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Thousands Mistakenly Enrolled During California’s Medicaid Expansion, Feds Find

Kaiser Health News:Madicaid - March 28, 2018

California signed up an estimated 450,000 people under Medicaid expansion who may not have been eligible for coverage, according to a report by the U.S. Health and Human Services’ chief watchdog.

In a Feb. 21 report, the HHS’ inspector general estimated that California spent $738.2 million on 366,078 expansion beneficiaries who were ineligible. It spent an additional $416.5 million for 79,055 expansion enrollees who were “potentially” ineligible, auditors found.

Auditors said nearly 90 percent of the $1.15 billion in questionable payments involved federal money, while the rest came from the state’s Medicaid program, known as Medi-Cal. They examined a six-month period from Oct. 1, 2014, to March 31, 2015, when Medicaid payments of $6.2 billion were made related to 1.9 million newly eligible enrollees.

There were limitations to the California review, however. The audit extrapolated from a sample of 150 beneficiaries. The authors reported a 90 percent confidence level in their results — whereas 95 percent would be more common. That meant that the number of those ineligible could have been as low as 260,000 or as high as 630,000.

“If HHS has a strong reason to believe that California is systematically making enrollment errors, it would be helpful to show that in a more robust analysis,” said Ben Ippolito, a health care economist at the American Enterprise Institute, a conservative think tank. “The federal government should ensure that states are being good stewards of federal money.”

Nonetheless, the audit highlighted weaknesses in California’s Medicaid program, the largest in the nation with 13.4 million enrollees and an annual budget topping $100 billion, counting federal and state money. Medicaid covers 1 in 3 Californians.

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The inspector general found deficiencies in the state’s computer system for verifying eligibility and discovered errors by caseworkers. The Medicaid payments cited in the report covered people in the state’s fee-for-service system, managed-care plans, drug treatment programs and those receiving mental health services.

California’s Department of Health Care Services, which runs Medi-Cal, said in a statement that it agreed with nearly all of the auditors’ recommendations and that the agency “has taken steps to address all of the findings.”

In a written response to the inspector general, California officials said several computer upgrades were made after the audit period and before publication of the report that should improve the accuracy of eligibility decisions.

Among the 150 expansion enrollees analyzed in detail, 75 percent, or 112, were deemed eligible for the Medicaid program in California. Auditors discovered a variety of problems with the other 38 enrollees.

During the audit period, 12 enrollees in the sample group had incomes above 138 percent of the federal poverty line, making them ineligible financially for public assistance, according to the report.

In other instances, beneficiaries were already enrolled in Medicare, the federal health insurance for people 65 and older or who have severe disabilities, and did not qualify for Medi-Cal. One woman indicated she didn’t want Medi-Cal but was enrolled anyway.

In 2014, the state struggled to clear a massive backlog of Medi-Cal applications, which reached about 900,000 at one point. Many people complained about being mistakenly rejected for coverage, or their applications were lost in the state or county computer systems.

California was one of 31 states to expand Medicaid under the 2010 Affordable Care Act. The health law established a higher federal reimbursement for these newly eligible patients, primarily low-income adults without children. After expansion started in 2014, the HHS inspector general’s office began reviewing whether states were determining eligibility correctly and spending taxpayer dollars appropriately.

In a similar audit released in January, the inspector general estimated that New York spent $26.2 million in federal Medicaid money on 47,271 expansion enrollees who were ineligible for coverage. (The sample size there was 130 enrollees.) Overall, New York had far fewer expansion enrollees and related spending compared to California.

Audits of other states’ records are planned.

“It is inevitable that in a big rollout of new eligibility for any public program there are going to be glitches in implementation,” said Kathy Hempstead, a health-policy expert and senior adviser at the Robert Wood Johnson Foundation. “The inspector general wants to make sure that states are being sufficiently careful.”

Nationwide, Medicaid, the state-federal health insurance program designed for the poor, is the country’s largest health insurance program, covering 74 million Americans. In the past year, Republican efforts to reduce Medicaid funding and enrollment have sparked intense political debates and loud protests over the size and scope of the public program.

The federal government footed the entire cost of Medicaid expansion during the first three years, instead of taking the usual approach of splitting the costs with states. Now, states are picking up more of the bill. Their share of the costs grows to 10 percent by 2020.

The California audit didn’t request a specific repayment from the state, but the findings were sent to the U.S. Centers for Medicare & Medicaid Services for review. CMS officials didn’t return a request for comment.

Donald White, a spokesman for the inspector general’s office, said the agency stood by the report’s findings and declined to comment further.

Readers Seek Transparency On Surgery Centers, ‘Bill Of The Month’ Investigations

Letters to the Editor is a periodic Kaiser Health News feature. KHN welcomes all comments and will publish a selection. We edit for length and clarity and require full names.

Surgery Centers: The Bigger Picture

Here is my response—as a #journalist and #anesthesiologist–to the @KHNews/@USATODAY report on #surgerycenters. ANY death is horrific. But context matters–and makes for stronger #reporting. @ASCAssociation @By_CJewett @markalesia

— Dr. James Lozada (@DrJLozada) March 2, 2018

Surgery and anesthesia carry with them small but known risks, including death. The thrust of the story was that ASCs are more dangerous than hospitals. However, the data as we currently know it do not support that claim. It’s possible that better reporting of adverse events from ASCs will provide new information. And I fully support the push for more information. Still, contextual reporting is important.

— Dr. James Lozada, Chicago

Last year, more than 20 million Americans put their trust in ambulatory surgery centers (ASCs) for outpatient surgical procedures and treatments ranging from cataract surgery to total joint replacement. They did so because the surgeons, nurses and other health professionals who practice in ASCs have the same education, training and talent as their peers who work only in hospitals.

Regrettably, the Kaiser Health News-USA Today Network article “As Surgery Centers Boom, Patients Are Paying With Their Lives” (March 2) by Christina Jewett and Mark Alesia focused on a relatively small number of adverse events, while ignoring the more than 100 million successful procedures that ASCs provided during the same time frame.

Despite the innuendo and conjecture in this article, there is no empirical evidence that supports the inference that surgery centers pose risk to patients. The adverse events highlighted in the story were tragic anomalies.

Here are a few other essential facts about ASCs that the story does not cover:

Hospital Transfers. ASCs, like hospital outpatient departments, have all the medical equipment and training needed to respond to unanticipated emergencies. In rare instances, a hospital transfer becomes necessary, and surgery centers work with their local hospitals to have protocols in place to provide for those. More importantly, a recent study in the January issue of the Journal of Health Economics concluded: “We find that patients treated in an ASC are less likely to be admitted to a hospital or visit an emergency room a short time after outpatient surgery.”

Regulatory Approval For Outpatient Surgery. ASCs are an integral part of an extremely risk-averse health care system in this country. As such, new procedures move into the ASC setting only after the medical community is convinced that the surgical technique, anesthesia, pain control and recovery time associated with these outpatient procedures support the same outcomes as when those procedures are performed in the hospital.

Transparency. ASCs have long supported meaningful health care quality reporting across all sites of service and continue to work for improvements in these systems to help patients make informed decisions. Patients deserve better access to data on the safety, quality and cost of the care they are to receive, regardless of where they go for the procedure.

Cost Savings. ASCs also have a superior record of providing real value to patients, since the payments for procedures performed in surgery centers are typically much lower than the same procedures performed in hospital outpatient departments. For Medicare beneficiaries, as an example, ASC fees are approximately 50 percent of those that hospital outpatient departments receive. A review of commercial claims data found that U.S. health care costs are reduced by more than $38 billion per year due to the availability of ASCs as an appropriate setting for care. More than $5 billion of those savings benefit patients through lower deductible and coinsurance payments.

The stories these reporters told were, indeed, tragic, and will no doubt be deeply concerning to your readers. As health care professionals dedicated to helping patients, the doctors, nurses and other health professionals in ASCs share in the loss and regret that accompanies any adverse medical event. But we also know these events are both rare and occur across all sites of care, including hospitals.

While serious adverse events are rare in every setting, they are even rarer in ASCs because the model of care is based on using each patient’s health history to ensure that they can be seen safely as an outpatient. Patients considering surgery should talk to their doctors about their health, ask questions and do their own research on the sites of care available to them. When they do, we are confident that, for most patients, the facts will lead them to the conclusion that an ASC is the right choice for the outpatient surgical care they need.

— William Prentice, CEO of the Ambulatory Surgery Center Association, Alexandria, Va.

My father was one of those patients… the gastroenterologist who botched his colonoscopy causing his death the next day was also part-owner of the Surgery Center where the colonscopy was performed…it was like a cattle call…get em in & get em out

Without Context Or Cushion, Do Online Medical Results Make Sense?

As she herded her two young sons into bed one evening late last December, Laura Devitt flipped through her phone to check on the routine blood tests that had been performed as part of her annual physical. She logged onto the patient portal link on her electronic medical record, scanned the results and felt her stomach clench with fear.

Devitt’s white blood cell count and several other tests were flagged as abnormal. Beyond the raw numbers, there was no explanation.

“I got really tense and concerned,” said Devitt, 39, a manager of data analysis who lives in New Orleans. She immediately began searching online and discovered that possible causes ranged from a trivial infection to cancer.

“I was able to calm myself down,” said Devitt, who waited anxiously for her doctor to call. Two days later, after hearing nothing, she called the office. Her doctor telephoned the next day. She reassured Devitt that the probable cause was her 5-year-old’s recent case of pinkeye and advised her to get tested again. She did, and the results were normal.

“I think getting [test results] online is great,” said Devitt, who says she wishes she had been spared days of needless worry waiting for her doctor’s explanation. “But if it’s concerning, there should be some sort of note from a doctor.”

Devitt’s experience illustrates both the promise and the perils of a largely unexamined transformation in the way growing numbers of Americans receive sensitive — sometimes life-changing — medical information. A decade ago, most patients were informed over the phone or in person by the doctor who had ordered testing and could explain the results.

But in the past few years, hospitals and medical practices have urged patients to sign up for portals, which allow them rapid, round-the-clock access to their records. Lab tests (with few exceptions) are now released directly to patients. Studies estimate that between 15 and 30 percent of patients use portals.

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The push for portals has been fueled by several factors: the widespread embrace of technology, incentive payments to medical practices and hospitals that were part of 2009 federal legislation to encourage “meaningful use” of electronic records, and a 2014 federal rule giving patients direct access to their results. Policymakers have long regarded electronic medical records as a way to foster patient engagement and improve patient safety. Studies have found that between 8 and 26 percent of abnormal lab results were not communicated to patients promptly.

Are portals delivering on their promise to engage patients? Or are these results too often a source of confusion and alarm for patients and the cause of more work for doctors because information is provided without adequate — or sometimes any — guidance?

Releasing results on portals remains “an answer with many questions,” said Hardeep Singh, a patient safety researcher at the Michael E. DeBakey VA Medical Center in Houston. “There is just not enough information about how it should be done right,” said Singh, who is also an associate professor at Baylor College of Medicine and one of the few researchers to study patients’ experiences obtaining test results from portals. “There are unintended consequences for not thinking it through.”

Although what patients see online and how quickly they see it differs — sometimes even within the same hospital system — most portals contain lab tests, imaging studies, pathology reports and less frequently, doctors’ notes. It is not uncommon for a test result to be posted before the doctor has seen it.

