws.

Ben Teicher, a spokesperson for the American Hospital Association, whose members include more than 6,000 nonprofit, for-profit, and government hospitals, did not respond to a question about whether the organization offers guidance to hospitals regarding the legal uses of volunteers.

Meanwhile, the pandemic made the importance of hospital volunteers more apparent. In March 2020, volunteer programs nationwide were largely disbanded, and the volunteers’ roles were filled by staff members — or left unfilled — when hospitals closed their doors to everyone except employees, patients, and a few visitors. Volunteers were welcomed back once vaccines became widely available, but many didn’t return.

“We’ve lost so many volunteers,” said Ledbetter, who runs the volunteer group at East Cooper Medical Center. “They found something else to do.”

On South Carolina’s Hilton Head Island, Vicki Gorbett, president of the island’s hospital auxiliary, estimated 60% of the group’s volunteers who left during the pandemic haven’t returned. Much larger hospital systems, some of which boast hundreds or thousands of volunteers, have been affected, too.

“We’re building back from the absolute bottom,” said Kelly Hedges, who manages volunteers at the Medical University of South Carolina.

Hedges was furloughed for the better part of six months when hospital volunteers were sent home in March 2020. She estimates there are about 600 volunteers at MUSC’s hospital campus in Charleston now, down from 700 before the pandemic.

“During a labor crisis, this is a department you want in operation,” she said.

While hospital volunteer programs reboot across the country, labor experts say using volunteers may expose some medical facilities to liability.

The Fair Labor Standards Act prohibits “employees” — defined broadly as people an employer “requires or allows” to work — from volunteering their time to for-profit private employers. The same law also requires these employees to be paid no less than the federal minimum wage.

These regulations make it “very, very difficult” for a volunteer to donate time to a for-profit hospital, explained Jenna Bedsole, an employment attorney in Birmingham, Alabama.

The right to be paid isn’t waivable, McCormick said, meaning that even those volunteers who don’t consider themselves employed may be entitled to compensation. However, the U.S. Department of Labor is “stretched pretty thin” and doesn’t enforce the rules that apply to for-profit companies, except in extreme circumstances, she said.

She cited a court ruling in 2017 that found people who volunteered at consignment events for Rhea Lana — a for-profit company that organizes the resale of children’s clothing — were employees who should be paid.

But in most cases, McCormick said, it is difficult to determine the outcome of enforcement actions against for-profit companies.

“The Department of Labor sends a letter to the putative employer warning them that it thinks the FLSA is being violated,” she said, “and it may not take any other action. And it only issues news releases for big cases.”

Companies are more likely to be targeted for the inappropriate use of unpaid interns, she said.

But this isn’t to say that, in some cases, individuals can’t donate their time in a for-profit setting. In a for-profit nursing home, the federal government has said, people may volunteer without pay if they’re attending “to the comfort of nursing home residents in a manner not otherwise provided by the facility.” That might include reading to a resident, for example.

One-off charitable opportunities are also possible. A choir group could host a concert in a hospital lobby without violating the law, or a community organization could serve hospital staffers an appreciation lunch.

Beyond that, for-profit “hospitals potentially expose themselves to risk of civil liability,” Bedsole said, which could add up in terms of back pay due to employees, fines, and legal fees. If hospital volunteers provide essential services, there is a danger they could be held liable, she said.

Nonprofit hospitals must follow federal labor laws, too.

At the small, nonprofit Baptist Memorial Hospital-Leake in Carthage, Mississippi, the coordinator of volunteers, Michelle McCann, can’t use a volunteer in any role that matches an employee’s job description. She said she’s also prohibited from asking a hospital employee who is off the clock to volunteer their time for a job similar to their own.

“We’d have to pay them for the hours,” said McCann, national president of the Society of Healthcare Volunteer Leaders.

Nonprofit hospitals are required to provide a benefit to their communities, such as offering charity care, in exchange for their special tax status. But when it comes to making money, the differences between for-profit and nonprofit hospitals are often negligible to the casual observer, said Femida Handy, a professor of social policy at the University of Pennsylvania.

“When you go to the hospital, do you ask for the tax status?” she asked.

Sam Fankuchen, CEO of Golden, a company that develops software used to organize volunteer labor, said the pandemic hastened a change in public opinion. “Just because an organization is nonprofit, it doesn’t necessarily mean they’re 100% dedicated to the greater good,” he said. “Some nonprofits are better run than others.”

Most volunteers are simply trying to figure out how and where they can help in the best possible way, he said.

“The consideration about the tax structure is secondary,” said Fankuchen, whose software is used by hospitals and other businesses. “The big picture is that hospitals exist to deliver care. I think it’s reasonable that they have volunteer programs.”

Jay Johnson, support services manager at Trident Medical Center in North Charleston, South Carolina, coordinates roughly 50 volunteers who contribute an estimated 133,000 hours annually to the for-profit hospital, which is owned by HCA Healthcare.

Trident’s volunteers are widely beloved by the staff, he said.

“We actually had a ceremony for them when they came back” when restrictions loosened, Johnson said. Beyond that, volunteers benefit from premium parking spaces and free lunches “to really make sure they’re appreciated,” he said.

Trident volunteers are required to be vaccinated and undergo a background check. Then, they are assigned to the areas that best match their interests.

Breast cancer survivor Pat LoPresti for example, volunteers in Trident’s Breast Care Center. Volunteering provides a sense of purpose and an opportunity to socialize, said LoPresti, a retiree who met her husband, another volunteer, while volunteering at the hospital.

“I started volunteering there because they could use me,” LoPresti said. “It’s such a privilege to help people in a time when they need it.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Behavioral Telehealth Loses Momentum Without a Regulatory Boost

Controlled substances became a little less controlled during the pandemic. That benefited both patients (for their health) and telehealth startups (to make money).

Some potentially addictive medications — like buprenorphine and Adderall — are now far more available online to patients because of regulatory changes. Given the scarcity of qualified doctors to treat some of the behavioral health conditions associated with these drugs, like opioid use disorder or attention-deficit/hyperactivity disorder, doctors’ new ability to prescribe online or, in some cases, by telephone is a huge change. But easier access to the drugs has both upsides and downsides, since they’re often dispensed without accompanying therapy that improves the odds of a patient’s success.

Pre-pandemic, patients sometimes traveled several hours for addiction care, said Emily Behar, director of clinical operations for Ophelia, a New York startup serving people with opioid addictions. Or patients might be struggling with multiple jobs or a lack of child care. Such obstacles made sustaining care fraught.

“How do you reach those people?” she asked.

It’s a question preoccupying much of the behavioral health sector, complicated by the reality that most patients with opioid use disorder aren’t in treatment, said Dr. Neeraj Gandotra, chief medical officer of the Substance Abuse and Mental Health Services Administration.

Increased access to telehealth has started to provide an answer. Behar, the startup executive, says its patients can see expert providers at their convenience. Missed appointments are dropping, say many in the industry.

The startup has secured solid funding — nearly $68 million, according to Crunchbase, an industry database — but addiction specialists and other prescribers of controlled substances online are a mixed group. Some are nonprofits; others are large startups attracting scrutiny from the news media and law enforcement for allegedly sloppy prescription practices.

The influx of new providers is attributable to loosened requirements born of pandemic-era necessity. To help patients get access to care while maintaining physical distance, the Drug Enforcement Administration and SAMHSA waived restrictions on telehealth for controlled substances.

But whether those changes will endure is uncertain. The federal government is working piecemeal to codify new rules for prescribing controlled substances, in light of the health care system’s pandemic experience.

On Dec. 13, SAMHSA issued a proposal to codify telehealth regulations on opioid treatment programs — but that affects only part of the sector. Left unaddressed — at least until the DEA issues rules — is the process for individual providers to register to prescribe buprenorphine. The new rules “get us at least a little bit closer to where we need to go,” said Sunny Levine, a telehealth and behavioral health lawyer at the D.C.-based firm Foley & Lardner.

Congress also tweaked rules around buprenorphine, doing away with a long-standing policy to cap the number of patients each provider can prescribe to. Ultimately, however, the DEA is the main regulatory domino yet to fall for telehealth providers.

In addition, pharmacies are taking a more skeptical stance on telehealth prescriptions — especially from startups. Patients were getting accustomed to using telemedicine to fill and refill their prescriptions for medications for some controlled substances, like Adderall, primarily used to treat ADHD. A shortage of Adderall has affected access for some patients. Now, though, some pharmacies are refusing to fill those prescriptions.

Cheryl Anderson, one Pennsylvanian with ADHD, said she sought online options because of her demanding schedule.

“My husband is frequently out of town, so I don’t have someone to reliably watch the baby to go to an in-person appointment,” she said. It was tough, with three kids, to find the time. Telehealth helped for about half of 2022. Previously, the DEA and state governments imposed tough rules on obtaining controlled substances from online pharmacies.

But in September, after her doctor wrote a refill prescription, she got a phone call saying her local pharmacy wouldn’t dispense medications if the prescription came through telehealth. Other local pharmacies she called took the same position.

Those denials seem to reflect a broader cultural shift in attitudes. Whereas patients and politicians hailed telemedicine at the beginning of the pandemic — first for its safety but also for its increased convenience and potential to extend care to rural areas and neighborhoods without specialists — hints of skepticism are creeping in.

The telehealth boom attracted shady actors. “You had a lot of people who saw an opportunity to do things that were less than scrupulous,” particularly in the behavioral health market, said Michael Yang, a managing partner at the venture capitalist firm OMERS Ventures. Skeptical media coverage has proliferated of startups that, allegedly, shotgun prescriptions for mental health conditions without monitoring patients receiving those medications. “It’ll settle down.”

The startups pose quandaries for local pharmacists, said Matt Morrison, owner of Gibson’s Pharmacy in Dodge City, Kansas.

Pharmacists have multiple obligations related to prescriptions, he said: to make sure incoming prescriptions are from legitimate physicians and that they’re connected to an actual health condition before filling the order. The sense around the industry, Morrison said, is that prescriptions from startups are tricky. They might come from a distant provider, whom the pharmacist can’t contact easily.

Those qualms pose difficulties for addiction treatment. Persuading pharmacists to fill prescriptions is one of the biggest administrative tasks for Ophelia, Behar said. Still, the shift online has been helpful.

“Telehealth picks up the gaps,” said Josh Luftig, a founding member of CA Bridge, a program based in Oakland, California, that helps patients in emergency departments initiate treatment for substance misuse. The supply of care providers wasn’t enough to meet demand. “Across the board, there’s been a lack of access to treatment in the outpatient setting. Now all they need is a phone and to get to a pharmacy.”

Treatment is more efficient for patient and provider alike, providers say. “The majority of our patients prefer to have a telehealth experience,” he said. “The telehealth appointments are more efficient. It increases the capacity of each person involved.”

Well-established organizations also report success: Geisinger, a large mid-Atlantic health system, said 94% of participants in one maternity-focused program were compliant, spokesperson Emile Lee said.

