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From The ER To Inpatient Care — At Home

Kaiser Health News:Insurance - March 06, 2018

Phyllis Petruzzelli spent the week before Christmas struggling to breathe. When she went to the emergency department on Dec. 26, the doctor at Brigham and Women’s Faulkner Hospital near her home in Boston’s Jamaica Plain neighborhood said she had pneumonia and needed hospitalization. Then the doctor proposed something that made Petruzzelli nervous. Instead of being admitted to the hospital, she could go back home and let the hospital come to her.

As a “hospital-at-home” patient, Petruzzelli, 71 this week, learned doctors and nurses would come to her home twice a day and perform any needed tests or bloodwork.

A wireless patch a little bigger than her index finger would be affixed to her skin to track her vital signs and send a steady stream of data to the hospital. If she had any questions, she could talk face-to-face via video chat anytime with a nurse or doctor at the hospital.

Hospitals are germy and noisy places, putting acutely ill, frail patients at risk for infection, sleeplessness and delirium, among other problems. “Your resistance is low,” the doctor told her. “If you come to the hospital, you don’t know what might happen. You’re a perfect candidate for this.”

So Petruzzelli agreed. That afternoon, she arrived home in a hospital vehicle. A doctor and nurse were waiting at the front door. She settled on the couch in the living room, with her husband, Augie, and dog, Max, nearby. The doctor and nurse checked her IV, attached the monitoring patch to her chest and left.

When Dr. David Levine arrived the next morning, he asked why she’d been walking around during the night. Far from feeling uncomfortable that her nocturnal trips to the bathroom were being monitored, “I felt very safe and secure,” Petruzzelli said. “What if I fell while my husband was out getting me food? They’d know.”

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After three uneventful days, she was “discharged” from her home hospital stay, and the equipment removed from her home. “I’d do it again in a heartbeat,” Petruzzelli said.

Brigham Health in Boston is one of a slowly growing number of health systems that encourage selected acutely ill emergency department patients who are stable and don’t need intensive, round-the-clock care to opt for hospital-level care at home.

In the couple of years since Brigham and Women’s Hospital started testing this type of care, hospital staff who were initially skeptical have generally embraced it, said Levine.

“They very quickly realize that this is really what patients want, and it’s really good care,” he said.

This approach is quite common in Australia, England and Canada but it’s faced an uphill battle in the United States.

A key obstacle, clinicians and policy analysts agree, is getting health insurers, whose systems aren’t generally set up to cover hospital care provided in the home, to pay for it.

At Brigham Health, the hospital can charge an insurer for a physician house call, but the remainder of the hospital-at-home services are covered by grants and funding from Partners HealthCare’s Center for Population Health, which is affiliated with Brigham Health, said Levine.

Health insurers don’t have a position on hospital-at-home programs, said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry trade group.

“Overall, health insurance providers are committed to ensuring patients have access to care they need, and there are Medicare Advantage plans that do cover this type of at-home care,” Donaldson said in a statement.

Levine, a clinician-investigator at Brigham and Women’s Hospital and an instructor at Harvard Medical School, was the lead author of a study published last month that reported the results of a small, randomized, controlled trial comparing the health care use, experience and costs of Brigham patients who either received hospital-level care at home or in the hospital in 2016.

The 20 patients analyzed in the trial had one of several conditions, including infection, heart failure, chronic obstructive pulmonary disease or asthma. The trial found that while there were no adverse events in the home-care patients, their treatment costs were significantly lower, about half that of patients treated in the hospital.

Why? For starters, labor costs for at-home patients are lower than for patients in a hospital, where staff must be on hand 24/7. Home-care patients also had fewer lab tests and visits from specialists.

The study found that both groups of patients were about equally satisfied with their care, but the home-care group was more physically active.

Brigham Health is conducting further randomized controlled trials to test the at-home model for a broader range of diagnoses.

Dr. Bruce Leff began exploring the hospital-at-home concept more than 20 years ago, conducting early studies at Veterans Affairs medical centers and Medicare Advantage plans that found fewer patient complications, better outcomes and lower costs in home-care patients.

Caregivers reported less stress, Leff’s research found. For caregivers, traveling to an unfamiliar hospital, finding and paying for parking and trying to time bedside meetings with clinical staff, all the while worried about a loved one’s health, is wearing, experts note.

Hospitals, accustomed to the traditional “heads-and-beds” model that emphasizes filling hospital beds in a brick-and-mortar facility have been slow to embrace change, however.

There are practical hurdles, too.