That means that a patient may be the first to learn of a suspicious breast mass, a recurrence of cancer or possible kidney failure. At Johns Hopkins medical system in Baltimore, for example, results of a PSA test to screen for prostate cancer come with this disclaimer: “While Johns Hopkins providers check results frequently, you may see results before your provider has seen them.”

Breast cancer specialist Lidia Schapira is an associate professor at the Stanford University Medical Center and editor-in-chief of, the patient information website of the American Society of Clinical Oncology. While she regards online access as beneficial, “the danger is that the patient may learn information they’re unprepared to receive and may feel abandoned if they can’t reach their doctor.”

“Those are the Friday afternoon phone calls,” she said, when “at 4:59 [p.m.] a patient has accessed the results of a scan and the doctor signs out at 5.” The recipient of the anguished inquiry that follows is typically a covering doctor who doesn’t know the patient or details of the case.

When Is Use Meaningful?

A recent study by Singh and his colleagues found that, like Devitt, nearly two-thirds of 95 patients who obtained test results via a portal received no explanatory information about the findings. As a result, nearly half conducted online searches. Many with abnormal results called their doctors.

That echoes a 2016 study led by researchers from the University of Pittsburgh. These scientists found that in addition to engaging patients, portal use may increase anxiety and lead to more doctor visits.

Among patients with low health literacy and numerical skills, confusion about the meaning of results is common. Many tests are reported in the same form that the doctor sees them, which even savvy patients may find “literally meaningless,” observed Brian Zikmund-Fisher, an associate professor in the school of public health at the University of Michigan.

“In some situations we run the risk of patients misinterpreting that there is no problem when there is one, or assuming there’s a problem when there isn’t,” said Zikmund-Fisher, lead author of a study that advocates the use of explanatory graphics to convey results. “What we need to be focusing on is giving patients context.”

A year or so ago, Geisinger Health System in Pennsylvania began making most test results — but not biopsies or HIV screening — available to patients within four hours of being finalized.

“We essentially release results twice a day seven days a week with a four-hour lag,” said Ben Hohmuth, Geisinger’s associate chief medical informatics officer. The delay, he said, gives doctors time to review results. Patients who log on over a weekend can contact an on-call physician if they can’t reach their own doctor. The goal of rapid release, Hohmuth said, is to “be patient-centered and transparent.”

“The majority [of patients] want early access to their results, and they don’t want it to be impeded” while waiting for doctors to contact them, Hohmuth said, even if the news is bad.

Patient reaction, he adds, has been “overwhelmingly positive”; the few complaints have come from physicians.

Health lawyer Kathleen Kenyon said she would have appreciated faster access to blood test results for her elderly mother, who had multiple medical problems including Alzheimer’s disease. Kenyon, who managed and closely monitored her mother’s condition, said she believes speedier access could have helped stave off a four-day hospitalization in the intensive care unit of a Washington hospital caused by her mother’s plummeting sodium level.

“It is safer for patients to have more information,” said Kenyon, formerly a senior policy analyst at the Department of Health and Human Services. “I was begging them to get my mother’s lab information in earlier.”

What Does This Mean?

At 46, writer Rebecca Esparza has survived Stage 4 ovarian cancer as well as thyroid cancer. She normally loves having round-the-clock access to her records and the ability to email her doctors.

But in 2016, immediately after extensive abdominal surgery at a hospital several hours from her home in Corpus Christi, Texas, doctors told her they suspected she had developed colon cancer. Confirmation would require further evaluation by a pathologist.

Esparza went home and waited, checking her portal repeatedly. A week later, she logged on to find a highly technical biopsy report she could not understand. A friend who is a nurse read it and told Esparza there was no mention of a malignancy. Two weeks after Esparaza left the hospital and a week after the report appeared on her portal, one of her doctors confirmed that she didn’t have cancer after all.

“It was really traumatic and the one time I wish I hadn’t had access,” said Esparza, an advocate for the National Coalition for Cancer Survivorship.

Although Esparza considers her experience to be “a fluke,” she notes similar confusion among other cancer patients in the online support groups she runs.

“People post their blood test and other results all the time and ask what it means,” she said. Esparza said she intercedes by reminding participants “we’re not doctors.”

One way for a physician to provide guidance, said Stanford’s Schapira, is for doctors to negotiate with patients in advance, particularly if they are concerned the news might be bad.

It is a strategy she employed at her previous job at Massachusetts General Hospital in Boston. “I would say, ‘Let’s do a scan and then schedule a visit two days later, and we can discuss the results,'” she said.

One Doctor’s Experience

Mass General internist Katharine Treadway knows what it’s like to obtain shocking news from an electronic medical record. The experience, she said, has influenced the way she practices.

More than a decade ago — long before most patients had portals — Treadway, with her husband’s permission, pulled up the results of his MRI scan on a hospital computer while waiting to see the specialist treating his sudden, searing arm pain.

“It showed a massive tumor” and widespread metastatic disease, Treadway recalled. She never suspected that her 59-year-old husband had cancer, let alone a highly aggressive and usually fatal form of advanced lymphoma.

Treadway said she remembers intently checking the name and date of birth, certain she had the wrong patient, then rebooting the computer several times “like I was going to get a different answer.”

“The difference is that I knew exactly who to call and what to do,” said Treadway, whose husband has been cancer-free for more than a decade. “In the event of bad news, a doctor has to surround the patient with ‘I am here for you and here’s the plan.'”

Schapira agrees. “Clinicians have to start tackling the issues that have arisen as a result of instant access,” she said.

Tele-Monitoring Can Reduce Medical Appointments For Low-Risk Pregnancies

When Allison Matthews was pregnant with her first child four years ago, her obstetrics clinic scheduled frequent appointments to make sure everything was proceeding normally.

“I was taking time off work and it wasn’t doing a lot for me,” said Matthews, who was considered at low risk for complications like pregnancy-related high blood pressure, also known as preeclampsia. “I kind of felt like I was almost doing it more for the clinic’s benefit than for myself.”

When she got pregnant again early last summer, the obstetrics practice at the Mayo Clinic in Rochester, Minn. gave her the option of coming in for just eight clinic visits rather than the usual 12 to 14. Matthews is a clinical services designer at the Mayo Clinic.

As part of its OB Nest program for low-risk expectant mothers, she would monitor her weight and track her blood pressure and fetal heart rate at home with equipment provided by the clinic. If she had abnormal results or any questions or concerns, she could contact her nurse online or by phone.

If she wished, she could join a social media group of other OB Nest patients monitored by clinic nurses.

Matthews loved the idea. The approach fit with her wish to treat pregnancy as a normal, healthy process rather than a medical illness that required frequent clinical interventions.

Doing the tests at home also made monitoring the baby’s progress a family event with her husband, Marc, and 4-year-old son, Gus, who could listen to his sister’s heartbeat.

“It was something we explored together rather than having it done for us,” said Matthews, 35. Their daughter, Lottie, was born about a month ago.

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Technology increasingly allows clinicians and patients to connect online, via video or remote monitoring rather than face-to-face. But most obstetrics practices continue to follow the traditional model that includes at least a dozen in-person office visits over the course of an average 40-week pregnancy, with lab work and ultrasounds at intervals along the way.

According to the American College of Obstetricians and Gynecologists, the standard pregnancy visit schedule is once every four weeks up to 28 weeks, every two weeks until 36 weeks, and weekly after that.

Although prenatal care is important for healthy outcomes, how much low-risk pregnancies need is debatable, health researchers say.

A study published in the Journal of Perinatology in 2016 found that babies born to women with uncomplicated pregnancies who had more than 10 prenatal visits were no healthier than those born to women with fewer, based on outcomes such as admission to the neonatal intensive care unit, low scores on the Apgar test that evaluates a newborn’s wellbeing, and death. Women with more than 10 prenatal visits, were, however, more likely to be induced or have a cesarean section delivery, the study found.

Patients at the Mayo obstetrics clinic in Rochester, many of whom, like Matthews, are employees of the medical center, can still go the traditional route. They can also opt for OB Nest or have joint appointments with other pregnant women in a group.

“Our goal is that OB Nest care becomes the model for low-risk women,” said Dr. Yvonne Butler Tobah, a Mayo obstetrician and health sciences researcher. Most pregnancies are low-risk, and if more patients choose OB Nest, which was added as a standard option for patients in 2016, it frees up time for doctors and midwives to focus on patients with high-risk pregnancies, she said.

But fewer visits may not translate into out-of-pocket savings on health care costs for women, since professional service fees for pregnancy, labor and delivery and postpartum care are typically bundled if the woman uses the same physician or physician group, said Katy Kozhimannil, an associate professor of public health at the University of Minnesota who studies women’s health care policy.

Women find savings in other ways, said Butler Tobah.

Many patients say the convenience helps save time and money, Butler Tobah said. “If it was their second or third child, patients [with an appointment at the clinic have] to pay for parking, get child care and wait in the doctor’s office, only to be told after a 15-minute visit that their pregnancy was fine.”

The potential of programs like OB Nest to make care more convenient and easily accessible to women who don’t live in urban areas is very appealing, said Kozhimannil. Although Mayo offers the program only in Rochester, it is moving ahead with plans to offer OB Nest to patients outside the Rochester area, said Butler Tobah.

Other obstetrics practices are experimenting with remote-monitoring programs for low-risk expectant mothers, said Dr. Nathaniel DeNicola, co-chair of the telehealth task force for the American Congress of Obstetricians and Gynecologists.

At the George Washington University Medical Faculty Associates in the District of Columbia, where he works, they’re one of several practices nationally using an app called Babyscripts to educate expectant moms, who can also transmit their weight and blood pressure data to the practice via a Wi-Fi connection. Some expectant mothers who use the app have fewer clinical appointments compared with the standard, he said.

A crucial element of these emerging remote-monitoring programs is that they’re closely integrated with the work of clinical staff, DeNicola said.

“All the remote monitoring is a way of augmenting traditional care, not replacing it,” DeNicola said.

As Trump Targets Immigrants, Elderly Brace To Lose Caregivers

BOSTON — After back-to-back, eight-hour shifts at a chiropractor’s office and a rehab center, Nirva arrived outside an elderly woman’s house just in time to help her up the front steps.

Nirva took the woman’s arm as she hoisted herself up, one step at a time, taking breaks to ease the pain in her hip. At the top, they stopped for a hug.

“Hello, bella,” Nirva said, using the word for “beautiful” in Italian.

“Hi, baby,” replied Isolina Dicenso, the 96-year-old woman she has helped care for for seven years.

The women each bear accents from their homelands: Nirva, who asked that her full name be withheld, fled here from Haiti after the 2010 earthquake. Dicenso moved here from Italy in 1949. Over the years, Nirva, 46, has helped her live independently, giving her showers, changing her clothes, washing her windows, taking her to her favorite parks and discount grocery stores.

Now Dicenso and other people living with disabilities, serious illness and the frailty of old age are bracing to lose caregivers like Nirva due to changes in federal immigration policy.

Nirva is one of about 59,000 Haitians living in the U.S. under Temporary Protected Status (TPS), a humanitarian program that gave them permission to work and live here after the January 2010 earthquake devastated their country. Many work in health care, often in grueling, low-wage jobs as nursing assistants or home health aides.