Ophelia, which started up just before the pandemic, expected to treat patients both in-office and online. “We have an office in Philadelphia we’ve never used,” she said. Now the company labors every few months — in anticipation of the end of state and federal public health emergencies — to make sure that the end of the associated looser rules doesn’t lead to disruptions in care for their patients.

More clarity on the future of online treatment could result from permanent regulations from the DEA. What the agency’s rule — which would create a registration process for providers interested in prescribing controlled substances online — will say is “anyone’s guess,” said Elliot Vice, an executive specializing in telehealth with the trade group Faegre Drinker. That rule has been pending for years. “To see this still not move, it is puzzling.”

The agency, which declined to comment specifically for this article, pointed to previous statements praising increased access to medication-assisted treatment.

“There shouldn’t be any change in the rules for telehealth,” Luftig said. “It would be the most horrific thing in terms of access for our communities. It would be an unmitigated disaster.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

En cárceles de Pennsylvania, guardias utilizan gas pimienta y pistolas paralizantes para controlar a personas con crisis de salud mental

Kaiser Health News:States - January 09, 2023

Cuando llegó la policía, encontró a Ishmail Thompson desnudo delante de un hotel cerca de Harrisburg, Pennsylvania. Acababa de golpear a un hombre. Tras su detención, un especialista en salud mental de la cárcel del condado dijo que Thompson debía ir al hospital para recibir atención psiquiátrica.

Sin embargo, tras unas horas en el hospital, un médico dio de alta a Thompson para que volviera a la cárcel. Así pasó de ser un paciente de salud mental a un recluso de la prisión del condado de Dauphin. A partir de ese momento, se esperaba que cumpliera las órdenes, o que se le obligara a hacerlo.

A las pocas horas de regresar a la cárcel, Thompson se enzarzó en una pelea con los guardias. Su historia es uno de los más de 5,000 incidentes de “uso de fuerza” que se registraron en 2021 en las cárceles de los condados de Pennsylvania.

El caso de Thompson figura en una investigación, efectuada por WITF, que revisó 456 incidentes de “uso de fuerza” en 25 cárceles de condados en Pennsylvania, durante el último trimestre de 2021. Entre los casos revisados, casi 1 de cada 3 involucraba a una persona que sufría una crisis psiquiátrica o que padecía una enfermedad mental.

En muchos casos, los guardias utilizaron armas, como pistolas paralizantes y aerosoles de pimienta, para controlar y doblegar a presos con condiciones psiquiátricas graves que podrían haberles impedido seguir órdenes, o entender lo que estaba sucediendo.

Los registros muestran que cuando Thompson intentó huir del personal de la cárcel durante un intento de palparlo en busca de armas, un agente le roció con gas pimienta en la cara y luego intentó tirarlo al suelo.

Según la documentación, Thompson se defendió por lo que llegaron otros agentes para esposarlo y ponerle grilletes. Un oficial cubrió la cabeza de Thompson con una capucha y lo sentó en una silla, atándolo de brazos y piernas, y unos 20 minutos después, otro policía notó que Thompson no respiraba bien. Lo llevaron de urgencia al hospital.

Días después, Thompson murió. El fiscal del distrito no presentó cargos. El fiscal del distrito, el alcaide de la prisión y los funcionarios del condado que supervisan la cárcel no respondieron a las solicitudes de entrevistas sobre el tratamiento de Thompson, o se negaron a hacer comentarios.

La mayoría de los casos de uso de fuerza en las cárceles no conducen a la muerte. En el caso de Thompson, la causa de la muerte fue “complicaciones derivadas de una arritmia cardíaca”, pero la forma en que se produjo fue “indeterminada”, según el forense del condado.

En otras palabras, no pudo determinar si la muerte de Thompson se debió a que le rociaron gas pimienta y lo sujetaron, pero tampoco dijo que Thompson muriera por causas naturales.

El vocero del condado de Dauphin, Brett Hambright, también declinó hacer comentarios sobre el caso de Thompson, pero señaló que casi la mitad de las personas en la cárcel padecen una enfermedad mental, “junto con un número significativo de individuos encarcelados con tendencias violentas”.

“Siempre va a haber incidentes de uso de fuerza en la cárcel”, indicó Hambright. “Algunos de ellos involucrarán a reclusos con enfermedades mentales”.

Durante la investigación, expertos legales y en salud mental declararon que las prácticas empleadas en las cárceles del condado pueden poner a los presos y al personal en riesgo de sufrir lesiones, y pueden dañar a personas vulnerables listas para regresar a la sociedad en cuestión de meses.

“Algunos presos con enfermedades mentales quedan tan traumatizados por los malos tratos que nunca se recuperan; otros se suicidan, y a otros se les disuade de llamar la atención sobre sus problemas de salud mental porque denunciar estos problemas suele dar lugar a un trato más duro”, afirmó Craig Haney, profesor de psicología de la Universidad de California-Santa Cruz, especializado en las condiciones de los centros penitenciarios.

Los expertos afirman que el uso de la fuerza es una opción para prevenir la violencia entre los encarcelados, o la violencia contra los guardias.

Sin embargo, los informes de los funcionarios de las 25 cárceles de condados de Pennsylvania muestran que solo el 10% de los incidentes de “uso de fuerza” se produjeron en respuesta a la agresión de un preso a otra persona. Otro 10% informa de un preso amenazando a miembros del personal.

WITF descubrió que uno de cada cinco casos de uso de fuerza (88 incidentes) tuvo que ver con un preso que intentó suicidarse, autolesionarse o que amenazó con autolesionarse. Entre las respuestas más comunes del personal penitenciario figuró el uso de las mismas herramientas utilizadas con Thompson: una silla de inmovilización y gas pimienta. En algunos casos, los funcionarios utilizaron dispositivos de electroshock, como pistolas paralizantes.

Además, la investigación descubrió 42 incidentes en los que el personal penitenciario observó que un recluso mostraba problemas de salud mental, pero los guardias igual utilizaron la fuerza cuando no obedeció las órdenes.

Los defensores de estas técnicas afirman que salvan vidas al prevenir la violencia o las autolesiones; pero algunas cárceles de Estados Unidos han abandonado estas prácticas, y los administradores han afirmado que las técnicas son inhumanas y no funcionan.

El costo humano puede extenderse más allá de la cárcel, alcanzando a las familias de las personas encarceladas que mueren o quedan traumatizadas, así como a los funcionarios implicados, apuntó Liz Schultz, abogada de derechos civiles y defensa penal en la zona de Philadelphia.

“E incluso si el costo humano no fuera suficiente, los contribuyentes deberían preocuparse, ya que las demandas resultantes pueden ser costosas”, agregó Schultz. “Pone de relieve que debemos garantizar unas condiciones seguras en las cárceles, y que deberíamos ser un poco más juiciosos sobre a quién encerramos y por qué”.

“Solo necesitaba a una persona a mi lado”

La experiencia de Adam Caprioli comenzó cuando llamó al 911 durante un ataque de pánico.

Caprioli, de 30 años, vive en Long Pond, Pennsylvania, y ha sido diagnosticado con trastorno bipolar y trastorno de ansiedad. También lucha contra el alcoholismo y la drogadicción, según declaró.

Cuando la policía respondió a la llamada al 911, en otoño de 2021, llevaron a Caprioli al correccional del condado de Monroe.

Dentro de la cárcel, la ansiedad y la paranoia de Caprioli aumentaron. Dijo que el personal ignoró sus pedidos de hacer una llamada telefónica o hablar con un profesional de salud mental.

Tras varias horas de angustia extrema, Caprioli se ató la camisa al cuello y se asfixió hasta perder el conocimiento. Cuando el personal penitenciario lo vio, agentes entraron en su celda, con chalecos antibalas y cascos. El equipo de cuatro hombres tiró al suelo a Caprioli, que pesaba 150 libras. Uno de ellos llevaba una pistola de aire comprimido que dispara proyectiles con sustancias químicas irritantes.

“El recluso Caprioli movía los brazos y pateaba”, escribió un sargento en el informe del incidente. “Presioné el lanzador de Pepperball contra la parte baja de la espalda del recluso Caprioli y le impacté tres (3) veces”. El abogado Alan Mills explicó que los funcionarios suelen justificar el uso de la fuerza física diciendo que intervienen para salvar la vida de la persona.

“La inmensa mayoría de las personas que se autolesionan no van a morir”, señaló Mills, que ha litigado casos de uso de fuerza y es director ejecutivo del Uptown People’s Law Center de Chicago. “Más bien se trata de algún tipo de enfermedad mental grave. Y, por lo tanto, lo que realmente necesitan es una intervención para desescalar la crisis, mientras que el uso de la fuerza provoca exactamente lo contrario y agrava la situación”.

En Pennsylvania, Caprioli contó que cuando los agentes entraron en su celda sintió el dolor de las ronchas en su carne y el escozor del polvo químico en el aire, y se dio cuenta de que nadie le ayudaría.

“Eso es lo peor de todo”, dijo Caprioli. “Ven que estoy angustiado. Ven que no puedo hacerle daño a nadie. No tengo nada con lo que pueda hacerte daño”.

Finalmente, lo llevaron al hospital, donde, según Caprioli, evaluaron sus lesiones físicas, pero no recibió ayuda de un profesional de salud mental. Horas después, estaba de nuevo en la cárcel, donde permaneció cinco días. Al final se declaró culpable de un cargo de “embriaguez pública y mala conducta” y tuvo que pagar una multa.

Caprioli reconoció que sus problemas empeoran cuando consume alcohol o drogas, pero dijo que eso no justifica el trato que recibió en la cárcel.

“Esto no debería ocurrir. Solo necesitaba a una persona a mi lado que me dijera: ‘Hola, ¿cómo estás? ¿Qué te pasa?’ Y nunca me lo dijeron, ni siquiera el último día”, añadió.

El alcaide del correccional del condado de Monroe, Garry Haidle, y el fiscal del distrito, E. David Christine Jr., no respondieron a las solicitudes de comentarios.

Algunas cárceles prueban nuevas estrategias

La cárcel no es un entorno adecuado para el tratamiento de enfermedades mentales graves, afirmó la doctora Pamela Rollings-Mazza. Trabaja con PrimeCare Medical, que presta servicios médicos y conductuales en unas 35 cárceles de condados en Pennsylvania.

El problema, según Rollings-Mazza, es que las personas con problemas psiquiátricos graves no reciben la ayuda que necesitan antes de entrar en crisis. En ese momento, puede intervenir la policía, y quienes necesitaban atención de salud mental acaban en la cárcel.

“Así que los pacientes que vemos están muchas veces muy, muy, muy enfermos”, explicó Rollings-Mazza. “Por lo que nuestro personal debe atender esa necesidad”.

Los psicólogos de PrimeCare califican la salud mental de los presos en una escala de la A a la D. Los que tienen una calificación D son los más gravemente enfermos.

Rollings-Mazza indicó que constituyen entre el 10% y el 15% de la población total de las cárceles atendidas por PrimeCare. Otro 40% de la población tiene una calificación C, también indicativa de enfermedad grave.