Now these workers’ days are numbered: The Trump administration decided to end TPS for Haitians, giving them until July 22, 2019, to leave the country or face deportation.

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In Boston, the city with the nation’s third-highest Haitian population, the decision has prompted panic from TPS holders and pleas from health care agencies that rely on their labor. The fallout offers a glimpse into how changes in immigration policy are affecting older Americans in communities around the country, especially in large cities.

Ending TPS for Haitians “will have a devastating impact on the ability of skilled nursing facilities to provide quality care to frail and disabled residents,” warned Tara Gregorio, president of the Massachusetts Senior Care Association, which represents 400 elder care facilities, in a letter published in The Boston Globe. Nursing facilities employ about 4,300 Haitians across the state, she said.

“We are very concerned about the threat of losing these dedicated, hardworking individuals, particularly at a time when we cannot afford to lose workers,” Gregorio said in a recent interview. In Massachusetts, 1 in 7 certified nursing assistant (CNA) positions are vacant, a shortage of 3,000 workers, she said.

Nirva (left) helps Isolina Dicenso into her car for an outing. (Melissa Bailey/KHN)

Nationwide, 1 million immigrants work in direct care — as CNAs, personal care attendants or home health aides — according to the Paraprofessional Healthcare Institute, a New York-based organization that studies the workforce. Immigrants make up 1 in 4 workers, said Robert Espinoza, PHI’s vice president of policy. Turnover is high, he said, because the work is difficult and wages are low. The median wage for personal care attendants and home health aides is $10.66 per hour, and $12.78 per hour for CNAs. Workers often receive little training and leave when they find higher-paying jobs at retail counters or fast-food restaurants, he said.

The country faces a severe shortage in home health aides. With 10,000 baby boomers turning 65 each day, an even more serious shortfall lies ahead, according to Paul Osterman, a professor at Massachusetts Institute of Technology’s Sloan School of Management. He predicts a national shortfall of 151,000 direct care workers by 2030, a gap that will grow to 355,000 by 2040. That shortage will escalate if immigrant workers lose work permits, or if other industries raise wages and lure away direct care workers, he said.

Nursing homes in Massachusetts are already losing immigrant workers who have left the country in fear, in response to the White House’s public remarks and immigration proposals, Gregorio said. Nationally, thousands of Haitians have fled the U.S. for Canada, some risking their lives trekking across the border through desolate prairies, after learning that TPS would likely end.

Employers are fighting to hold on to their staff: Late last year, 32 Massachusetts health care providers and advocacy groups wrote to the Department of Homeland Security urging the acting secretary to extend TPS, protecting the state’s 4,724 Haitians with that special status.

“What people don’t seem to understand is that people from other countries really are the backbone of long-term care,” said Sister Jacquelyn McCarthy, CEO of Bethany Health Care Center in Framingham, Mass., which runs a nursing home with 170 patients. She has eight Haitian and Salvadoran workers with TPS, mostly certified nursing assistants. They show up reliably for 4:30 a.m. shifts and never call out sick, she said. Many of them have worked there for over five years. She said she already has six CNA vacancies and can’t afford to lose more.

“There aren’t people to replace them if they should all be deported,” McCarthy said.

Nirva works 70 hours a week taking care of elderly, sick and disabled patients. She started working as a CNA shortly after she arrived in Boston in March 2010 with her two sons.

She chose this work because of her harrowing experience in the earthquake, which destroyed her home and killed hundreds of thousands, including her cousin and nephew. After the disaster, she walked 15 miles with her sister, a nurse, to a Red Cross medical station to try to help survivors. When she got there, she recounted, the guards wouldn’t let her in because she wasn’t a nurse. Nirva spent an entire day waiting for her sister in the hot sun, without food or water, unable to help. It was “very frustrating,” she said.

“So, when I came here — I feel, people’s life is very important,” she said. “I have to be in the medical field, just to be able to help people.”

Caregiver Nirva and Isolina Dicenso have grown close, bonding in part over their Catholic faith. “Thank God I met this woman,” Dicenso, 96, says of Nirva. (Melissa Bailey/KHN)

The work of a CNA or home health aide — which includes dressing and changing patients and lifting them out of bed — was difficult, she found.

“At the beginning, it was very tough for me,” Nirva said, especially “when I have to clean their incontinence. … Some of them, they have dementia, they are fighting. They insult you. You have to be very compassionate to do this job.”

A few months ago, Nirva was injured while tending to a 285-pound patient who was lying on her side. Nirva said she was holding the patient up with one hand while she washed her with the other hand. The patient fell back on her, twisting Nirva’s wrist.

Injury rates for nursing assistants were more than triple the national average in 2016, federal labor statistics show. Common causes were falling, overexertion while lifting or lowering, and enduring violent attacks.

Nirva works with a soft voice, a bubbling laugh and disarming modesty, covering her face with both hands when receiving a compliment. She said her faith in God — and a need to pay the bills to support her two sons, now in high school and college — help her get through each week.

She started caring for Dicenso in her Boston home as the older woman was recovering from surgery in 2011. Like many older Americans, Dicenso doesn’t want to move out of her home, where she has lived for 63 years. She is able to keep living there, alone, with help from her daughter, Nirva and another in-home aide. She now sees Nirva once a week for walks, lunch outings and shopping runs. The two have grown close, bonding in part over their Catholic faith. Dicenso gushed as she described spending her 96th birthday with Nirva on a daylong adventure that included a Mass at a Haitian church. At home, Dicenso proudly displays a bedspread that Nirva gave her, emblazoned with the word LOVE.

On a recent sunny winter morning, Nirva drove Dicenso across town to a hilltop clearing called Millennium Park.

“What a beautiful day!” Dicenso declared five times, beholding the open sky and views of the Charles River. As she walked with a cane in one hand and Nirva’s hand firmly clasped in the other, Dicenso stopped several times due to pain in her hips.

“Thank God I have her on my arm,” Dicenso said. “Nirva, if I no have you on my arm, I go face-down. Thank God I met this woman.”

In addition to seeing Dicenso, Nirva works three shifts a week at a chiropractor’s office as a medical assistant. Five nights a week, she works the overnight shift, from 11 p.m. to 7 a.m., at a rehabilitation center in Boston run by Hebrew SeniorLife. CEO Louis Woolf said Hebrew SeniorLife has 40 workers with TPS, out of a total of 2,600.

It’s not clear how many direct care workers rely on TPS, but PHI calculates there are 34,600 who are non-U.S. citizens from Haiti, El Salvador, Nicaragua (for which TPS is ending next year) and Honduras, whose TPS designation expires in July. In addition, another 11,000 come from countries affected by Trump’s travel ban, primarily from Somalia and Iran, and about 69,800 are non-U.S. citizens from Mexico, PHI’s Espinoza said. Even immigrants with secure legal status may be affected when family members are deported, he noted. Under Trump, non-criminal immigration arrests have doubled.

The “totality of the anti-immigrant climate” threatens the stability of the workforce — and “the ability of older people and people with disabilities to access home health care,” Espinoza said.

Asked about the impact on the U.S. labor force, a DHS official said that “economic considerations are not legally permissible in TPS decisions.” By law, TPS designation hinges instead on whether the foreign country faces adverse conditions, such as war or environmental disaster, that make it unsafe for nationals to return to, the official said.

The biggest hit to the immigrant workforce that cares for older patients may come from another program — family reunification, said Robyn Stone, senior vice president of research at LeadingAge, an association of nonprofit groups that care for the elderly. Trump is seeking to scrap the program, which he calls “chain” migration, in favor of a “merit-based” policy.

Osterman, the MIT professor, said the sum of all of these immigration policy changes may have a serious impact. If demand for workers exceeds supply, he said, insurers may have to restrict the number of hours of care that people receive, and wages may rise, driving up costs.

“People aren’t going to be able to have quality care,” he said. “They’re not going to be able to stay at home.”

But since three-quarters of the nation’s direct care workers are U.S. citizens, then “these are clearly not ‘jobs that Americans won’t do,’” argued David Ray, spokesman for the Federation for American Immigration Reform, which supports more restrictive immigration policies. The U.S. has 6.7 million unemployed people, he noted. If the health care industry can’t find anyone to replace workers who lose TPS and DACA, he said, “then it needs to take a hard look at its recruiting practices and compensation packages. There are clearly plenty of workers here in the U.S. already who are ready and willing to do the work.”

Angelina Di Pietro, Dicenso’s daughter and primary caretaker, disagreed. “There’s not a lot of people in this country who would take care of the elderly,” she said. “Taking care of the elderly is a hard job.”

“Nirva, pray to God they let you stay,” said Dicenso, sitting back in her living-room armchair after a long walk and ravioli lunch. “What would I do without you?”

Podcast: KHN’s ‘What The Health?’ Health Law Fix Misses The Spending Bill Train

Kaiser Health News:States - March 23, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Anna Edney



Read Anna's Stories Joanne Kenen



Read Joanne's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

Congress passed a bill to fund much of the federal government for the remainder of the fiscal year just hours before its March 23 deadline. But not included in that legislation is a bipartisan bill aimed at stabilizing premiums for individuals who buy their own health insurance. That proposal collapsed in partisan rancor after lawmakers were unable to resolve a fight over abortion and other issues.

Meanwhile, the Food and Drug Administration is moving forward with potentially landmark rules that could dramatically change the tobacco industry. And the spending bill loosens two decades of restrictions on the public health impact of guns.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Joanne Kenen of Politico and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • In the big spending bill passed by Congress, a number of health agencies and initiatives — including the Centers for Disease Control and Prevention, the National Institutes of Health and efforts to combat opioid addiction – received additional funding.
  • With the passage of the federal spending bill now over, it seems highly unlikely that there will be another effort to stabilize the Affordable Care Act’s insurance marketplaces this year. One possible reason is that health care does not appear — at this point — to be much of a motivating issue for voters as they think about the midterm elections. While they did get activated by the threat of a repeal of the ACA in 2017, dealing with trying to fix the marketplaces is much more complicated and unlikely to galvanize voters in the same way.
  • The House has now passed a bill letting terminally ill patients appeal to drugmakers to get experimental medicines. But the House version of this “right-to-try” legislation is different than the Senate version that passed last year, and it’s not yet clear which bill will go forward. Patient groups and government drug officials past and present have complained the bill could do more harm than good. A new study in the New England Journal of Medicine helps explain that financial problems patients face after a hospitalization are based on more than just their health insurance status.
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Plus, for “extra credit,” the panelists recommend their favorite health stories of the week they think you should read, too.

Julie Rovner: Kaiser Health News’ “The Dream Among ‘Dreamers’ To Become A Doctor Now ‘At The Mercy’ Of Courts,” by Ana B. Ibarra.

Also: CNN’s “Juul e-cigarettes and teens: ‘Health problem of the decade’?” by Ana B. Ibarra.

Joanne Kenen: Slate’s “The New Spending Bill Could Finally Pave the Way for Federal Research on Gun Violence,” by Alex Barasch.

Margo Sanger-Katz:’s The Weeds podcast, “The opioid debate: Could reversing overdoses worsen the epidemic?” by Ezra Klein and Sarah Kliff.

Anna Edney: Stat’s “That’s $425,000 right there’ — The anxious launch of a gene therapy with a record sticker price,” by Eric Boodman.

To hear all our podcasts, click here.

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

Readout of HHS Secretary Azar’s Listening Session with State PDMP Leaders

HHS Gov News - March 23, 2018

On Thursday, HHS Secretary Alex Azar held a listening session with state officials who work on prescription drug monitoring programs (PDMPs) in the District of Columbia, Kentucky, Maryland, Virginia, and West Virginia. The Secretary was joined by Acting CDC Director Anne Schuchat and staff from other parts of HHS, including CDC and the Office of the National Coordinator for Health IT.

The gathering follows President Trump’s Monday announcement in New Hampshire of the administration’s new opioid addiction initiative, as well as travel and meetings by top HHS officials in seven states this week.

Participants discussed ways in which their states have developed and enhanced PDMPs, including efforts to make programs interoperable between states, raise rates of provider and prescriber participation, and make the best use possible of data generated. A number of participants individually shared the importance of combating stigma surrounding addiction, an issue Secretary Azar has made a priority.

Secretary Azar noted that PDMPs are an important part of ensuring the appropriate prescribing and use of legal opioids, a key piece of the three-point administration opioids strategy unveiled on Monday, which covers addiction prevention, supply interdiction, and treatment provision. The strategy proposes a nationally interoperable PDMP network, building on work HHS already does to promote and support PDMPs, including through CDC’s Prevention For States grant program.

Secretary Azar thanked the participants for their valuable insights and tireless work in confronting the challenge of opioid addiction. He emphasized President Trump’s personal commitment to taking bold action against the crisis, and emphasized that the federal government will continue to engage with state officials and support their work.

Poll: Americans Aghast Over Drug Costs But Aren’t Holding Their Breath For A Fix

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The recent school shootings in Florida and Maryland have focused attention on the National Rifle Association’s clout in state and federal lobbying activities.

Yet more than the NRA or even Wall Street, it’s the pharmaceutical industry that Americans think has the most muscle when it comes to policymaking.

A poll from the Kaiser Family Foundation found that 72 percent of people think the drug industry has too much influence in Washington —outweighing the 69 percent who feel that way about Wall Street or the 52 percent who think the NRA has too much power. Only the large-business community outranked drugmakers. (Kaiser Health News is an editorially independent program of the foundation.)

Drug prices are among the few areas of health policy where Americans seem to find consensus. Eighty percent of people said they think drug prices are too high, and both Democrats (65 percent) and Republicans (74 percent) agreed the industry has too much sway over lawmakers.

Democrats were far more likely than Republicans — 73 vs. 21 percent — to say the NRA had too much influence.

The monthly poll also looked at views about health care. Americans may be warming to the idea of a national health plan, such as the Medicare-for-all idea advocated by Sen. Bernie Sanders (I-Vt.). Overall, 59 percent said they supported it, and even more, 75 percent, said they would support it if it were one option among an array for Americans to choose.

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Americans are far more concerned with lowering prescription drug prices, though they don’t trust the current administration to fix the problem. Fifty-two percent said lowering drug costs should be the top priority for President Donald Trump and Congress, but only 39 percent said they were confident that a solution would be delivered.

“There’s more action happening on the state level; what we are finding is they’re not seeing the same action on the federal level,” said Ashley Kirzinger, a senior survey analyst for KFF’s public opinion and survey research team. “They’re holding the president accountable as well as leaders of their own party.”

Overall, at least three-quarters of people don’t think Democrats and Republicans in Congress, as well as the Trump administration, are doing enough to bring costs down.

Twenty-one percent reported that they didn’t trust either party to lower prices, up from 12 percent in 2016. And, unlike other health-related policy questions such as repealing the Affordable Care Act or creating a national health plan, the poll does not find a partisan divide on this perception.

Passing legislation to lower drug prices was at the top of the list of the public’s priorities, making it more important than infrastructure, solving the opioid epidemic, immigration reform, repealing the ACA or building a border wall.

Looking ahead to the 2018 midterm elections, 7 percent reported that creating a national health plan was the “single most important factor” for how they would vote in 2018. However, 7 in 10 said it is an important consideration, and 22 percent said it is not an important factor at all.

The poll found that support for the federal health law fell this month, from February’s all-time high of 54 percent to 50 percent in March. Opposition moved up slightly from 42 to 43 percent.

The poll was conducted March 8-13 among 1,212 adults. The margin of sampling error is +/-3 percentage points.

For One Father And Son In Puerto Rico, Hurricane Maria’s Cloud Has Not Lifted

Kaiser Health News:Madicaid - March 23, 2018

To reach the Martinez home in Puerto Rico’s central mountains, social worker Eileen Calderon steers around piles of dirt, treacherous potholes and power company trucks that block the road. Finally, she pulls up to a sagging, cement home, its roof done in by Hurricane Maria. Laundry hangs under a tarp, and a cat is tied to a leash outside the door.

Calderon, who is based in San Juan, and works for VarMed, a company that handles complex medical cases in Puerto Rico, has brought two colleagues — a nurse, Anamelia Velazquez, and a primary care physician, Dr. Carla Rossotti — to check in on Osvaldo Martinez and his son, Osvaldo Daniel Martinez.

Inside a darkened bedroom, the elder Martinez, a 67-year-old former star pitcher in the local baseball league, spoons rice and sausage into his son’s mouth. The younger Martinez lies in a hospital bed, his arms and fingers spasm and his eyes loll around in his head. He’s 37, born in Chicago, a former security guard.

Three years ago, after he and his father moved back to Puerto Rico from Illinois, the younger Martinez started showing early signs of multiple sclerosis. During the past year, his world became this room, then this bed.

His father points to the ceiling — leaking from the morning’s rain and covered in mold.

“All of this leaking that you can see came out because of the hurricane,” he said.

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The power came back on in his house about a month ago, and the family has running water, so he is able to keep his son clean. The father carries a plastic basin into the bathroom and draws the water. Then, as he does a few times each day, he returns to the bedroom to bathe his adult son and gently change his diaper.

But Rossotti, whose company, VarMed, has been paid by the Puerto Rican government to help take care of the junior Martinez, said the younger man can’t yet get an appointment to see a neurologist to confirm his multiple sclerosis and start treatment. There is a chronic shortage of neurologists on the island, and those who remained after the storm have few slots in their schedules for Medicaid patients.

Calderon, the social worker, said she has been trying for a year to get an appointment for Martinez, but receptionist after receptionist tells her the neurologists they work for are taking no new patients. “We have a patient who was stable a year ago, and now he’s bedridden,” Rossotti said. “He hasn’t been able to get that neurologist evaluation.”

The roof of the Martinezes’ home in Cayey, Puerto Rico, was damaged in Hurricane Maria, leading to moisture and mold problems in the house. (Sarah Varney/KHN)

People here in Puerto Rico talk about life “before Maria” and life after. Accessing medical care here has always been a challenge, given the island’s chronic shortage of physicians and its unusual system for Medicaid — known as a block grant. The government provides a certain amount of money for each citizen in the program, no matter how great the needs are for care.

And for many of the island’s most vulnerable residents, like the Martinez family, the 2017 storm turned a challenge into a full-blown medical crisis that cannot be easily reversed. Since the turn of the century, a number of effective medicines that treat MS have come on the market, transforming the lives of people with the progressive disease, which can damage nerve conduction to anywhere in the body — the eye, the brain, the bladder, the legs. Treatment both helps slow progression and resolves symptoms. But it is less effective once damage to the nervous system is done.

The island’s financial crisis has sent doctors fleeing to the States during the past decade; Hurricane Maria added further fuel to that exodus. There is no exact accounting yet of just how many physicians have left the island, but from 2006 to 2016, the number of doctors dropped from 14,000 to 9,000, according to the Puerto Rico College of Physicians and Surgeons.

Nearly half of Puerto Ricans on the island rely on Medicaid — compared with around 20 percent of the population in the continental U.S. The territory’s government has long struggled to cover the costs of health care.

Currently, Molina Healthcare, a California-based company that provides insurance coverage to low-income people on Medicaid in Puerto Rico and elsewhere in the U.S., is ostensibly responsible for guaranteeing access to needed doctors.

A spokeswoman for Molina, Laura Murray, said the company cannot comment on the Martinez case, or that of any individual patient, because of privacy laws. But in a written statement, the company representative reported that it contracts with 41 neurologists in Puerto Rico’s eastern and southwestern regions, and meets “the network adequacy requirements in our contract.”

“However,” the statement continued, “we recognize that there is an island-wide shortage of physicians — particularly specialists — and we are proposing suggestions to [the Puerto Rican government] on how we could work together to remediate this.”

The island government recently announced that it will overhaul how Medicaid contracts are awarded.

Osvaldo Martinez tends to his son, Osvaldo Daniel Martinez, whose world, over the past year, has slowly become one room, then one hospital bed.  (Sarah Varney/KHN)

For now, the younger Martinez languishes — each day and night no different than the next, as the disease lays siege to his central nervous system, disrupting the vital connections between brain and body.

Without a confirmed diagnosis, he can’t get certain public disability benefits. And he isn’t getting medication for his condition or his pain; the agency Rossotti works for can only advocate for patients, not treat them.

The outward perseverance of father and son belies the true terror of their confinement. As the elder Martinez describes his son’s decline, tears come to his eyes; his son, who can understand everything, rolls on his side and begins to weep.

“I have to do all that needs to be done for him,” Martinez said. But he is not in good health himself, with severe arthritis and a painful bulge in his abdomen. During the months they went without power, he said, the hospital bed didn’t go up and down. He showed a photo of his arm — black-and-blue and swollen — from pressing against the metal bars of the bed as he leaned down to tend to his son.

But it’s his son’s withering away that pains him most.

“If something would happen to me,” the father said, clasping his hands together in prayer — “I don’t know.”

HHS Secretary Azar to Name Robert R. Redfield, M.D., Director of the Centers for Disease Control and Prevention

HHS Gov News - March 22, 2018

On Wednesday, the Department of Health and Human Services announced that Secretary Alex Azar will name Robert R. Redfield, M.D., as the 18th Director of the Centers for Disease Control and Prevention and Administrator of the Agency for Toxic Substances and Disease Registry.

Upon the announcement, Secretary Azar issued the following statement:

“Dr. Redfield has dedicated his entire life to promoting public health and providing compassionate care to his patients, and we are proud to welcome him as director of the world’s premier epidemiological agency. Dr. Redfield’s scientific and clinical background is peerless: As just one example, during his two-decade tenure at Walter Reed Army Institute of Research, he made pioneering contributions to advance our understanding of HIV/AIDS. His more recent work running a treatment network in Baltimore for HIV and Hepatitis C patients also prepares him to hit the ground running on one of HHS and CDC’s top priorities, combating the opioid epidemic.”

“Furthermore, all of us at HHS are grateful to Dr. Anne Schuchat for her service as Acting Director at CDC, especially during this year’s severe flu season. We look forward to CDC continuing its important work on the opioid epidemic and America’s many other pressing public health challenges.”

Biographical Background

Dr. Robert R. Redfield has been a public health leader actively engaged in clinical research and clinical care of chronic human viral infections and infectious diseases, especially HIV, for more than 30 years.

He served as the founding director of the Department of Retroviral Research within the U.S. Military’s HIV Research Program, and retired after 20 years of service in the U.S. Army Medical Corps. Following his military service, he co-founded the University of Maryland’s Institute of Human Virology with Dr. William Blattner and Dr. Robert C. Gallo and served as the Chief of Infectious Diseases and Vice Chair of Medicine at the University of Maryland School of Medicine. 