Añadió que ese sistema de clasificación ayuda a determinar la atención que prestan los psicólogos, pero tiene poco efecto en las políticas de las cárceles.

“Hay algunas cárceles en las que no entienden o no quieren apoyarnos”, dijo. “Algunos agentes no están formados en salud mental al nivel que deberían”.

Rollings-Mazza explicó que su equipo ve con frecuencia llegar a la cárcel a personas que “no se ajustan a la realidad” debido a una enfermedad psiquiátrica y no pueden entender o cumplir órdenes básicas. A menudo se les mantiene alejados de otras personas, entre rejas, por su propia seguridad, y pueden pasar hasta 23 horas al día solos.

Ese aislamiento prácticamente garantiza que las personas vulnerables entren en una espiral de crisis, afirmó la doctora Mariposa McCall, psiquiatra residente en California que ha publicado recientemente un artículo en el que analiza los efectos del aislamiento.

Su trabajo forma parte de un amplio conjunto de investigaciones que demuestran que mantener a una persona sola en una celda pequeña, todo el día, puede causar daños psicológicos duraderos.

McCall trabajó durante varios años en prisiones estatales de California y dijo que es importante comprender que la cultura de los funcionarios de prisiones prioriza la seguridad y la obediencia por encima de todo. Por lo que pueden llegar a creer que quienes se autolesionan, en realidad, tratan de manipularlos.

Muchos guardias también ven a los presos con problemas de salud mental como potencialmente peligrosos.

“Y así se crea un cierto nivel de desconexión con el sufrimiento o la humanidad de las personas, porque se alimenta esa desconfianza”, señaló McCall. En ese entorno, los agentes se sienten justificados para usar la fuerza, sin importarles que la persona encarcelada les entienda o no.

Jamelia Morgan, profesora de la Facultad de Derecho Pritzker de la Universidad Northwestern, afirmó que, para comprender el problema, es útil examinar las decisiones tomadas en las horas y días previos a un incidente de uso de fuerza.

Morgan investiga un número creciente de demandas por uso de fuerza en las que están implicados presos con problemas de salud mental. Los abogados han argumentado con éxito que exigir que una persona con una enfermedad mental cumpla órdenes, que puede no entender, es una violación de sus derechos civiles. Esas demandas sugieren que las cárceles deberían proporcionar “soluciones razonables”.

“En algunos casos, es tan sencillo como que responda el personal médico, en lugar del personal de seguridad”, apuntó Morgan.

Los casos individuales pueden ser difíciles de litigar debido a un complejo proceso de quejas que los presos deben seguir antes de presentar una demanda, indicó Morgan y apuntó que para resolver el problema, los alcaides tendrán que redefinir lo que significa estar en la cárcel.

Esta investigación incluyó solicitudes de “derecho a saber” presentadas en 61 condados de Pennsylvania, y el equipo de investigación realizó un seguimiento con los guardias de algunos de los condados que publicaron informes sobre el uso de la fuerza. Ninguno accedió a hablar sobre la formación de sus funcionarios o sobre si podrían cambiar su forma de responder a las personas en crisis.

Algunas cárceles prueban nuevas estrategias. En Chicago, el departamento penitenciario del condado de Cook no tiene alcaide. En su lugar, tiene un “director ejecutivo” que también es psicólogo.

Este cambio forma parte de una revisión del funcionamiento de las cárceles después de que un informe del Departamento de Justicia, de 2008, revelara violaciones generalizadas de los derechos civiles de los presos.

En los últimos años, el sistema penitenciario del condado de Cook ha eliminado el confinamiento solitario, optando en su lugar por poner a los presos problemáticos en zonas comunes, pero con medidas de seguridad adicionales siempre que sea posible, declaró el sheriff del condado, Tom Dart.

La cárcel incluye un centro de transición de salud mental que ofrece alojamiento alternativo, un “entorno universitario de cabañas Quonset y jardines”, como lo describió Dart. Allí, los presos tienen acceso a clases de arte, fotografía y jardinería. También hay formación laboral, y los gestores de casos trabajan con agencias comunitarias locales, planificando lo que ocurrirá una vez que alguien salga de la cárcel.

Igualmente importante, según Dart, es que la dirección de la cárcel ha trabajado para cambiar la formación y las normas sobre cuándo es apropiado utilizar herramientas como el gas pimienta.

“Nuestro papel es mantenerlos seguros, y si tienes a alguien con una enfermedad mental, no veo cómo las pistolas Taser y el espray [de pimienta] pueden hacer otra cosa que agravar los problemas, solo deberían utilizarse como la última opción”, dijo Dart.

Las reformas del condado de Cook demuestran que el cambio es posible, pero hay miles de cárceles locales en todo Estados Unidos, y dependen de los gobiernos locales y estatales que establecen las políticas penitenciarias y que financian, o no, los servicios de salud mental que podrían evitar que personas vulnerables fueran a la cárcel.

En el condado de Dauphin, en Pennsylvania, donde murió Ishmail Thompson, las autoridades afirmaron que el problema, y las soluciones, van más allá de los muros de la cárcel. Hambright, vocero del condado, señaló que la financiación se ha mantenido estancada mientras aumenta el número de personas que necesitan servicios de salud mental. Eso ha llevado a una dependencia excesiva de las cárceles, que “siempre están disponibles”.

“Ciertamente nos gustaría ver a algunos de estos individuos tratados y alojados en lugares mejor equipados para tratar la especificidad de sus condiciones”, añadió Hambright. “Pero debemos utilizar lo que nos ofrece el sistema lo mejor que podamos con los recursos que tenemos”.

Esta historia es parte de una aliuanza que incluye a WITF, NPR, y KHN.

Brett Sholtis recibió la Rosalynn Carter Fellowship for Mental Health Journalism 2021-22, y esta investigación recibió apoyo adicional de The Benjamin von Sternenfels Rosenthal Grant for Mental Health Investigative Journalism, en alianza el Carter Center and Reveal del the Center for Investigative Reporting.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

In PA County Jails, Guards Use Pepper Spray and Stun Guns to Subdue People in Mental Crisis

Kaiser Health News:States - January 09, 2023

When police arrived on the scene, they found Ishmail Thompson standing naked outside a hotel near Harrisburg, Pennsylvania. He had just punched a man. After his arrest, a mental health specialist at the county jail said Thompson should be sent to the hospital for psychiatric care.

However, after a few hours at the hospital, a doctor cleared Thompson to return to jail. With that decision, he went from being a mental health patient to a Dauphin County Prison inmate. At that point, he was expected to comply with orders — or be forced to.

Within hours of returning to jail from the hospital, Thompson was locked in a physical struggle with corrections officers. His story is one of more than 5,000 “use of force” incidents that were recorded in 2021 inside Pennsylvania county jails.

Thompson’s story is culled from an investigation, led by WITF, that reviewed 456 “use of force” incidents from 25 county jails in Pennsylvania, during the last quarter of 2021. Among the reviewed cases, nearly 1 in 3 involved a person who was having a mental health crisis or who had a known mental illness.

In many cases, guards used weapons like stun guns and pepper spray to control and subdue incarcerated people with severe psychiatric conditions that may have prevented them from following orders — or understanding what was going on.

Records show that when Thompson ran away from jail staff during an attempted strip search, an officer pepper-sprayed him in the face and then tried taking him to the ground.

According to the records, Thompson fought back, and additional officers flooded the area, handcuffing and shackling him. An officer covered Thompson’s head with a hood and put him in a restraint chair, strapping down his arms and legs, according to the records, and about 20 minutes later, an officer noticed something wrong with Thompson’s breathing. He was rushed to the hospital.

Days later, Thompson died. The district attorney declined to bring charges. The DA, warden, and county officials who help oversee the jail did not respond to requests for interviews about Thompson’s treatment, or declined to comment.

Most uses of force in jails don’t lead to death. In Thompson’s case, the immediate cause of death was “complications from cardiac dysrhythmia,” but the way that occurred was “undetermined,” according to the county coroner. In other words, he couldn’t determine whether Thompson’s death was due to being pepper-sprayed and restrained, but he also did not say Thompson died of natural causes.

Dauphin County spokesperson Brett Hambright also declined to comment on Thompson’s case but said nearly half of the people at the jail have a mental illness, “along with a significant number of incarcerated individuals with violent propensities.”

“There are always going to be use of force incidents at the prison,” Hambright said. “Some of them will involve mentally ill inmates due to volume.”

During the investigation, mental health and legal experts said that practices employed by corrections officers every day in county jails can put prisoners and staff at risk of injury and can harm vulnerable people who may be scheduled to return to society within months.

“Some mentally ill prisoners are so traumatized by the abuse that they never recover; some are driven to suicide, and others are deterred from bringing attention to their mental health problems because reporting these issues often results in harsher treatment,” said Craig Haney, a psychology professor at the University of California-Santa Cruz who specializes in conditions in correctional facilities.

Corrections experts said the use of physical force is an important option to prevent violence among those in jail, or violence against guards. However, records kept by correctional officers at the 25 Pennsylvania county jails show that just 10% of “use of force” incidents were in response to a prisoner assaulting someone else. Another 10% describe a prisoner threatening staff members.

WITF found that 1 in 5 uses of force — 88 incidents — involved a prisoner who was either attempting suicide, hurting themselves, or threatening self-harm. Common responses by jail staff included deploying the tools used on Thompson — a restraint chair and pepper spray. In some cases, officers used electroshock devices such as stun guns.

In addition, the investigation uncovered 42 incidents in which corrections staffers noted that an inmate appeared to have a mental health condition — and guards deployed force after the person failed to respond to commands.

Defenders of these techniques said they save lives by preventing violence or self-harm, but some jails in the U.S. have moved away from the practices, and administrators have said the techniques are inhumane and don’t work.

The human costs can extend far beyond the jail, reaching the families of incarcerated people who are killed or traumatized, as well as the corrections officers involved, said Liz Schultz, a civil rights and criminal defense attorney in the Philadelphia area.

“And even if the human costs aren’t persuasive, the taxpayers should care, since the resulting lawsuits can be staggering,” Schultz said. “It underscores that we must ensure safe conditions in jails and prisons, and that we should be a bit more judicious about who we are locking up and why.”

‘All I Needed Was One Person’

Adam Caprioli’s experience began when he called 911 during a panic attack.

Caprioli, 30, lives in Long Pond, Pennsylvania, and has been diagnosed with bipolar disorder and anxiety disorder. He also struggles with alcohol and drug addiction, he said.

When police responded to the 911 call in fall 2021, they took Caprioli to the Monroe County Correctional Facility.

Inside the jail, Caprioli’s anxiety and paranoia surged. He said the staff ignored his requests to make a phone call or speak to a mental health professional.

After several hours of extreme distress, Caprioli tied his shirt around his neck and choked himself until he passed out. After corrections staff saw Caprioli with his shirt around his neck, officers wearing body armor and helmets rushed into his cell. The four-man team brought the 150-pound Caprioli down to the floor. One of them had a compressed air gun that shoots projectiles containing chemical irritants.