Dr. Redfield made several important early contributions to the scientific understanding of HIV, including the demonstration of the importance of heterosexual transmission, the development of the Walter Reed staging system for HIV infection, and the demonstration of active HIV replication in all stages of HIV infection.  

In addition to his research work, Dr. Redfield oversaw an extensive clinical program providing HIV care and treatment to more than 5,000 patients in the Baltimore/Washington, D.C. community.

Dr. Redfield served as a member of the President’s Advisory Council on HIV/AIDS from 2005 to 2009, and was appointed as Chair of the International Subcommittee from 2006 to 2009. 

He is a past member of the Office of AIDS Research Advisory Council at the National Institutes of Health, the Fogarty International Center Advisory Board at the National Institutes of Health, and the Advisory Anti-Infective Agent Committee of the Food and Drug Administration.

States Extend Medicaid For Birth Control, Cutting Costs — And Future Enrollment

Kaiser Health News:States - March 22, 2018

The Trump administration is weighing whether to allow Texas to receive millions of federal Medicaid dollars for its family planning program, which bars abortion providers.

The Lone Star State eliminated its Medicaid-funded family planning program five years ago when state officials said they wanted to specifically exclude Planned Parenthood because the group provides abortions. Dozens of women’s health clinics closed as Texas established a wholly state-funded program that officials say today serves 220,000 women.

This KHN special series examines the reach and the role of Medicaid, the federal-state program that began as a medical program for the poor but now provides a wide variety of services for a large swath of America.

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Medicaid’s family planning program is optional for states and used by half of them to provide contraception services for low-income women who earn too much to qualify for traditional Medicaid.

Texas, Iowa and Missouri gave up that federal money to avoid supporting groups that offer abortion. Planned Parenthood says it does not use any government money for abortions.

Texas is the first state to appeal to a more conservative White House to restore the funds. The federal government has historically declined to provide Medicaid dollars to states that don’t allow patients to choose between “any willing provider.” Texas is asking for a change in that position.

As part of its “Medicaid Nation” series, Kaiser Health News is examining the far-reaching impact of Medicaid — which has expanded its services in the past decade — and how millions of American households routinely access health care through its programs.

The provision that covers only family planning is a tiny part of Medicaid, which now serves about 74 million Americans. But it is seen by advocates as a vital way to avoid unwanted pregnancies and for states to save money by reducing Medicaid-covered births and coverage for infants and children.

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Nationally, about 2.8 million people were enrolled in the coverage last year, according to a Kaiser Health News survey of state Medicaid officials. California alone had 1.8 million people in the program.

“This is expanding Medicaid to cut Medicaid,” said Elizabeth Momany, associate research scientist at the University of Iowa. “If you avert one childbirth, you save quite a bit,” she said, noting that children on full Medicaid remain in the program for at least five years after birth, on average.

Medicaid began in 1965 as a way to provide for poor children, their mothers and people with disabilities. Maternal benefits are a key part of traditional Medicaid. It pays for half of all U.S. births and covers 45 percent of children under the age of 6.

The federal government encourages the benefit limited to family planning— which does not include physician visits or hospital care — by covering 90 percent of the cost. In contrast, Medicaid covers births and related costs at 50 to 74 percent, with states picking up the rest of the tab.

The cost savings help explain why the family planning program is popular among states. Even some of those most opposed to the expansion of Medicaid under the Affordable Care Act — including the entire Southeast — largely take part in the Medicaid family planning program. North Carolina, South Carolina, Alabama and Florida rank in the top five by enrollment, behind California, the Kaiser survey found.

“For two decades, states across the country, red, blue and purple, have expanded Medicaid eligibility for family planning services because doing so helps people to avoid unintended pregnancies and to plan and space wanted pregnancies,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, a reproductive health research organization that supports abortion rights. “In the process, that has also been proven to save the state and federal governments many millions of dollars.”

While eligibility and benefits vary by state, the family planning programs generally provide free coverage for a wide array of contraceptives, including birth control pills and long-acting implants. Some also provide checkups, assistance in kicking tobacco, cancer screenings and testing for sexually transmitted infections.

In family planning programs around the country, services are generally provided by Planned Parenthood clinics, county health departments, federally funded community health centers and private physician offices. Critics say prohibiting Planned Parenthood from family planning programs would hurt patients’ access to services.

Eligibility in some states starts as early as age 12, while others automatically enroll women in the programs after their maternity benefit expires, typically 60 days after giving birth.

In California and some other states, both men and women are eligible, but women make up the vast majority of the enrollees.

North Carolina Medicaid officials estimate the program saves the state about $15 million a year, according to spokesman Cobey Culton. 

Alabama has also seen savings. Kari White, a health policy professor at the University of Alabama at Birmingham, said the program covers about 120,000 women in the state with income levels below 141 percent of the federal poverty level, or about $17,000 for an individual.

An evaluation she conducted for the state last year found the birth rate for women enrolled in the program was one-third of what would have been estimated without the coverage.

“It helps to save Medicaid dollars overall to have these programs,” White said. 

Even the Trump administration, which is seeking to reduce the number of adults on Medicaid rolls, signaled its support of the family planning program in late December when it approved a 10-year extension of Mississippi’s program.

California’s program — called Family Pact (Planning, Access, Care and Treatment) — covers people with incomes up to 200 percent of the federal poverty level (about $24,000) who don’t have other sources of family planning coverage.

“It provides a very essential public health benefit to all Californians who otherwise wouldn’t get these services,” said Claire Brindis, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco, who evaluated California’s program.

A big reason California’s enrollment is so much higher than other states, in addition to its much larger population, is that undocumented immigrants can also receive the services, although their care is paid for only with state funds. 

Marta Mateo of Los Angeles is using the family planning program for a tubal ligation to prevent another pregnancy.

“I’m ready to have my tubes tied,” she said in the lobby at Eisner Pediatric & Family Medical Center as the youngest of her four children slept in her arms. “I don’t want any more babies.”

Mateo said she’s grateful for the coverage because her factory job doesn’t offer it, and she can’t afford to buy it on her own.

“I just don’t have the money for that,” she said. “This is a good opportunity for us to get care.”

Nationwide, the number of women covered by the Medicaid family planning program dropped from 3.8 million in 2013 to last year’s 2.8 million, as many people gained other coverage through the Affordable Care Act, according to the KHN survey and interviews with state officials. The enrollment decline was also due to several states discontinuing the program.

Three states that expanded Medicaid under the ACA dropped the program — Michigan, Illinois and Ohio. But the Medicaid expansion covers women up to 138 percent of the federal poverty level, which is an annual income of about $16,700 for an individual, while the family planning programs had an average eligibility level of 185 percent of federal poverty level, or $22,400.

Graphic: Opioid Painkiller Is Top Prescription In 11 States

Kaiser Health News:States - March 22, 2018

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Americans fill about 4.5 billion prescriptions each year, at a cost of more than $323 billion. But what are we actually buying? In 11 states, the top prescriptions are opioid pain pills that are mixtures of acetaminophen and hydrocodone (brand names Vicodin and Norco), according to new data from GoodRx, an online prescription cost service.

The company looked at the top 10 drugs prescribed in each state from March 2017 to February 2018 and then presented the data as a map.

“There’s a geography to medications,” said Thomas Goetz, chief of research at GoodRx. “Our goal is to start bringing more transparency to drugs and drug pricing information.”

In more than half of states, Synthroid and its generics — to treat hypothyroidism — came in at No. 1. About 123 million prescriptions for the drug were written in 2016. And despite recent controversy questioning its effectiveness in the elderly, more than 15 percent of older adults are prescribed the drug.

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Though opioid prescriptions appear to be on the decline, Vicodin and Norco remain popular, especially in the South. In Tennessee, however, Suboxone, a medication used to treat opioid addiction, is even more popular. Oddly, Adderall and generic versions of the medicine for attention deficit and hyperactivity disorder are the most prescribed drugs in South Carolina.

Drugs to treat high blood pressure and cholesterol were also widely prescribed.

Geoffrey Joyce, director of health policy at the Schaeffer Center at the University of Southern California, warns that the data represented in the map could give a misleading picture of prescription drug patterns. It looks at individual drug products instead of larger classes of drugs used to treat a given medical issue. Overall, when similar types of drugs are grouped together the most common prescriptions are for drugs to treat high blood pressure, pain and mental health issues, according to recent data from IQVIA, a health data company.

GoodRx offers discounts on prescription drugs and provides an online tool that allows consumers to compare what a drug will cost at local pharmacies. Its state-by-state data come from several sources, including pharmacies and insurers, and reflect millions of prescriptions.

Readout of Assistant Secretary McCance-Katz’s Visit to Prestera Center

HHS Gov News - March 21, 2018

HHS Assistant Secretary for Mental Health and Substance Use, Dr. Elinore McCance-Katz traveled on Monday to Charleston, West Virginia, to visit Prestera Center, a behavioral health and substance abuse service provider, to hear from individuals affected by the opioid crisis.

Assistant Secretary McCance-Katz toured Prestera Center with West Virginia Department of Health and Human Resources Secretary Bill Crouch before participating in a roundtable with individuals who have been affected by the crisis, including three Prestera clients.

The roundtable was led by Prestera Center CEO, Karen Yost, and included West Virginia Health Secretary Crouch; Dana Petroff, Prestera’s Director of Addiction Services; Chad Napier, a prevention specialist with the Appalachian High Intensity Drug Trafficking Area (HIDTA); Jennifer Ballard, Director of Programs at the WV Department of Corrections; Heather McDaniel, Program Director, Help 4 WV, and; Victor Nease, a psychiatrist with Prestera Center. Participants individually highlighted the need for a multitude of partnerships – including with law enforcement – to provide effective and timely services.

Following the roundtable, Assistant Secretary McCance-Katz, Secretary Crouch, and Karen Yost held a press conference, where Dr. McCance-Katz emphasized President Trump’s personal commitment to the struggle, including today’s initiative to “stop opioid abuse and reduce drug supply demand.”

The visit was a part of an ongoing effort by HHS to visit with communities on the frontlines of the opioid epidemic, and followed the launch of the President’s initiative and trip to New Hampshire.

Updates from the Department are also available at:

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Reporter’s Notebook: The Tale Of Theranos And The Mysterious Fire Alarm

It was November 2014, and I was working on a feature story about a buzzed-about blood-testing company in Silicon Valley that promised to “disrupt” the lab industry with new technology. The company, Theranos, claimed its revolutionary finger-prick test would be a cheap and less painful way to screen for hundreds of diseases with just a few drops of blood. Old-fashioned venous blood draws, where the patient watches as vial after vial of blood is collected, would quickly become obsolete, Theranos promised.

The interviews took a month to arrange. The public relations officer wanted to know, did I “plan on sourcing other people?” and implied that CEO Elizabeth Holmes might not be available to me if I did talk to other sources. I rejected that condition, but finally the company’s public relations contacts agreed to let me visit its site at the Walgreens in Palo Alto, Calif. — one of the first such setups in the country — followed by a sit-down interview with Holmes at her office.