“Inmate Caprioli was swinging his arms and kicking his legs,” a sergeant wrote in the incident report. “I pressed the Pepperball launcher against the small of Inmate Caprioli’s back and impacted him three (3) times.” Attorney Alan Mills said prison staffers often justify their use of physical force by saying they’re intervening to save the person’s life.

“The vast majority of people who are engaged in self-harm are not going to die,” said Mills, who has litigated use of force cases and who serves as executive director of Uptown People’s Law Center in Chicago. “Rather, they are acting out some form of serious mental illness. And, therefore, what they really need is intervention to de-escalate the situation, whereas use of force does exactly the opposite and escalates the situation.”

In Pennsylvania, Caprioli said when officers entered his cell he felt the pain of welts in his flesh and the sting of powdered chemicals in the air, and realized nobody would help him.

“That’s the sick part about it,” Caprioli said. “You can see I’m in distress. You can see I’m not going to try and hurt anyone. I have nothing I can hurt you with.”

Eventually, he was taken to the hospital — where Caprioli said hospital staffers assessed his physical injuries — but he didn’t get help from a mental health professional. Hours later, he was back in jail, where he stayed for five days. He eventually pleaded guilty to a charge of “public drunkenness and similar misconduct” and had to pay a fine.

Caprioli acknowledged that he makes his problems worse when he uses alcohol or drugs, but he said that doesn’t justify how he was treated in jail.

“That’s not something that should be going on at all. All I needed was one person to just be like, ‘Hey, how are you? What’s going on?’ And never got that, even to the last day,” he said.

Monroe County Warden Garry Haidle and Monroe County District Attorney E. David Christine Jr. did not respond to requests for comment.

Some Jails Are Trying New Strategies

Jail is not an appropriate setting for treating serious mental illness, said Dr. Pamela Rollings-Mazza. She works with PrimeCare Medical, which provides medical and behavioral services at about 35 county jails in Pennsylvania.

The problem, Rollings-Mazza said, is that people with serious psychiatric issues don’t get the help they need before they are in crisis. At that point, police can be involved, and people who started off needing mental health care end up in jail.

“So the patients that we’re seeing, you know, a lot of times are very, very, very sick,” Rollings-Mazza said. “So we have adapted our staff to try to address that need.”

PrimeCare psychologists rate prisoners’ mental health on an A-through-D scale. Those with a D rating are the most seriously ill.

Rollings-Mazza said they make up between 10% and 15% of the overall population of jails served by PrimeCare. An additional 40% of people have a C rating, also a sign of significant illness.

She said that rating system helps determine the care psychologists provide, but it has little effect on jail policies.

“There are some jails where they don’t have that understanding or want to necessarily support us,” she said. “Some security officers are not educated about mental health at the level that they should be.”

Rollings-Mazza said her team frequently sees people come to jail who are “not reality-based” due to psychiatric illness and can’t understand or comply with basic orders. They are often kept away from other people behind bars for their own safety and may spend up to 23 hours a day alone.

That isolation virtually guarantees that vulnerable people will spiral into a crisis, said Dr. Mariposa McCall, a California-based psychiatrist who recently published a paper looking at the effects of solitary confinement.

Her work is part of a large body of research showing that keeping a person alone in a small cell all day can cause lasting psychological damage.

McCall worked for several years at state prisons in California and said it’s important to understand that the culture among corrections officers prioritizes security and compliance above all. As a result, staff members may believe that people who are hurting themselves are actually trying to manipulate them.

Many guards also view prisoners with mental health conditions as potentially dangerous.

“And so it creates a certain level of disconnect from people’s suffering or humanity in some ways, because it feeds on that distrust,” McCall said. In that environment, officers feel justified using force whether or not they think the incarcerated person understands them.

To really understand the issue, it helps to examine the decisions made in the hours and days leading up to a use of force incident, said Jamelia Morgan, a professor at Northwestern University Pritzker School of Law.

Morgan researches a growing number of lawsuits centered on use of force incidents that involve people in jail with mental health problems. Lawyers have successfully argued that demanding that a person with mental illness comply with orders they may not understand is a violation of their civil rights. Those suits suggest that jails should instead provide “reasonable accommodations.”

“In some cases, it’s as simple as having medical staff respond, as opposed to security staff,” Morgan said.

Individual cases can be difficult to litigate due to a complex grievance process that those locked up must follow before filing suit, Morgan said. Morgan said to solve the overall problem, wardens will need to redefine what it means to be in jail.

This investigation included right-to-know requests filed with 61 counties across Pennsylvania and the investigative team followed up with wardens in some of the counties that released use of force reports. None agreed to talk about how their officers are trained or whether they could change how they respond to people in crisis.

Some jails are trying new strategies. In Chicago, the Cook County corrections department doesn’t have a warden. Rather, it has an “executive director” who is also a trained psychologist.

That change was one part of a total reimagining of jail operations after a 2008 Department of Justice report found widespread violations of prisoners’ civil rights.

In recent years, Cook County’s jail system has gotten rid of solitary confinement, opting instead to put problematic prisoners in common areas, but with additional security measures whenever possible, Cook County Sheriff Tom Dart said.

The jail includes a mental health transition center that offers alternative housing — a “college setting of Quonset huts and gardens,” as Dart described it. There, prisoners have access to art, photography, and gardening classes. There’s also job training, and case managers work with local community agencies, planning for what will happen once someone leaves the jail.

Just as important, Dart said, jail leadership has worked to change the training and norms around when it’s appropriate to use tools such as pepper spray.

“Our role is to keep people safe, and if you have someone with a mental illness, I just don’t see how Tasers and [pepper] spray can do anything other than aggravate issues, and can only be used as the last conceivable option,” Dart said.

Cook County’s reforms show that change is possible, but there are thousands of local jails across the U.S., and they depend on the local and state governments that set correctional policies and that fund — or fail to fund — the mental health services that could keep vulnerable people out of jail in the first place.

In Pennsylvania’s Dauphin County, where Ishmail Thompson died, officials said that the problem — and solutions — extend beyond jail walls. County spokesperson Hambright said funding has remained stagnant amid an increase in people needing mental health services. That’s led to an over-reliance on jails, where the “lights are always on.”

“We would certainly like to see some of these individuals treated and housed in locations better equipped to treat the specificity of their conditions,” Hambright added. “But we must play the hands we are dealt by the existing system as best we can with the resources that we have.”

This story is part of a partnership that includes WITF, NPR, and KHN.

Brett Sholtis received a 2021-22 Rosalynn Carter Fellowship for Mental Health Journalism, and this investigation received additional support from The Benjamin von Sternenfels Rosenthal Grant for Mental Health Investigative Journalism, in partnership with the Carter Center and Reveal from the Center for Investigative Reporting.

To learn more about how WITF reported this article, check out this explainer.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Medicaid and Abortion Top Health Agenda for Montana Lawmakers

Kaiser Health News:Medicaid - January 09, 2023

HELENA, Mont. — Montana lawmakers said lowering costs and expanding patient access will be their top health care goals for the new legislative session. But they also will have to contend with making changes to Medicaid, a management crisis at the Montana State Hospital, and proposals to regulate abortion.

Republicans, who hold a veto-proof majority, said they will focus on three areas of health care: transparency, costs, and patient options.

Party leaders aim to keep “taking small bites that are moving the ball in the right direction on those three big things,” Senate Republican spokesperson Kyle Schmauch said.

Democrats, who are the minority party and need Republican help to pass their bills, identified lowering health care costs, protecting Medicaid coverage, and preserving reproductive freedom as their priorities.

As the 90-day Montana session enters its second week, here are some of the top health issues on the agenda:

Expanding Patient Access

Expanding telehealth and making it easier for qualified providers from outside the state to practice in Montana are two ways Republican Gov. Greg Gianforte proposes to improve health care access, said spokesperson Brooke Stroyke.

House Speaker Matt Regier (R-Kalispell) agreed that telehealth is key to improving access. Republicans plan to build on a law passed in the 2021 session that made permanent some of the pandemic-driven emergency regulations that loosened restrictions on telehealth.

Schmauch said legislators will consider spending proposals to expand Montana’s broadband reach to make telehealth a viable option for more people, particularly rural residents.

Other proposals meant to give rural patients with limited access to care more options are planned, such as allowing physicians to dispense prescription drugs to patients, and allowing pharmacists to prescribe certain drugs, Schmauch said.


Eleven Montana nursing homes announced closures in 2022, with officials citing staffing shortages and low Medicaid reimbursement rates as the primary reasons for the industry’s ongoing struggles.

Lawmakers will debate raising reimbursement rates for nursing homes and many other types of health providers after a state-commissioned study found they were too low to cover the cost of care.

“Increasing provider rates at the study’s recommended level will ensure a strong health care workforce and should be a priority for this legislature,” said Heather O’Loughlin, executive director of the Montana Budget and Policy Center, a nonprofit organization that analyzes the state budget, taxes, and economy.

Gianforte’s budget proposal includes reimbursement rate increases that fall short of what the study recommends. A bill by Rep. Mary Caferro (D-Helena) would base provider rates on the study’s findings.

Federal rules dictated that anybody enrolled in Medicaid could not be dropped from the program during the public health emergency. But the omnibus spending bill recently passed by Congress allows states to begin reviewing the eligibility of their beneficiaries in April, and millions of people across the U.S. are at risk of losing coverage as a result.

“That will have an inherent outcome of removing people who qualified for Medicaid but because of this process being so complicated, they’ll lose it,” Caferro said.

Caferro said she plans to introduce legislation that restores 12-month continuous eligibility for adults enrolled in Montana Medicaid. The measure is likely to be opposed by legislative Republicans and Gianforte, who co-signed a letter to President Joe Biden in December saying the public health emergency had artificially expanded the Medicaid population.

Montana State Hospital

The Montana State Hospital lost its federal accreditation after a spate of injuries and deaths, making management of the psychiatric hospital and the availability of behavioral health services a top priority of the session.

Stroyke said Gianforte’s two-year budget plan, which is a starting point for legislative budget writers, includes $300 million for the state hospital and for expanding access to intensive behavioral health care across the state.

Legislators are considering measures that would shift care for some patients from the state-run hospital to community-based health services. Regier said moving more public health services from state institutions to community providers would relieve some strain on facilities like the Montana State Hospital.


Lawmakers from both parties have filed more than a dozen bill draft requests dealing with abortion. One from Regier would restrict the type of abortions that can be performed in the state, and, at the other end of the debate, a proposal by Sen. Ryan Lynch (D-Butte) would codify abortion access in state law. The Gianforte administration also recently proposed an administrative rule that would make it more difficult for women to have an abortion paid for by Medicaid.

But the Republican majority is restricted from enacting a sweeping abortion ban in the wake of the U.S. Supreme Court’s 2022 decision to overturn Roe v. Wade. That’s because a 1999 Montana Supreme Court ruling determined the state constitution’s right-to-privacy protection covers abortion access. The state is seeking to overturn that precedent after a judge blocked three anti-abortion laws passed by the 2021 legislature.