I arrived at the Walgreens on the morning of Nov. 4 and was met by two Theranos press representatives who would supervise my visit. I took out my recording equipment (the story was for NPR) and began approaching patients who were waiting in line to check in for testing. Some didn’t want to talk to a reporter, but others were open and gracious, sharing with me the reasons they had decided to give Theranos a try. One couple offered to let me come with them into the small testing room, set up to feel like a relaxing spa.

A pattern quickly emerged — none of the patients I talked to that day could get a finger-prick test, as promised. Instead, they received a regular venous blood draw, the same as I’d received on numerous occasions at my doctor’s office, though the phlebotomist said the needle was slightly smaller.

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I asked the phlebotomist: Was this standard? Did most patients get the venous draw? She told me they “did more finger sticks than venous draws,” but couldn’t give me a number. One of the PR people approached me — I was not authorized to talk to the phlebotomist, he said — and asked me to erase the audio I had recorded. I declined.

I asked him: Why were none of the patients getting a finger prick? Just bad luck and timing, he said. This wasn’t how it usually was, he promised. And wouldn’t I just rather get a finger prick myself and report on the experience, as so many other journalists had agreed to do?

I said no. I needed an actual patient to make a compelling radio story. So, I continued waiting for other patients.

Soon, the two Theranos representatives approached me again — with a third on the phone, who said she wanted to talk to me. They were getting complaints about my asking patients questions, she told me. The main Theranos office had gotten several calls from people who had been in the Walgreens that morning, she claimed, complaining that a reporter was bothering them.

I hadn’t pressured anyone. The patients I’d interviewed had all been perfectly friendly and willing. I’ve also been a health reporter for 10 years, and never have I been told I was pushing patients to do something that made them uncomfortable.

Something seemed very wrong.

Soon, one of the Theranos representatives approached me again, clearly nervous. They appeared worried. Unless I found a patient getting a finger prick, he said, they would likely have to cancel my interview with Holmes.

It was clearly a threat to try to steer me away from where the story was taking me: Theranos seemed to be doing very few, if any, of its revolutionary tests on actual patients. I asked the press representatives to get the other one on the phone again; I didn’t like being threatened and I wanted to hash it out with her.

Meanwhile, I sat down with another couple, who had driven 45 minutes to experience the vaunted finger prick. Would they too be steered to a traditional blood test?

As I was interviewing them — but before we knew which test they could get — a sudden and jolting BEEP BEEP BEEP reverberated through the drugstore. “Fire alarm!” someone called out, and we evacuated to the street.

I’d never been in a drugstore when the fire alarm went off. There was no smoke and no fire.

I decided to cancel the feature. I had pitched it as a consumer-focused story about how often “less is more” in health care. I clearly no longer had that story. I made a few more calls to various experts on lab testing to try to figure out what was happening: Was Theranos for real? I was given an interview with a lawyer at Theranos, who promised me that “significantly more than 50 percent of the tests are done with a finger prick,” though she would say no more.

Now that Theranos has been implicated in massive fraud, that encounter serves as a reminder of the skepticism both journalists and health care consumers need to have in an age when public relations, marketing and advertising try to guide the story and our treatment.

Theranos generated huge hype and laudatory coverage in places like The New Yorker, Wired and Fortune by selling a compelling idea — even as its PR people couldn’t show me an actual patient who had benefited. Sometimes, in health care, an idea that seems too good to be true, isn’t. We all — patients and journalists — have to do our due diligence.

The PR tactics Theranos employed blocked journalists from providing the kind of scrutiny that might have revealed the fantasy the company was weaving for investors sooner.

And 11 months after my experience at that Walgreens, John Carreyrou of The Wall Street Journal published the first of his groundbreaking investigations surrounding Theranos, blowing the lid off of the company’s fraudulent claims. Of the 240 types of blood tests the company said it did, only 15 used finger-pricking.

Now comes the news that Theranos has accepted a settlement in the fraud case with the Securities and Exchange Commission. Which has me thinking.

Had someone pulled the fire alarm? I’ve been suspicious since the moment it happened.

Last week, I wrote to Theranos to ask. No surprise: They did not respond.

Clash Over Abortion Hobbles A Health Bill. Again. Here’s How.

The Affordable Care Act very nearly failed to become law due to an intraparty dispute among Democrats over how to handle the abortion issue. Now a similar argument between Democrats and Republicans is slowing progress on a bill that could help cut soaring premiums and shore up the ACA.

At issue is the extent to which the Hyde Amendment — language commonly used by Congress to prohibit most federal abortion funding — should be incorporated into any new legislation affecting the health law.

Republicans generally want more restrictions on abortion funding. Democrats generally want fewer. Here’s a guide to the history of the current impasse:

What Is The Hyde Amendment?

The Hyde Amendment, named for Rep. Henry Hyde (R-Ill.), an anti-abortion crusader who died in 2007, prohibits federal funding of abortion in Medicaid and several other health programs run by the Department of Health and Human Services. Current exceptions allow for funding in cases of rape, incest or “where a physical condition endangers a woman’s life unless an abortion is performed.”

But the Hyde Amendment is not permanent law. Rather, it has been included every year since 1977 as a “rider” to federal spending bills. Hence, its exact language changes from time to time. The rape and incest exceptions, for example, were not included in the annual HHS spending bill from 1981 to 1993. During that time, the only exception was for abortions required to save a pregnant woman’s life.

Hyde-like language has been added to other annual spending bills over the years, so federal abortion funding is also now forbidden in private health insurance plans for federal employees, women in federal prisons, those in the Peace Corps and women in the military, among others.

Over the years, Democrats have worked, unsuccessfully, to eliminate the Hyde Amendment, charging that it unfairly harms low-income women who cannot afford to pay for abortions. Proposed elimination of the language was included in the Democratic Party’s 2016 platform.

Republicans have tried, also so far unsuccessfully, to write the Hyde funding prohibitions into permanent law. “A ban on taxpayer funding of abortion is the will of the people and ought to be the law of the la

nd,” said then-House Speaker John Boehner (R-Ohio) in 2011.

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How Did The Affordable Care Act Deal With Federal Abortion Funding?

Republicans in both the House and Senate unanimously refused to support the Affordable Care Act when it passed Congress in 2010. Even without their backing, abortion remained a huge hurdle.

In order to pass the bill over GOP objections, Democrats needed near unanimity among their ranks. But the Democratic caucus at the time had a significant number of abortion opponents, particularly those representing more conservative districts and states. In order to facilitate the bill’s movement, House and Senate leaders agreed that the health bill should be “abortion-neutral,” meaning it would neither add to nor subtract from existing abortion restrictions.

That proved difficult. So difficult that to this day there is disagreement about whether the law expands or contracts abortion rights.

Democratic sponsors of the bill were buffeted by appeals from women’s groups, who wanted to make sure the bill did not change existing coverage of abortion in private health insurance; and from abortion opponents, led by the United States Conference of Catholic Bishops , who called the bill a major expansion of abortion rights.

The bill passed the House in 2009 only after inclusion of an amendment by Rep. Bart Stupak (D-Mich.), a longtime opponent of abortion. That bill included a government-sponsored health plan and Stupak’s provision would have made the Hyde Amendment a permanent part of that plan. The amendment also banned federal premium subsidies for private health insurance plans that offered abortion as a covered service, although it allowed for plan customers to purchase a rider with non-federal money to cover abortion services.

The Senate bill jettisoned the government-sponsored plan, so no restrictions were necessary on the abortion issue. And it was the Senate plan that went forward to become law. Still, differences remained over how to ensure that subsidies provided by taxpayers did not go to private plans that covered abortions.

In the upper chamber, a compromise was eventually reached by abortion-rights supporter Sen. Barbara Boxer (D-Calif.) and Sen. Ben Nelson (D-Neb.), who opposed abortion. Nelson was the final holdout on the bill, which needed all 60 Democrats then in the Senate to overcome unanimous GOP opposition. The Boxer-Nelson language was a softening of the Stupak amendment, but still allowed states to prohibit plans in the ACA’s insurance marketplaces from covering abortion.

In addition, President Barack Obama agreed to issue an “executive order” intended to ensure no federal funds were used for abortions.

In the end, both sides remained unhappy. Abortion opponents wanted the Hyde Amendment guarantees in the actual legislation rather than the executive order. Abortion-rights backers said the effort constricted abortion coverage in private health plans.

And both sides are still unhappy. According to the Guttmacher Institute, a reproductive health research group, 26 states have passed legislation restricting abortion coverage in any plan sold through the ACA’s insurance exchanges.

Another 11 states have passed laws restricting abortion coverage in all private insurance sold in the state. Nine of those states allow separate abortion “riders” to be sold, but no carriers offer such coverage in those marketplaces, according to a 2018 analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Three states — California, New York and Oregon — require nearly all insurance plans to provide abortion coverage, according to the National Women’s Law Center.

What Abortion Provisions Do Republicans Want To Add To The Latest Health Bill?

The issue for 2018 is a bipartisan bill that seeks to “stabilize” the individual insurance market and the ACA’s health insurance exchanges by providing additional federal funding to offset some recent premium increases. Some options include restoring federal subsidies for insurers who cover out-of-pocket costs for very low-income customers and setting up a federal reinsurance pool to help insurers pay for very expensive patients.

But once again, the abortion debate threatens to block a consensus.

Many Republicans are dubious about efforts to shore up the health law. They still hope its failure could lead to a repeal they were unable to accomplish in 2017.

Even some who say they are sympathetic to a legislative remedy want to add the permanent Hyde Amendment language that was left out of the final ACA, although included in Obama’s executive order.

That is “not negotiable for House Republicans,” a spokeswoman for House Speaker Paul Ryan (R-Wis.) told The Hill newspaper. The White House has also endorsed a permanent Hyde Amendment.

But Sen. Patty Murray (D-Wash.), who has been negotiating the insurance bill for the Democrats, calls any additional abortion restrictions “a complete nonstarter” for Democrats.

Research Misconduct Allegations Shadow Likely CDC Appointee

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President Donald Trump’s likely pick to lead the Centers for Disease Control and Prevention is facing significant criticism because of a 20-year-old controversy over shoddy HIV research.

The Army in 1994 acknowledged accuracy issues with HIV vaccine research led by Dr. Robert Redfield, who is expected to head the CDC, but concluded at the time that the data errors did not constitute misconduct.

Yet one of the whistleblowers who first raised the matter to the Army told Kaiser Health News this week that he remains so troubled about Redfield’s handling of the vaccine research that he has decided to speak out publicly.

Redfield was principal investigator over clinical trials of a treatment vaccine at the Walter Reed Army Institute of Research. The research was conducted at a time when there was intense pressure to come up with a treatment for HIV/AIDS, which often killed patients within a matter of months.

“Either he was egregiously sloppy with data or it was fabricated,” said former Air Force Lt. Col. Craig Hendrix, a doctor who is now director of the division of clinical pharmacology at Johns Hopkins University School of Medicine. “It was somewhere on that spectrum, both of which were serious and raised questions about his trustworthiness.”

In a letter to Trump this week, Washington Sen. Patty Murray, the ranking Democrat on the health committee, cited the research controversy as an example of a “pattern of ethically and morally questionable behavior” by Redfield that should prompt the president to reconsider the appointment.

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Redfield’s appointment, which does not require Senate confirmation, was leaked to the news media over the weekend. Redfield did not respond to questions, and the Department of Health and Human Services, which oversees the CDC, declined to comment.