Hospital Oversight

Lawmakers also will consider proposals to increase oversight of the way nonprofit hospitals report community benefits.

State health officials have wanted to set standards for the charitable contributions those hospitals make in exchange for their tax-exempt status. A KHN investigation found that Montana’s nonprofit hospitals spent about 8% of their total annual expenses on charity benefits in 2019, which is below the national average.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Journalists Review 2022’s Top Health Stories and the CDC’s Policy on Remote Work

Kaiser Health News:States - January 07, 2023

KHN Florida correspondent Daniel Chang discussed some of 2022’s top health stories from the Sunshine State on WLRN Miami’s “The Florida Roundup” on Dec. 29.

KHN senior editor Andy Miller discussed the policy at the Centers for Disease Control and Prevention that allows its employees to work remotely on WUGA’s “The Georgia Health Report” on Dec. 16.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

California Senate’s New Health Chair to Prioritize Mental Health and Homelessness

California state Sen. Susan Talamantes Eggman, a Stockton Democrat who was instrumental in passing Gov. Gavin Newsom’s signature mental health care legislation last year, has been appointed to lead the Senate’s influential health committee, a change that promises a more urgent focus on expanding mental health services and moving homeless people into housing and treatment.

Eggman, a licensed social worker, co-authored the novel law that allows families, clinicians, first responders, and others to petition a judge to mandate government-funded treatment and services for people whose lives have been derailed by untreated psychotic disorders and substance use. It was a win for Newsom, who proposed the Community Assistance, Recovery and Empowerment Act, or CARE Court, as a potent new tool to address the tens of thousands of people in California living homeless or at risk of incarceration because of untreated mental illness and addiction. The measure faced staunch opposition from disability and civil liberties groups worried about stripping people’s right to make decisions for themselves.

“We see real examples of people dying every single day, and they’re dying with their rights on,” Eggman said in an interview with KHN before the appointment. “I think we need to step back a little bit and look at the larger public health issue. It’s a danger for everybody to be living around needles or have people burrowing under freeways.”

Senate Pro Tem Toni Atkins announced Eggman’s appointment Thursday evening. Eggman replaces Dr. Richard Pan, who was termed out last year after serving five years as chair. Pan, a pediatrician, had prioritized the state’s response to the covid-19 pandemic and championed legislation that tightened the state’s childhood vaccination laws. Those moves made him a hero among public health advocates, even as he faced taunts and physical threats from opponents.

The leadership change is expected to coincide with a Democratic health agenda focused on two of the state’s thorniest and most intractable issues: homelessness and mental illness. According to federal data, California accounts for 30% of the nation’s homeless population, while making up 12% of the U.S. population. A recent Stanford study estimated that in 2020 about 25% of homeless adults in Los Angeles County had a severe mental illness such as schizophrenia and 27% had a long-term substance use disorder.

Eggman will work with Assembly member Jim Wood, a Santa Rosa Democrat who is returning as chair of the Assembly Health Committee. Though the chairs may set different priorities, they need to cooperate to get bills to the governor’s desk.

Eggman takes the helm as California grapples with a projected $24 billion budget deficit, which could force reductions in health care spending. The tighter financial outlook is causing politicians to shift from big “moonshot” ideas like universal health care coverage to showing voters progress on the state’s homelessness crisis, said David McCuan, chair of the political science department at Sonoma State University. Seven in 10 likely voters cite homelessness as a big problem, according to a recent statewide survey by the Public Policy Institute of California.

Eggman, 61, served eight years in the state Assembly before her election to the Senate in 2020. In 2015, she authored California’s End of Life Option Act, which allowed terminally ill patients who meet specified conditions to get aid-in-dying drugs from their doctor. Her past work on mental health included changing eligibility rules for outpatient treatment or conservatorships, and trying to make it easier for community clinics to bill the government for mental health services.

She hasn’t announced her future plans, but she has around $70,000 in a campaign account for lieutenant governor, as well as $175,000 in a ballot measure committee to “repair California’s mental health system.”

Eggman said the CARE Court initiative seeks to strike a balance between civil rights and public health. She said she believes people should be in the least restrictive environment necessary for care, but that when someone is a danger to themselves or the community there needs to be an option to hold them against their will. A Berkeley Institute of Governmental Studies poll released in October found 76% of registered voters had a positive view of the law.

Sen. Thomas Umberg (D-Santa Ana), who co-authored the bill with Eggman, credited her expertise in behavioral health and dedication to explaining the mechanics of the plan to fellow lawmakers. “I think she really helped to put a face on it,” Umberg said.

But it will be hard to show quick results. The measure will unroll in phases, with the first seven counties — Glenn, Orange, Riverside, San Diego, San Francisco, Stanislaus, and Tuolumne — set to launch their efforts in October. The remaining 51 counties are set to launch in 2024.

County governments remain concerned about a steady and sufficient flow of funding to cover the costs of treatment and housing inherent in the plan.

California has allocated $57 million in seed money for counties to set up local CARE Courts, but the state hasn’t specified how much money will flow to counties to keep them running, said Jacqueline Wong-Hernandez, deputy executive director of legislative affairs at the California State Association of Counties.

Robin Kennedy is a professor emerita of social work at Sacramento State, where Eggman taught social work before being elected to the Assembly. Kennedy described Eggman as someone guided by data, a listener attuned to the needs of caregivers, and a leader willing to do difficult things. The two have known each other since Eggman began teaching in 2002.

“Most of us, when we become faculty members, we just want to do our research and teach,” Kennedy said. “Susan had only been there for two or three years, and she was taking on leadership roles.”

She said that Eggman’s vision of mental health as a community issue, rather than just an individual concern, is controversial, but that she is willing to take on hard conversations and listen to all sides. Plus, Kennedy added, “she’s not just going to do what Newsom tells her to do.”

Eggman and Wood are expected to provide oversight of CalAIM, the Newsom administration’s sweeping overhaul of Medi-Cal, California’s Medicaid program for low-income residents. The effort is a multibillion-dollar experiment that aims to improve patient health by funneling money into social programs and keeping patients out of costly institutions such as emergency departments, jails, nursing homes, and mental health crisis centers. Wood said he believes there are opportunities to improve the CalAIM initiative and to monitor consolidation in the health care industry, which he believes drives up costs.

Eggman said she’s also concerned about workforce shortages in the health care industry, and would be willing to revisit a conversation about a higher minimum wage for hospital workers after last year’s negotiations between the industry and labor failed.

But with only two years left before she is termed out, Eggman said, her lens will be tightly framed around her area of expertise: improving behavioral health care across California.

“In my last few years,” she said, “I want to focus on where my experience is.”

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

During In-Flight Emergencies, Sometimes Airlines’ Medical Kits Fall Short

Kaiser Health News:States - January 06, 2023

In March, a Frontier Airlines flight was headed from Phoenix to Las Vegas when a female passenger stopped breathing. The flight attendant yelled in the cabin for help.

A passenger who was trained as a wilderness first responder, Seth Coley, jumped into action and found the woman was unresponsive and had a weak pulse. Coley dug through the plane’s medical kit but couldn’t find an oropharyngeal airway, a tool that was supposed to be there and that he needed to help the woman breathe. Instead, he cleared the airway by manipulating her neck.

Afterward, Coley sent a message to Denver-based Frontier Airlines via an online customer service form: “I saved somebody’s life on one of your flights,” he wrote. “I would like to speak about the medical kit you guys have on your flights. You are missing some very valuable and simple things. She almost died.”

Americans are flying at levels reaching pre-pandemic numbers. While covid-19 ushered in new health and cleaning protocols designed to make airplane travel safer, incidents like Coley’s raise questions about airlines’ readiness for medical emergencies because of incomplete or insufficient medical kits and the training of flight crews, who often rely on other passengers in emergencies.

Frontier did not respond to KHN’s requests for comment about that incident or its emergency kits. But Coley’s experience illustrates the risks travelers take every time they board a flight. For every 20,000 passengers who take a flight on a U.S.-based airline, there is one medical event — defined as any health-related incident, not only emergencies — according to estimates from airplane medical services company MedAire.

The Federal Aviation Administration requires commercial aircraft to carry at least one sealed emergency medical kit containing a minimum of 25 specified instruments and medications, plus first-aid kits and automated external defibrillators. But the FAA does not track data on the use of those kits during in-flight medical emergencies. Instead, the agency leaves it to the airlines to inspect the kits and replace them if the seals are broken.

“Ensuring complete, sealed emergency medical kits are present is part of the cabin crew’s preflight inspection,” FAA spokesperson Ian Gregor said in a statement.

But, as Coley and other passengers who have responded to an in-flight emergency have found out, an item required in a medical kit can sometimes be missing. Some items the FAA doesn’t require, such as the overdose reversal drug naloxone, are carried voluntarily by some airlines. The agency has issued guidance recommending items to add to the kits, but they are not yet mandated.

Gregor said the FAA investigates all reports of issues with medical kits and ensures any concerns are addressed. He did not respond to a KHN request for details on the number of reports investigated, their outcomes, or whether the emergencies described in this article were among those investigated.

In June, Boston surgeon Dr. Andrea Merrill was aboard a Delta Air Lines flight when she assisted in a medical emergency and found the kit fell short of what she needed.

It needs “a glucometer, epi pen, and automatic blood pressure cuffs — it’s impossible to hear with a disposable stethoscope in the air,” Merrill tweeted to Delta after the incident. “Please improve this for passenger safety!”

After Merrill’s tweet went viral, Delta followed up with her, saying it would switch to automatic blood pressure cuffs and “real” stethoscopes, as well as consider glucometers at gates. Merrill declined an interview request.

KHN asked U.S. airlines to detail their medical emergency protocols and the contents of their medical kits. Seven responded with limited information: Alaska, Allegiant, Hawaiian, JetBlue, Southwest, Sun Country, and United. All said that their kits meet or exceed FAA requirements and that they train their staff to respond to medical emergencies. Many airlines also contract with a MedAire service called MedLink that connects flight crews with a medical professional on the ground in an in-flight emergency.

Allegiant officials said passengers with medical conditions should not assume their planes will have everything they need in an emergency. “Although our crews are trained to respond to a wide array of unplanned medical emergencies, we want to remind readers who have anticipated medical needs to bring their own medical supplies in carry-on luggage and not rely on aircraft emergency equipment,” Allegiant spokesperson Andrew Porrello said in a statement.

Delta, along with American, Frontier, and Spirit, did not respond to requests for comment. A 2019 article on the Delta website said its flight attendants are given training in first aid and CPR. Additionally, Delta wrote that its medical equipment exceeds FAA requirements. The airline mentioned it uses STAT-MD, a service that lets flight crews consult with trained personnel at the University of Pittsburgh Medical Center.

The FAA requires flight attendants to receive specific medical training, but medical professionals who have intervened as passengers during an in-flight emergency said the crew is not always quick to respond.

“Passengers believe that there are probably more safeguards in place than there actually are,” said Dr. Comilla Sasson, a Denver-area emergency physician and associate clinical professor at the University of Colorado.

Sasson was on a United Airlines flight in 2018 when a passenger passed out. When she volunteered to help, crew members asked for proof that she was a doctor as she mobilized to check the passenger’s vital signs. Sasson questioned the extent to which crew members are trained to help in medical emergencies, saying other health care providers have told her about their own experiences of aiding a passenger in need while the flight personnel stood aside.

“It’s interesting to me that the airlines really kind of depend on the kindness of strangers in a lot of ways, much more so than I would think,” Sasson said.

The goodwill of a fellow passenger is something Bay Area resident Meera Mani is thankful for after a 2011 experience. She was on a United flight from Toronto to San Francisco when her now-deceased father, then in his 80s, began showing concerning symptoms: The right side of his face and arm drooped. Worried her dad was having a stroke, Mani shouted for help but was frustrated by flight attendants’ slow response.

“And then finally, I said: ‘Is there a doctor on the flight?’” Mani recounted.

There was. The doctor used a defibrillator to stabilize her father.

“It was very clear to me that the [flight] staff were completely flummoxed,” Mani said. “They had the equipment, they took it out, they gave it to him, but the doctor took care of it.”

United helped organize an ambulance to meet Mani and her father on the ground at the San Francisco airport and later called to see if her dad was OK. He ended up being diagnosed with a condition that could lead to fainting.

MedAire, which runs the MedLink consulting service, said it covers around 70% of the U.S. market but declined to specify airlines. Dr. Paulo Alves, MedAire’s global medical director of aviation health, said 98% of medical events are managed on board and are non-life-threatening, while 2% are serious cases that might divert a flight.

Alves said his company also provides medical consultations before passengers board a flight.

“An airplane — although I love aviation — is never the best place for you to have a medical event,” Alves said. “The first line of prevention is actually preflight.”

Alves also defended the contents of airlines’ medical kits. The medically trained volunteers who step in to help fellow passengers in an emergency may expect resources available in a hospital, but “the airplane is not a hospital. You cannot carry everything,” he said.

Mani said she would like to see airlines disclose which medical emergencies they’re trained to address — potentially on flight safety cards. Sasson said it would be helpful if airlines clearly shared information about what medical supplies are available on board.

“I think the general public doesn’t realize how much of a crapshoot it is when they’re up in the air that somebody with some sort of medical training will know what to do, if something were to happen,” Sasson said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

More Orthopedic Physicians Sell Out to Private Equity Firms, Raising Alarms About Costs and Quality

Dr. Paul Jeffords and his colleagues at Atlanta-based Resurgens Orthopaedics were worried about their ability to survive financially, even though their independent orthopedic practice was the largest in Georgia, with nearly 100 physicians.

They nervously watched other physician practices sell out entirely to large hospital systems and health insurers. They refused to consider doing that. “It was an arms race,” Jeffords said, “and we knew we had to do something different if we wanted to remain independent and strong and offer good quality of care.”

So, in December 2021, Resurgens sold a 60% share in United Musculoskeletal Partners, their own management company, to Welsh, Carson, Anderson & Stowe, a large New York-based private equity firm known as Welsh Carson. Although details of the sale were not disclosed, physician-shareholders in deals like this typically each receive a multimillion-dollar cash payout, plus the potential for subsequent big payouts each time the practice is sold to another investor in future years.

Orthopedic surgeons, long seen as fiercely independent, are rapidly catching up with other specialist physicians, such as dermatologists and ophthalmologists, in selling control of their practices to private equity investment firms. They hope to grab a bigger chunk of the surging market in outpatient surgery and maintain their position as one of the highest-paid specialties in medicine — $633,620 was the average compensation for orthopedists in 2021. For older doctors, the upfront cash payout and the potential second payout when the business is flipped offers the promise of a posh retirement.

Proponents say private equity investment has the potential to reduce total spending on musculoskeletal care and improve quality by helping physicians move more procedures to cheaper outpatient surgery centers, which have less overhead. It also could help the doctors shift to value-based payment models, in which they charge fixed amounts for whole episodes of care, such as total joint replacements and spine surgeries — receiving bonuses or penalties from insurers based on cost and quality performance.

But critics warn that profit-hungry private equity ownership alternatively could result in higher prices for patients and insurers, more unnecessary surgery, and less access to care for patients on Medicaid or those who are uninsured or underinsured. A recent study found that in the two years after a sale, PE-owned practices in three other medical specialties had average charges per claim that were 20% higher than at places not owned by private equity.

Critics also worry that PE investors will put pressure on doctors to see more patients and use more non-physician providers in ways that could lead to poorer care, as KHN has reported about gastroenterology and other specialties.

“Private equity has no interest in reducing the cost of medicine,” said Dr. Louis Levitt, chief medical officer of MedVanta, a Maryland orthopedic management company whose physician-owners have rejected partnering with private equity. “Their goal is to increase profitability in three to five years and sell to the next group that comes along. They can only do it by making the doctors work longer and reduce service delivery.”

There are now at least 15 PE-backed management companies — called platforms — that own orthopedic practices across the country, said Gary Herschman, a New York lawyer who advises physicians in these deals. The first orthopedic deals were done in 2017, and dozens of sales have occurred since then, with the pace expected to quicken. In 2022 alone, at least 15 orthopedic practices were sold to PE-owned management companies.

Dana Jacoby, CEO of the Vector Medical Group, a strategic consultancy for physician groups, said several orthopedic platforms built by private equity investors already are on the market for resale to other investors, though she wouldn’t say which ones. The government does not require public reporting of these deals unless they exceed $101 million, a threshold that is adjusted over time.

Private equity investors have rolled up orthopedic practices in at least 12 states, with concentrations in Georgia, Texas, Florida, and Colorado.

Besides United Musculoskeletal Partners, other sizable PE-owned orthopedic platforms include Phoenix-based HOPCo, backed by Audax Group, Linden Capital Partners, and Frazier Healthcare Partners, with 305 physicians in seven states; Alpharetta, Georgia-based U.S. Orthopaedic Partners, backed by FFL Partners and Thurston Group, with 110 physicians in two states; and Fort Lauderdale, Florida-based Orthopedic Care Partners, backed by Varsity Healthcare Partners, with 120 physicians in four states.

Private equity funds, with a reported $1.8 trillion to invest in health care, are attracted to the size of the orthopedic care market. Annual patient spending is nearly $50 billion alone for treating back pain. The soaring demand of aging Americans for joint replacements, the high rates insurers pay for musculoskeletal procedures — such as nearly $50,000 for a knee replacement — and the lucrative array of orthopedic service lines and ancillary businesses, including ambulatory surgery centers, physical therapy, diagnostic imaging, pain management, and sports medicine, make this a tantalizing line of business.

The standard playbook of private equity firms is to pull profits of 20% out of their physician groups each year, then reap up to a 350% return on their cash investment when they sell the platform, say experts involved in these deals.

Orthopedic surgeons “are very excited about getting a $5 million to $7 million check,” said Dr. Jack Bert, former chair of the practice management committee of the American Academy of Orthopedic Surgeons. “But some I’ve talked to say the suits come in and tell the doctors, ‘You’re not working hard enough, you’ve got to increase production by 20%.’ That can be a big problem.”

Through their sale to Welsh Carson, the Resurgens orthopedists in Atlanta got a capital partner and executive expertise to help them expand by acquiring other orthopedic practices in Georgia and other markets. Soon after the deal, United Musculoskeletal Partners acquired large orthopedic practices in Dallas and Denver, and brought in a second private equity firm as an additional investor. Several other acquisitions are imminent, said Sean Traynor, a general partner at Welsh Carson.

Traynor said the investment capital and the company’s growing size in major markets will sharpen the doctors’ ability to negotiate richer contracts with insurers, get better deals on equipment and supplies, build more outpatient surgery centers, and improve quality of care for patients.

The physicians, he added, retain full responsibility for clinical governance, and that is protected by a permanent contract provision binding on all future owners.

“Other physicians ask what’s changed [since the sale], and I say nothing, which is great,” said Dr. Irfan Ansari, one of the Resurgens orthopedists.

But some large employers, whose self-funded health plans pay for orthopedic care for their workers, view the trend toward private equity ownership warily. They fear the new owners will milk the current fee-for-service system, which financially rewards doctors for providing more — and more expensive — surgical procedures, rather than promoting less costly but effective services such as physical therapy for lower back pain.

“The worry we have is we’re not seeing private equity fulfilling the promise of value-based care,” said Alan Gilbert, vice president for policy at the Purchaser Business Group on Health, which represents nearly 40 large private and public employers. “We’re seeing the same short-term financial goals you see with other private equity investments, including pressure to perform non-indicated procedures.”

At least two PE-backed orthopedic groups, however, are working with insurers on cost-saving value-based care programs. U.S. Orthopaedic Partners and HOPCo tout their partnerships with insurers, boasting that they’ve built systems to deliver entire episodes of care at lower costs under fixed-payment models.

Jennifer Allen, chief financial officer at Blue Cross & Blue Shield of Mississippi, said her health plan has saved nearly 40% by collaborating with Mississippi Sports Medicine, now owned by U.S. Orthopaedic Partners, on bundled payments for hip, knee, and shoulder replacement procedures as well as several spine procedures. But Allen said the program was launched in 2016 before private equity investors bought that orthopedic group.

“We had established the protocols, the benefits, the bundle, and everything before that,” she said. “I didn’t see anything that the private equity platform brought to the table.”

Dr. David Jacofsky, HOPCo’s chairman, said private equity owners should be steering their orthopedic groups toward value-based care, but so far he’s not seeing that happening much. “Private equity has lofty goals of wanting to build these things, but the time frame it takes is much longer than private equity wants to stay in these deals,” he said. Instead, he added, most are trying to grow bigger and demand higher payments from insurers, and “that’s not good for anyone.”

Still, MedVanta’s Levitt isn’t optimistic about his orthopedic colleagues’ ability, or willingness, to resist private equity. “We’re on an island and pieces are being chipped away by piranhas in the water,” he said. “I’m not sure it’s possible to remain independent.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

Sueño alterado y nervios de punta: la contaminación acústica afecta la mente y el cuerpo

Kaiser Health News:States - January 05, 2023

SACRAMENTO, CA. — Los amigos de Mike Thomson no quieren quedarse en su casa.

Thomson vive a media cuadra de una transitada autopista que divide la ciudad capital de California, una vía que se ha utilizado cada vez más como pista de carreras de alta velocidad, y por donde pasan camiones grandes que arrojan diesel, motocicletas que aceleran y automóviles que han sido modificados ilegalmente para hacer aún más ruido.

Casi el único momento en que hay calma es el sábado por la noche entre las 3 y las 4 am, dijo Thomson.

El resto del tiempo el estruendo es casi constante y, la mayoría de las noches, se despierta cinco o seis veces.

“Los autos pasan y no tienen silenciadores”, dijo Thomson, de 54 años, quien trabaja remodelando casas. “Es terrible. No se lo recomiendo a nadie”.