Redfield, who denied any scientific misconduct at the time, is now an HIV/AIDS expert at the University of Maryland School of Medicine. He has been praised by his supporters for his care of patients. He oversees a clinical program that treats 6,000 patients in the Baltimore-Washington area, according to an online bio.

But Redfield’s critics said the expected appointment demonstrates that the Trump administration is not vetting appointees thoroughly. The first CDC head, Brenda Fitzgerald, stepped down in January after a controversy over her purchase of tobacco stocks, and former HHS Secretary Tom Price resigned late last year amid criticism over his use of government and private planes for official travel.

“The White House claimed they would do better background checks,” said Dr. Sidney Wolfe, founder and senior adviser of Public Citizen’s Health Research Group. “But that statement is dangerously laughable. If they had done a proper background check, they wouldn’t have chosen Dr. Redfield.”

Public Citizen, a Washington watchdog group, was a leading critic of the Army’s handling of Redfield’s data at the time and obtained and published documents that detailed the controversy.

Hendrix, who was the director of an Air Force HIV clinical unit when he raised the concerns, said: “Two members of his [Redfield’s] team told me they had tried to replicate the analysis, but they couldn’t. When they tried to go to the Army, they said they were ignored.”

After Hendrix couldn’t replicate the results, he drafted a letter to his superiors reporting the data problems.

Hendrix said Redfield’s superiors initially told him not to send a letter detailing the concerns. Instead, the military scheduled a meeting with Redfield and other researchers so Hendrix could discuss the concerns. In the meeting, Hendrix recalled, Redfield acknowledged he had overstated how promising the results were.

“I thought it was resolved,” said Hendrix, who said he later called Redfield to say he was proud to work in an organization that could openly discuss such concerns.

However, Hendrix soon heard Redfield make the same inaccurate representations of the data at a conference and decided to file an official complaint requesting an investigation into scientific misconduct.

An Air Force institutional review board also recommended that the Army launch an inquiry stating: “The committee agreed the information presented by Dr. Redfield seriously threatens his credibility as a researcher and has the potential to negatively impact AIDS research funding for military institutions as a whole.”

But the Army did not appear to launch a full investigation, said Hendrix, who was interviewed at the time by the military official who conducted the inquiry. The military official declined Hendrix’s attempts to provide documented evidence, telling him the investigation was “informal.”

Hendrix later asked the commander of his hospital about the outcome of the investigation. He recalled that the commander called another officer to ask.

“I just remember him saying “Yes, sir,” he said. “When he hung up, he told me, ‘We will not be discussing this again.’”

Redfield was transferred from the laboratory he headed and assigned to treat patients, although the Army said he was not being punished. The Army also said the data would be corrected, and the military scrapped the program.

The project had earlier drawn criticism because Congress had set aside $20 million for the vaccine after lobbying by a former senator on behalf of the manufacturer.

Hendrix said he occasionally interacted over the years with Redfield and holds no grudges.

“Before this happened, he made important contributions to HIV-prevention efforts,” he said. “I respected him.”

However, he said, he remains disturbed by the military’s handling of the matter. He teaches a class on medical ethics and uses his own experience without naming Redfield to describe to his students the ethical quandaries faced in research.

Faulty data can lead other scientists to repeat the same mistakes and prompt participants to seek out trials for drugs and vaccines that don’t work.

“It’s a huge waste of funds,” he said. “But just as importantly, it diminishes trust, which is essential in science. If truth is eroded, then the whole enterprise falls apart.”

Paying Hospitals To Keep People Out Of Hospitals? It Works In Maryland.

Saturdays at Mercy Medical Center used to be perversely lucrative. The dialysis clinic across the street was closed on weekends.

That meant the downtown Baltimore hospital would see patients with failing kidneys who should have gone to the dialysis center. So Mercy admitted them, collecting as much as $30,000 for treatment that typically costs hundreds of dollars.

“That’s how the system worked,” said Mercy CEO Thomas Mullen. Instead of finding less expensive alternatives, he said, “our financial people were saying, ‘We need to admit them.’”

Maryland’s ambitious hospital-payment overhaul, put in place in 2014, has changed such crass calculations, which are still business as usual for most of American health care. A modification of a long-standing state regulation that would be hard to replicate elsewhere, the system is nevertheless attracting national attention, analysts say.

As soon as Mercy started being penalized rather than rewarded for such avoidable admissions, it persuaded the dialysis facility to open on weekends, saving government insurance programs and other payers close to $1 million annually.

In the four years since Maryland implemented a statewide system of pushing hospitals to lower admissions, such savings are adding up to hundreds of millions of dollars for the taxpayers, employers and others who ultimately pay the bills, a new report shows.

Maryland essentially pays hospitals to keep people out of the hospital. Analysts often describe the change as the most far-reaching attempt in the nation to control the medical costs driving up insurance premiums and government spending.

Like a giant health maintenance organization, the state caps hospitals’ revenue each year, letting them keep the difference if they reduce inpatient and outpatient treatment while maintaining care quality. Such “global budgets,” which have attracted rare, bipartisan support during a time of rancor over health care, are supposed to make hospitals work harder to keep patients healthy outside their walls.

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Maryland’s system, which evolved from a decades-old effort to oversee hospitals as if they were public utilities, regulates all hospital payments by every private and government insurer. That makes it radically different from piecemeal attempts to lasso health spending, such as creating accountable care organizations, which seek savings among smaller groups of patients.

From the program’s launch in 2014 through 2016, per capita hospital spending by all insurers grew by less than 2 percent a year in Maryland. That’s below the economic growth rate, according to new results from the state’s hospital regulator and the federal Department of Health and Human Services.

Keeping hospital spending below economic growth — defined four years ago as 3.58 percent annually — is a key goal for the program and something that rarely happened.

Counting The Savings

The state plan saved the Medicare program for seniors and the disabled about half a billion dollars over three years and achieved “substantial reductions in hospitalization and especially improvements in quality of care,” said a Medicare spokesman.

In the three years measured so far, he added, “the state has already exceeded the required performance for the full five years of the model.”

As high costs for hospital care have been growing more slowly nationwide, Maryland hospital costs over that period rose even less.

“It looks like it has very strong results,” said John McDonough, a Harvard health policy professor who helped craft the federal Affordable Care Act.

What Maryland is doing, he said, “is pretty bold and it’s pretty thoughtfully done and has generated a huge amount of interest around the country.”

Comprehensive results through 2016 are the most recent available from Maryland and HHS, although savings continued last year, Maryland officials said. Independent researchers found mixed results for savings in the earlier years of Maryland’s system.

Maryland’s global budgets saved Medicare $293 million — 1.8 percent of total Medicare spending — in 2014 and 2015, research firm RTI International reported in August.

A separate paper from a team led by Eric Roberts at the University of Pittsburgh found that Maryland’s program in those years couldn’t be clearly credited for reducing hospital use.

The system’s advocates say several years of results are needed to show it’s working.

“These are not fake savings,” said Joseph Antos, an economist at the conservative-leaning American Enterprise Institute who sits on Maryland’s hospital-payment commission. “It didn’t happen instantaneously. It’s taken this number of years to achieve the kinds of savings that you see” for 2016 and beyond.

Even boosters such as Joshua Sharfstein, the former Maryland health secretary who got approval for global budgets from the Obama administration, say the system is far from perfect or finalized.

“There is a range of responses. Some hospitals have been able to do more than others,” said Sharfstein, now an associate dean at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “Change in health care is notoriously slow.”

Hospitals have lagged in delivering primary, preventive care to people with chronic conditions such as asthma, diabetes and heart failure, especially in low-income neighborhoods.

Maryland’s system does little to control soaring costs of drugs or nursing home care, doctors’ office treatments and other care not connected to hospitals, although policymakers are working on proposals to do both.

Even so, “what Maryland has done is just so far ahead of many of these other models” to try to control costs, said Dan D’Orazio, a management consultant who has worked with hospitals across the country. One Maryland hospital CEO told him: “This has fundamentally changed how we wake up and do business every day,” D’Orazio said.

Seeing A Difference

At Mercy, described by policymakers as more aggressive than many hospitals in watching costs, about a third of the patients now leave the hospital with medications in hand, said Dr. Wilma Rowe, the hospital’s chief medical officer. That bypasses the tendency for patients to skip a follow-up pharmacy visit and risk landing back in the emergency room.

A statewide data network notifies Mercy and other hospitals when one of their patients ends up in an emergency room somewhere else. That helps coordinate care.

Greater Baltimore Medical Center, north of the city, has hired dozens of primary care doctors to track around 1,000 people with diabetes — staying in touch, advising on diets and keeping them on insulin so they avoid the hospital.

Often clinicians visit elderly patients’ homes to prevent what might turn into an ambulance call and admission, said the hospital’s CEO, Dr. John Chessare.

Before global budgets, “I’d look at the waiting room in the [emergency department], and if it wasn’t full I’d get scared,” he said.

Now he worries it might be full of people who could be better treated elsewhere — including Gilchrist, a GBMC affiliate delivering hospice care for those at the end of life.

These days, he said, “we consider it a defect if someone with chronic disease dies in the hospital.”

Visita del Subsecretario de HHS Hargan a Puerto Rico

HHS Gov News - March 16, 2018

En inglés

Ayer, aproximadamente seis meses después del paso de los huracanes Irma y María, el subsecretario del Departamento de Salud y Servicios Humanos (HHS, sigla en inglés), Eric Hargan, viajó a Puerto Rico como parte de la campaña de recuperación que lleva a cabo todo el gobierno en la administración de Trump. Su visita se realizó luego de que el Secretario de HHS, Alex Azar, renovara la declaración de Emergencia de Salud Pública para Puerto Rico y las Islas Vírgenes, la cual se firmó el martes.

En Puerto Rico, el subsecretario Hargan se reunió primero con los líderes de la Agencia Federal para el Manejo de Emergencias (FEMA, sigla en inglés) y los empleados de HHS que también trabajan en la oficina federal conjunta. En este lugar el personal le informó sobre el proceso de recuperación y analizaron el trabajo que todavía debe realizarse para satisfacer las necesidades continuas en Puerto Rico.

Luego, el subsecretario Hargan visitó la oficina de la Administración de Alimentos y Medicamentos (FDA, sigla en inglés) en el distrito de San Juan para conocer sobre el trabajo que se realizó para apoyar a las compañías farmacéuticas y de dispositivos médicos afectadas por los huracanes el año pasado. Considerando que Puerto Rico produce más productos farmacéuticos para Estados Unidos (por un valor de $40 mil millones) que cualquiera de los 50 estados o cualquier país extranjero, la administración de Trump y HHS trabajaron para que dichas compañías no se retiren de Puerto Rico y así poder conservar miles de puestos estadounidenses de trabajo industrial. El subsecretario Hargan tuvo el privilegio de reunirse con el tenaz equipo de la FDA responsable de este éxito. 

Finalmente, como parte de la vigilancia continua y los esfuerzos para supervisar la recuperación que realiza HHS, el subsecretario Hargan se reunió con los representantes de personas de la tercera edad y con discapacidades para hablar sobre los programas de servicios para la tercera edad en Puerto Rico. También analizaron el estado de los programas vigentes y las necesidades actuales y futuras de la población.