Thomson es víctima de la contaminación acústica o sonora, que los expertos en salud advierten que es un problema creciente que no se limita a nuestros oídos, sino que causa condiciones relacionadas con el estrés, como la ansiedad, la hipertensión y el insomnio.

Los legisladores de California aprobaron dos leyes en 2022 destinadas a calmar el medio ambiente. Uno ordena a la Patrulla de Carreteras de California que pruebe las cámaras de detección de ruido, que eventualmente pueden emitir multas automáticas para los automóviles que hacen ruido por encima de cierto nivel. El otro obliga a los conductores de automóviles modificados ilegalmente a repararlos antes de que puedan renovar su registro.

“Hay un aspecto de nuestra sociedad al que le gusta ser ruidoso y orgulloso”, dijo el senador estatal Anthony Portantino (demócrata de Glendale), autor de la ley de cámaras de ruido. “Pero eso no debería afectar la salud de otra persona en un espacio público”.

La mayoría de los estados no han abordado el asalto a nuestros tímpanos. El tráfico es uno de los principales impulsores de la contaminación acústica, que afecta de manera desproporcionada a las comunidades desfavorecidas, y cada vez es más difícil escapar de los sonidos de los máquinas que recogen hojas, la construcción y otros irritantes.

Las leyes de California tomarán tiempo y tendrán un efecto limitado, pero los expertos en control del ruido las calificaron como un buen comienzo. Aún así, no hacen nada para abordar la contaminación acústica aérea de los helicópteros de la policía, los drones que zumban y otras fuentes de ruido, que son competencia del gobierno federal, dijo Les Blomberg, director ejecutivo de Noise Pollution Clearinghouse.

En octubre de 2021, la Asociación Estadounidense de Salud Pública declaró que el ruido es un peligro para la salud pública. Décadas de investigación vinculan la contaminación acústica no solo con la interrupción del sueño, sino también con una serie de afecciones crónicas, como enfermedades cardíacas, deterioro cognitivo, depresión y ansiedad.

“A pesar de la amplitud y gravedad de sus impactos en la salud, el ruido no ha sido priorizado como un problema de salud pública durante décadas”, dice la declaración. “La magnitud y la gravedad del ruido como peligro para la salud pública justifican la adopción de medidas”.

Cuando hay un ruido fuerte, el sistema auditivo señala que algo anda mal, desencadenando una respuesta de lucha o huida en el cuerpo e inundándolo con hormonas del estrés que causan inflamación y, en última instancia, pueden provocar enfermedades, dijo Peter James, profesor asistente de salud ambiental en la Escuela T.H. Chan de Salud Pública de la Universidad de Harvard.

La exposición constante al ruido aumenta el riesgo de enfermedad cardíaca en un 8% y de diabetes en un 6%, según muestra la investigación. En 2020, la Agencia Europea de Medio Ambiente estimó que la exposición al ruido causa alrededor de 12,000 muertes prematuras y 48,000 casos de enfermedades cardíacas cada año en Europa Occidental.

Si bien los funcionarios de la Patrulla de Carreteras de California pasarán los próximos años investigando las cámaras de detección de ruido, reconocen que el ruido de las carreras callejeras y los llamados espectáculos secundarios, donde las personas bloquean las intersecciones o los estacionamientos para quemar llantas o hacer “donas”, se ha disparado en últimos años y molesta a la gente ahora.

Se supone que los automóviles en California funcionan a 95 decibeles, un poco más alto que una cortadora de césped, o menos. Pero los conductores a menudo modifican sus automóviles y motocicletas para que sean más ruidosos, por ejemplo, instalando “silbatos” en el sistema de escape para hacer ruido o quitando los silenciadores.

En 2021, el último año completo del que hay datos disponibles, la patrulla de carreteras emitió 2,641 multas a conductores por ruido excesivo de vehículos, casi el doble de las 1,400 citaciones de 2018.

“Siempre ha habido un problema con el ruido de los caños de escape, y últimamente ha llamado más la atención”, dijo Andrew Poyner, capitán de la patrulla de carreteras. “Ha ido aumentando de manera constante en los últimos años”.

La Asociación Estadounidense de Salud Pública dice que el gobierno federal debería regular el ruido en el aire, en las carreteras y en los lugares de trabajo como un peligro ambiental, pero esa tarea se ha abandonado en su mayoría desde que, en 1981, bajo la presidencia de Ronald Reagan, se dejó de financiar a la Oficina Federal de Control y Reducción del Ruido.

Ahora, la tarea de silenciar a las comunidades depende principalmente de los estados y las ciudades. En California, la reducción del ruido suele ser un subproducto de otros cambios en la política ambiental. Por ejemplo, el estado prohibirá la venta de máquinas de hojas ruidosas a partir de 2024, una política destinada principalmente a reducir las emisiones que causan smog.

Una de las leyes de ruido aprobadas en California en 2022, AB 2496, requerirá que los propietarios de vehículos que hayan recibido multas por ruido solucionen el problema antes de que puedan volver a registrarlos a través del Departamento de Vehículos Motorizados. Actualmente, los conductores pueden pagar una multa y mantener sus autos modificados ilegalmente como están. La ley entra en vigor en 2027.

La otra ley, SB 1097, ordena a la patrulla de carreteras que recomiende una marca de cámaras detectoras de ruido a la legislatura para 2025. Estas cámaras, que ya se usan en París, la ciudad de Nueva York y Knoxville, Tennessee, emitirían multas automáticas a vehículos que retumban fuerte en la calle.

Originalmente, la ley habría creado programas piloto para comenzar a probar las cámaras en seis ciudades, pero los legisladores dijeron que querían ir paso a paso, y aprobaron solo el estudio.

Portantino dijo que se siente frustrado por la demora, especialmente porque las calles de Los Ángeles se han vuelto insoportablemente ruidosas.

“Está empeorando”, dijo Portantino. “La gente juega con sus autos y las carreras callejeras continúan siendo un problema”.

El estado es inteligente al apuntar inicialmente a los ruidos más fuertes, los automóviles y motocicletas que más molestan a las personas, dijo Blomberg.

“Puedes hacer que cada automóvil que sale de la línea sea la mitad de ruidoso que ahora y tendría muy poco impacto si no lidias con todas las personas que quitan los silenciadores”, dijo. “Eso supera todo”.

El ruido del tráfico no afecta a todos por igual. En un artículo de 2017, James y sus colegas encontraron que los niveles de ruido nocturno eran más altos en las comunidades de bajos ingresos y aquellas con una gran proporción de residentes de color.

“Hemos tomado estas decisiones conscientes o subconscientes como sociedad para colocar comunidades de razas minoritarias y comunidades de bajos ingresos que tienen la menor cantidad de poder político en áreas cercanas a carreteras y aeropuertos”, dijo James.

Elaine Jackson, de 62 años, siente esa disparidad de manera aguda en su vecindario, una comunidad de bajos ingresos en el norte de Sacramento ubicada entre autopistas.

Los fines de semana, los espectáculos en las calles y el ruido del tráfico la mantienen despierta. Sus nervios están alterados, pierde el sueño, sus perros entran en pánico y, en general, se siente insegura y olvidada, preocupada de que el nuevo desarrollo en su vecindario solo traerá más tráfico, ruido y contaminación del aire.

A la policía y los legisladores no parece importarles, dijo, aunque ella y sus vecinos constantemente plantean sus preocupaciones a los funcionarios locales.

“Es difícil para la gente conciliar el sueño por la noche”, dijo Jackson. “Y ese es un problema de calidad de vida”.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

NY requiere que doctores receten naloxona a algunos pacientes que toman analgésicos opioides

Kaiser Health News:States - January 05, 2023

Sin analgésicos opioides para aliviar el dolor de rodillas y otras articulaciones, Arnold Wilson no podría caminar media cuadra. El ex enfermero de la ciudad de Nueva York, de 63 años, tiene una artritis incapacitante y toma OxyContin dos veces al día, y oxicodona cuando necesita un alivio adicional.

En los últimos años, también ha tenido otro remedio a mano: naloxona, un medicamento para revertir una sobredosis, al que generalmente se menciona con el nombre de marca Narcan.

Aunque los titulares son por las muertes por sobredosis de drogas ilícitas vendidas en la calle, el riesgo de sufrirlas también es real para los pacientes que toman opioides recetados por sus médicos.

“Me da una sensación de alivio y seguridad”, dijo Wilson, quien tiene aerosol nasal Narcan en su auto y en su casa. Su médico en el Centro Médico Montefiore, en el Bronx, le recetó opioides en 2013, después que un episodio de meningitis exacerbara los problemas en las articulaciones que Wilson tenía como resultado de dos aneurismas cerebrales y varios accidentes cerebrovasculares. Su médico lo instó a comenzar a tener Narcan en 2017.

Generalmente otras personas administran la naloxona, que comienza a revertir una sobredosis en cuestión de minutos. Aunque nunca la ha necesitado, la hija de Wilson, de 18 años, sabe cómo usarla. “Le he dado instrucciones sobre cómo hacerlo, en caso de que esté letárgico”, dijo. Su novia y sus amigos también saben qué hacer.

Una ley recientemente promulgada en Nueva York tiene como objetivo garantizar que la naloxona esté disponible si la necesitan personas como Wilson que toman opioides recetados.

Según la ley, vigente desde el verano pasado, los médicos deben recetar naloxona junto con la primera receta de opioides cada año.

Los factores de riesgo que activarían el requisito incluyen tomar una dosis diaria alta de un opioide (al menos el equivalente a 90 miligramos de morfina, o MME); tomar ciertos medicamentos, como sedantes hipnóticos; o tener antecedentes de adicciones.

Al menos otros 10 estados tienen leyes similares, según una investigación de Network for Public Health Law.

“A veces, los pacientes, especialmente si han estado tomando opioides durante mucho tiempo, no entienden los riesgos”, dijo la doctora Laila Khalid, codirectora de la clínica de dolor crónico del Centro Médico Montefiore. La clínica proporciona naloxona gratis a los pacientes a través del programa de prevención de sobredosis de opioides del estado.

Por ejemplo, la persona puede haberse olvidado cuándo tomó la última dosis y, sin darse cuenta, tomar demasiado, o tomar algunos tragos adicionales en una fiesta, dijo Khalid. El alcohol y algunos medicamentos, como las benzodiazepinas, amplifican los efectos de los opioides.

“Las muertes por sobredosis de drogas continúan aumentando, como cada año durante más de dos décadas”, dijo Emily Einstein, jefa del área de Política Científica del Instituto Nacional sobre el Abuso de Drogas.

En 2021, apuntó Einstein, las muertes por sobredosis en Estados Unidos superaron las 100,000 estimadas por primera vez, según datos provisionales de los Centros para el Control y la Prevención de Enfermedades (CDC). Según estos datos, la gran mayoría de esas muertes, más de 80,000, involucraron a opioides, agregó. Si bien la mayoría de las muertes por sobredosis de opioides se atribuyeron al fentanilo ilegal, aproximadamente 17,000 muertes involucraron opioides recetados, incluida la metadona.