El personal de HHS trabajó junto con otros empleados federales para cuidar de 36,000 pacientes en Estados Unidos continental y en las islas después de los huracanes Harvey, Nate, Irma y María. La administración de Trump y HHS continúan con su compromiso para proteger la salud en las comunidades del sudeste de Estados Unidos, Puerto Rico y las Islas Vírgenes, mientras se recuperan de los huracanes.

With Some Republican Support, Virginia Edges Closer To Medicaid Expansion

Virginia is among 18 states that have not expanded Medicaid under the Affordable Care Act. But this year, the state legislature is closer to enacting expansion than it has been in the past, and the issue will be the sticking point as the legislature goes into a special session next month to hash out its budget.

Republican Del. Barry Knight from the Virginia Beach area calls it “the 800-pound gorilla in the room.” He’s one of more than a dozen Republicans who voted to include Medicaid expansion in the House budget — along with a work requirement — this year.

It’s a big shift in the House position on the issue and comes after 15 seats flipped to Democrats in the so-called blue wave of last November’s election, which also saw the election of Democratic Gov. Ralph Northam.

“On the big-picture issues, I think it was a reawakening and a call to look at things from a different perspective,” said Republican Del. Chris Peace, from the Richmond area, who also voted in favor of expansion.

A December poll showed that over 80 percent of likely Virginia voters support an expansion.

“I think the House heard that message, loud and clear. I think the Senate still needs to listen a little bit,” Northam said.

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The state Senate still has a strong bulwark against expansion, led by Senate Majority Leader Tommy Norment, who represents the Tidewater area in southeastern Virginia. Norment has come out against the House Republicans who want to expand. He reminds them that, despite a slim margin, Republicans are still in charge and could stop Medicaid expansion.

“I do think that the House of Delegates is waiting for that moment of lucidity and epiphany to realize that their majority is 51 to 49,” Norment said.

But opposition to President Donald Trump has energized Democratic voters, said Bob Holsworth, a former political science professor at Virginia Commonwealth University. He said he thinks expansion has a greater chance this year.

It could pass in the Senate, he said, because of a potential wildcard: Republican Sen. Emmett Hanger, from mostly rural central Virginia. Hanger has expressed support for some form of Medicaid expansion, and has a track record of voting independently, said Holsworth.

“What Hanger has said that’s very interesting … is that if he decides to support some version of Medicaid expansion, he says, ‘There are a number of other Republicans who are going to go over with me,'” said Holsworth.

However, Hanger said he isn’t happy about a tax on hospitals that has been incorporated into the House’s budget to help pay for the state’s share of expansion costs. The tax accounts for about three-quarters of the over $400 million Medicaid-related gulf between House and Senate budgets.

If legislators don’t come up with a budget that includes Medicaid expansion, Northam has a Plan B. He said he’ll introduce an amendment to add it back into the budget. In the amendment process, the lieutenant governor, Democrat Justin Fairfax, gets a vote if the Senate ties. Fairfax said he’d be happy to vote to expand coverage to up to 400,000 low-income Virginians.

“There are so many people that we can help, and we have the means to do it if we expand Medicaid. We just have to have the political will to do it,” Fairfax said.

Medicaid expansion in Virginia would especially benefit low-income adults without children.

“An adult who does not have children can have zero income — can be totally impoverished — and they cannot get Medicaid,” said Jill Hanken with the Virginia Poverty Law Center.

And a family of three with a total income of about $10,000 doesn’t qualify for Medicaid, she said.

“It’s hard to explain to them that they don’t have a choice, they’re not eligible for Medicaid,” she said, and they’re not eligible for subsidies for insurance on the exchange, so health insurance is out of reach. “And the reason is because Virginia hasn’t expanded Medicaid,” she said.

The special session begins April 11. The state needs a budget agreement by June 30 to prevent a government shutdown.

This story is part of a reporting partnership with NPR, local NPR member stations and Kaiser Health News.

Bill Of The Month: For Toenail Fungus, A $1,500 Prescription

Kaiser Health News:Insurance - March 16, 2018

When Anne Soloviev, a retiree who lives in Washington, D.C., received a prescription to treat toenail fungus, she never thought to ask how much it cost. As it turned out, she was prescribed a topical medication costing almost $1,500. (Cheryl Diaz Meyer for KHN)

During Anne Soloviev’s semiannual visit to Braun Dermatology & Skin Cancer Center in Washington, D.C., in January, the physician assistant diagnosed fungus in two of her toenails. Soloviev is vigilant about getting skin checks, since she is at heightened risk for skin cancer, but she hadn’t complained about her toenails or even noticed a problem.

The assistant noted some unusual discoloration where the nail meets the skin. “They took a toenail clipping and said, yeah, you have a fungus,” Soloviev recalled.

So the PA called a prescription into a specialty pharmacy with mail-order services, which would send medication to Soloviev’s Capitol Hill home.

It seemed like an easy fix to an inconsequential health issue. “I did not ask how much it cost — it never crossed my mind, ever,” said Soloviev, a former French teacher, who still works part time.

Then the bill came.

Patient: Anne Soloviev, 77 on March 18, of Washington, D.C.

The Bill: $1,496.09 for Kerydin, a topical medication that treats toenail fungus. Originally produced by Anacor Pharmaceuticals Inc., it is now a product of Sandoz, a Novartis division.

Service Provider: My Express Care Pharmacy, plus Braun Dermatology & Skin Cancer Center

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The Medical Treatment: Shortly after the physician assistant phoned in the prescription to My Express Care Pharmacy, in Maryland, the pharmacy contacted Soloviev for her health insurance information.

Soloviev is covered by Medicare, Parts A and B, and has supplemental insurance through her late husband’s government health benefits that covers prescription drugs. She also has a health reimbursement account (HRA), which contains almost $1,500 pretax dollars each year to pay for uncovered medical expenses. She typically uses that pot of money to cover copays for the other medicines she takes regularly.

Kerydin, the toenail medication, arrived by overnight mail, and an automatic refill came a few weeks later. She began swabbing it on the two toenails, as directed, having been told it would take about 11 months to treat the fungus.

She thought little of it.

But when Soloviev went to her local CVS to pick up another medication — a statin that is usually paid for by her HRA — she discovered her reserve was empty.

Anne Soloviev’s prescription for Kerydin, at $1,496.09 per monthly refill, wiped out her entire health reimbursement account for the year. (Courtesy of Anne Soloviev)

Unbeknownst to her, Kerydin, which it turned out costs nearly $1,500 per monthly refill, had wiped out her entire reimbursement account.

What Gives: We’re talking about mild toenail fungus. The price tag is difficult to rationalize, experts said.

“Reality check — this is $1,500 for a medicine to treat [it],” said Wendy Epstein, an associate law professor at DePaul University, who researches health care law. “That’s quite a chunk of change.”

Leslie Pott, Sandoz’s vice president of communications, explained that Kerydin is patent-protected and priced “at parity” with its one market competitor, Jublia. She also pointed out that to secure a place on an insurer’s list of approved drugs — its formulary — the drugmaker often had to offer substantial discounts to insurers and various middlemen. “We have no visibility into the extent to which these discounts are passed onto patients or payers,” she wrote in an email.

When Anne Soloviev visited the dermatologist in January, the physician assistant diagnosed fungus in two of her toenails and gave her a prescription for a topical medication. “I did not ask how much it cost — it never crossed my mind, ever,” Soloviev said. (Cheryl Diaz Meyer for KHN)

There are many prescription treatment options for toenail fungus — both older medicines in pill form and newer topical treatments such as Kerydin, said Dr. Shari Lipner, an assistant professor at Weill Cornell Medicine and director of its nail unit. The patient in this case would have been a candidate for “quite a few” of them.

Patients are likely to pay less for the pills, for which a course of treatment lasts three months, compared with the newer topical treatments, she said, adding that the pills also seem to have greater efficacy.

In its application for Food and Drug Administration approval granted in 2014, Anacor Pharmaceuticals highlighted that a yearlong treatment of Kerydin completely cured toe fungus in 6.5 percent of patients for one trial, and 9.1 percent of patients in another.

Over-the-counter treatments are also available, but there’s not much data on them, Lipner said.

Xavier Davis, Braun Dermatology & Skin Cancer Center’s practice manager, said a drug’s price tag simply isn’t a factor when prescribers recommend a course of treatment.

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“When our providers are treating patients, we’re not treating them based on what the cost’s going to be. We look for what’s the best care for the patient,” Davis said. “If the patient calls and says that’s too expensive, then we’ll look for alternatives.”

Kavita Patel, a nonresident fellow at the Brookings Institution and a practicing physician, said this process contributes to the problem. “My sister’s a dermatologist, and she’ll do the same thing — she’ll prescribe and she doesn’t know. You’re getting at many layers of how [messed] up the system is, starting with the doctor doesn’t know.”

And patients often don’t see the actual price. Or they see it too late, when they’re at the pharmacy counter picking up medicines they have been told they need or in a roundabout way discover unexpected payouts.

In January, Soloviev’s insurance plan was billed the full price of Kerydin. Of that, $1,439.57 came from her HRA. The difference, $56.52, was covered by a patient-assistance program from the drug manufacturer, explained Jonathan Lee, a pharmacist for My Express Care.

In February, when Soloviev’s prescription was refilled, her plan was again billed the full drug price. But she didn’t know about that either. A manufacturer coupon was applied to cover what remained of her insurer’s $2,000 annual deductible and the $60 copay. Her insurance then kicked in to pay the difference.

Such patient-assistance programs and coupons are meant to insulate patients from cost sharing, so that they don’t feel a pinch from a drug’s price. But in this case, the drugmaker’s patient-assistance program apparently took effect only once Soloviev’s HRA has been wiped out, allowing the manufacturer to maximize revenue from both patient and insurer.

DePaul University’s Epstein said it took her “15 minutes to figure out what was going on” here. And, unlike the average patient, she studies this issue for a living.

Lee, the pharmacist, said even he didn’t realize that money could be withdrawn directly from a patient’s HRA without her knowledge, and he’s been in the business for the better part of a decade.

None of that is consolation for Soloviev, who said: “I just find it is outrageous for a fungal medicine to cost $1,400, to be prescribed for 11 months, and for neither the PA nor the pharmacy to warn you,” Soloviev said.

Resolution: Though she has told My Express Care not to renew the prescription, Soloviev’s HRA is depleted. For the rest of the year, she’ll have to pay out-of-pocket costs for any other medications, an expense she hadn’t planned on.

The Takeaway: For even the most informed of patients, getting a new prescription can mean walking through a financial minefield. And Soloviev hit a number of booby traps.

Bottom line, experts say, medical professionals should make the patient aware if they prescribe a high-priced medicine and explain why it’s beneficial.

Patients should play defense and ask their physicians about the cost of every new prescription. They should ask again at the pharmacy — even if that means calling a mail-order pharmacy. Because costs can vary depending on each patient’s coverage, they may need to contact their insurance carrier or the PBM that handles their medicine claims.

And if the cost is extremely high, they should ask their doctor about generic or over-the-counter alternatives.

“This is an important component of the decision a patient’s going to make,” Epstein said. “If it’s toenail fungus and not life-or-death, it strikes me … an individual might want to have relevant data.”

This is a monthly feature from Kaiser Health News and NPR that will dissect and explain real medical bills in order to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. Do you have a medical bill that you’d like us to see and scrutinize? Submit it here and tell us the story behind it.