La naloxona, disponible como aerosol nasal o inyección, se considera segura y causa pocos efectos secundarios. No es adictiva. Los CDC recomiendan que las personas con riesgo de sobredosis la lleven consigo para que un familiar o transeúnte pueda administrarla si es necesario.

Los expertos en política de drogas señalan una estadística clave que leyes como la de Nueva York pretenden abordar: en casi el 40% de las muertes por sobredosis, otra persona está presente, según los CDC.

Si los transeúntes hubieran tenido la naloxona, “la mayoría de esas personas no habrían muerto”, dijo Corey Davis, director del Harm Reduction Legal Project en la Network for Public Health Law.

En todos los estados, incluido Nueva York, los farmacéuticos están autorizados a dispensar naloxona, a menudo bajo “órdenes permanentes” que permiten dispensarlo sin una receta, por lo general a personas que corren el riesgo de sufrir una sobredosis o están en condiciones de ayudar a alguien en riesgo.

Entonces, ¿por qué exigir que los médicos hagan recetas?

Obligar es más efectivo que recomendar, dicen expertos. Al requerir que los médicos receten el medicamento, más personas que podrían necesitar naloxona la tendrían a mano, si surten la receta. Pero no hay garantía de que lo hagan.

Una receta también puede ayudar a eliminar el estigma persistente de pedir una fármaco contra la sobredosis en el mostrador de una farmacia.

“Elimina los puntos de fricción”, dijo Davis. “Simplemente vas al mostrador y lo recoges”.

En un análisis de 2019, los farmacéuticos en los estados que requerían la receta conjunta de naloxona con opioides surtieron casi ocho veces más recetas de naloxona por cada 100,000 personas que los de los estados que no la requerían.

Missouri no tiene una ley de receta conjunta, pero el médico que ayuda a manejar el dolor a Danielle Muscato sugirió recientemente que llevara Narcan. La activista de derechos civiles de 38 años, que vive en Columbia, toma el opioide recetado tramadol y varios otros medicamentos para controlar su dolor lumbar severo y crónico. Está contenta de tener el aerosol nasal guardado en su bolso, por si acaso.

“Creo que es algo maravilloso” que la gente lo lleve y sepa cómo usarlo, dijo. “Ojalá esto fuera estándar en todas partes”.

Desde que entró en vigencia la ley de Nueva York, “definitivamente he visto un aumento de recetas que agregan naloxona a los opioides, especialmente si se trata de un pedido grande”, dijo Ambar Keluskar, gerente de farmacia de Rossi Pharmacy en Brooklyn.

Sin embargo, los pacientes no siempre entienden por qué lo obtienen, afirmó Toni Tompkins, farmacéutica supervisora de Phelps Hometown Pharmacy en la ciudad de Phelps, en el norte del estado de Nueva York.

Un caja de dos dosis de aerosol de naloxona generalmente cuesta alrededor de $150. El medicamento ahora está disponible en forma genérica, lo que puede reducir el costo de bolsillo. La mayoría de las aseguradoras lo cubren, aunque los pacientes suelen tener un copago.

Las personas sin seguro generalmente pueden obtener naloxona a través de programas estatales.

En Nueva York, las aseguradoras privadas están obligadas a cubrir la naloxona, y Medicaid también la cubre, dijo Monica Pomeroy, vocera del Departamento de Salud del estado. El Programa de asistencia de copago de naloxona (N-CAP) del estado cubre el costo de los copagos de hasta $40 para las personas con seguro, dijo Pomeroy.

Las personas sin seguro o aquellas que no han alcanzado su deducible pueden obtenerla gratis en uno de los sitios de prevención de sobredosis de opioides del estado.

En noviembre, la Administración de Alimentos y Drogas (FDA) anunció que está considerando que la naloxona esté disponible sin receta.

Aunque ofrecerla sin receta facilitaría la obtención del medicamento, a algunas personas les preocupa que el seguro no lo cubra. Además, “si un paciente simplemente lo recoge en algún lugar sin recibir orientación sobre cómo usarlo, eso podría ser un inconveniente”, dijo Anne Burns, vicepresidenta de asuntos profesionales de la Asociación Estadounidense de Farmacéuticos.

Algunos profesionales creen que se debe dispensar naloxona con cada receta de opioides, independientemente de los factores de riesgo. Así es en Rochester, Nueva York, y en los alrededores del condado de Monroe. En 2021, el ejecutivo del condado, Adam Bello, firmó la Ley de Maisie, que lleva el nombre de una niña local de 9 meses que murió después de tragarse una pastilla de metadona que encontró en el piso de la cocina de un vecino.

“Es horrible lo que pasó”, dijo Karl Williams, profesor de derecho farmacéutico y presidente de la junta de la Sociedad de Farmacéuticos del Estado de Nueva York. “Tal vez sea el próximo estándar que debería convertirse en ley”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).

NY Docs Are Now Required to Prescribe Naloxone to Some Patients on Opioid Painkillers

Kaiser Health News:States - January 05, 2023

Without opioid painkillers to dull the ache in his knees and other joints, Arnold Wilson wouldn’t be able to walk half a block. The 63-year-old former New York City nurse has crippling arthritis for which he takes OxyContin twice a day and oxycodone when he needs additional relief.

For the past several years, he’s kept another drug on hand as well: naloxone, an overdose reversal drug often referred to by the brand name Narcan.

Although overdose deaths from illicit drugs sold on the street make headlines, the risk of overdose is just as real for patients who take opioids prescribed by their doctors.

“It gives me a sense of relief and security,” said Wilson, who keeps Narcan nasal spray in his car and at home. His pain management doctor at Montefiore Medical Center in the Bronx prescribed the opioids in 2013, after a bout with meningitis exacerbated joint problems Wilson had as a result of two brain aneurysms and several strokes. His doctor urged him to start carrying Narcan in 2017.

Naloxone, which begins to reverse an overdose within minutes, is typically administered by others. Though he’s never needed it, Wilson’s 18-year-old daughter knows how to use it. “I’ve instructed her how to do it, in case I’m lethargic,” he said. His girlfriend and friends know what to do, too.

A recently enacted New York law aims to ensure that naloxone is available if needed by people like Wilson who take prescription opioids.

Under the law, which took effect last summer, doctors must co-prescribe naloxone to certain patients who are at risk of an overdose when writing the patients’ first opioid prescription each year. Risk factors that would trigger the requirement include taking a high daily dose of an opioid (at least 90 morphine milligram equivalents, or MME); taking certain other drugs, like sedative hypnotics; or having a history of substance use disorder.

At least 10 other states have similar laws, according to research by the Network for Public Health Law.

“Sometimes patients, especially if they’ve been taking opioids for a long time, don’t understand the risks,” said Dr. Laila Khalid, co-director of the chronic pain clinic at Montefiore Medical Center. The clinic provides free naloxone to patients through the state’s opioid overdose prevention program.

Someone may forget the timing of their last dose and inadvertently take too much, for example, or have a few extra drinks at a party, Khalid said. Alcohol and some medications, like benzodiazepines, amplify opioids’ effects.

“Drug overdose deaths continue to climb, as they have nearly every year for more than two decades,” said Emily Einstein, chief of the Science Policy Branch at the National Institute on Drug Abuse. In 2021, Einstein noted, overdose deaths in the United States topped an estimated 100,000 for the first time, according to provisional data from the Centers for Disease Control and Prevention. According to this provisional data, Einstein said, the vast majority of those deaths — over 80,000 — involved opioids. While most opioid overdose deaths were attributable to illicit fentanyl, approximately 17,000 deaths involved prescription opioids, including methadone.

Naloxone, available as either a nasal spray or injection, is considered safe and causes few side effects. It’s not addictive. The CDC recommends that people at risk of overdose carry it with them so that a family member or bystander can administer it if necessary.

Experts in drug policy point to a key statistic that laws like the one in New York aim to address: In nearly 40% of overdose deaths, another person is present, according to the CDC.

If bystanders had had naloxone, “most of those people wouldn’t have died,” said Corey Davis, director of the Harm Reduction Legal Project at the Network for Public Health Law.

In every state, including New York, pharmacists are authorized to dispense naloxone, often under “standing orders” that allow dispensing without a prescription, typically to people who are at risk of overdose or are in a position to help someone at risk.

So then why require physicians to write scripts?

Mandating is more effective than recommending, experts said. By requiring physicians to prescribe the drug, more people who might need naloxone would have it on hand — if they fill the prescription. But there’s no guarantee they will.

A prescription can also help remove the lingering stigma of asking for an overdose drug at the pharmacy counter.

“It removes friction points,” said Davis. “You just drive through the window and pick it up.”

In a 2019 analysis, pharmacists in states that required co-prescribing naloxone with opioids filled nearly eight times as many naloxone prescriptions per 100,000 people as those in states that didn’t require it.

Missouri doesn’t have a co-prescribing law, but Danielle Muscato’s pain management doctor recently suggested she carry Narcan. The 38-year-old civil rights activist, who lives in Columbia, takes the prescription opioid tramadol and several other drugs to keep her chronic severe lower back pain in check. She’s glad to have the nasal spray tucked in her purse, just in case.

“I think it’s a wonderful thing” that people carry it and know how to use it, she said. “I wish this was standard everywhere.”

Since the New York law went into effect, “I have definitely seen an uptick of prescribers adding naloxone to opioids, especially if it’s a large order,” said Ambar Keluskar, pharmacy manager at Rossi Pharmacy in Brooklyn.

Patients don’t always understand why they’re getting it, though, said Toni Tompkins, supervising pharmacist at Phelps Hometown Pharmacy in the upstate New York town of Phelps.

A two-dose package of naloxone spray typically costs about $150. The medication is now available in generic form, which may reduce the out-of-pocket cost. Most insurers cover it, although patients typically owe a copayment. The uninsured can generally get naloxone through state programs.

In New York, private insurers are required to cover naloxone, and Medicaid also covers it, said Monica Pomeroy, a spokesperson for the state health department. The state’s Naloxone Co-Payment Assistance Program (N-CAP) covers the cost of copays up to $40 for those with insurance, Pomeroy said. Uninsured people or those with unmet deductibles can get it free at one of the state’s opioid overdose prevention sites.

In November, the FDA announced it is considering making naloxone available without a prescription.

Although offering it over the counter would make the drug easier to get, some people are concerned that insurance might not cover it. Further, “if a patient is just picking it up somewhere without getting any guidance on how to use it, that could be a downside,” said Anne Burns, vice president of professional affairs at the American Pharmacists Association.

Some professionals believe naloxone should be dispensed with every opioid prescription, regardless of risk factors. In Rochester, New York, and surrounding Monroe County, that’s what happens. In 2021, the county executive, Adam Bello, signed Maisie’s Law, named after a local 9-month-old girl who died after swallowing a methadone pill she found on a neighbor’s kitchen floor.

“It’s horrible what happened,” said Karl Williams, a pharmacy law professor and chair of the board of the Pharmacists Society of the State of New York. “Maybe it’s a next-level standard that should become law.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.


This story can be republished for free (details).