“It’s still easier to get Chinese food delivered in New York City than to get oxygen delivered at home,” said Leff, a professor of medicine and director of Johns Hopkins Medical School’s Center for Transformative Geriatric Research.

Since Mount Sinai’s seven-hospital system launched its Hospital-at-Home program in New York City in 2014, more than 700 patients have chosen home over hospital care. Patients can be referred to the program from selected emergency departments as well as some Mount Sinai primary care practices and urgent care centers. And they have fared well on a number of measures.

The average length of stay for acute care was 5.3 days in the hospital versus 3.1 days of treatment for home-care patients, while 30-day readmission rates for home-based patients were about half of those in the hospital: 7.8 percent versus 16.3 percent for the two-year period ending December 2016.

Begun with a three-year, $9.6 million grant from the federal Center for Medicare & Medicaid Innovation in 2014, Mount Sinai’s program initially focused on Medicare patients with six conditions, including congestive heart failure, pneumonia and diabetes. Since then, the program has expanded to include dozens of conditions, including asthma, high blood pressure and serious infections like cellulitis, and is now available to some privately insured and Medicaid patients.

The health system has also partnered with Contessa Health, a company with expertise in home care, to negotiate contracts with insurers to pay for hospital-at-home services.

Among other things, insurers are worried about the slippery slope of what it means to be hospitalized, said Dr. Linda DeCherrie, clinical director of the mobile acute care team at Mount Sinai Health System.

“[Insurers] don’t want to be paying for an admission if this patient really wouldn’t have been hospitalized in the first place,” DeCherrie said.

CMS Issues Split Decision On Arkansas Medicaid Waiver

Kaiser Health News:Madicaid - March 05, 2018
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The Trump administration on Monday approved Arkansas’ request for a Medicaid work requirement but deferred a decision on the state’s request to roll back its Medicaid expansion that has added 300,000 adults to the program.

Arkansas had sought to reduce the number of people eligible for Medicaid by allowing only those with incomes below the federal poverty level, or about $12,140 for an individual, to qualify. For the past four years, Arkansas Medicaid covered everyone with incomes under 138 percent of the poverty level, or about $16,750. The new policy would have cut the number of people eligible for Medicaid in the state by about 60,000 people.

Seema Verma, administrator of the Centers for Medicare & Medicaid Services, who announced the decision, has said her goal as head of the program was to grant states more flexibility in running their Medicaid programs than they’ve had before.

Arkansas follows Indiana and Kentucky this year in winning CMS’ approval for the work requirement. Arkansas plans to start the new requirement affecting adults under age 50 by June, making it the first to do so.

Verma recused herself on CMS’ decisions involving Indiana and Kentucky because she used to consult with those state Medicaid agencies before joining the Trump administration in 2017. As a health care consultant, she also worked with Arkansas. But Verma decided to personally approve the Arkansas waiver on Monday and flew to Little Rock, Ark., to make the announcement with Republican Gov. Asa Hutchinson.

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CMS officials did not respond to questions about why she did not recuse herself again.

But a top Senate Democrat lambasted Verma’s decision.

“She pledged during her confirmation to recuse herself from working on many states’ Medicaid waivers to avoid conflicts of interest, including Arkansas, Sen. Ron Wyden (D-Ore.) said in a statement. “The Trump Administration has simply made a mockery of the HHS ethics process.”

It is unclear why she deferred deciding on Arkansas request to scale back its Medicaid decision. Deferring a decision on rolling back expansion could be a way of rejecting the application but in a less politically harsh way. Arkansas was one of the few Southern states to expand Medicaid under the ACA, a decision that brought hundreds of millions of federal dollars into the state.

Nine other states have requests pending with CMS to enact a Medicaid work requirement.

In Arkansas, enrollees who don’t work or volunteer at least 80 hours a month could lose coverage as early as September. The work requirement exempts many people such as those with opioid addiction and parents with dependent children.

Verma said the work requirement “is about helping people rise out of poverty to achieve the American dream.”

But advocates for the poor blasted the move, noting most Medicaid enrollees already work, go to school or are taking care of sick relatives.

“The Trump administration’s approval of Arkansas’ harsh work requirement in Medicaid will likely set back the state’s considerable progress under the Affordable Care Act in increasing coverage and improving access to care, health and financial stability for low-income Arkansans,” said Judith Solomon, vice president for health policy at the left-leaning Center on Budget and Policy Priorities.

Arkansas officials said they need the work requirement because without it many enrollees won’t seek out work or job training. Since January 2017, fewer than 5 percent of Medicaid enrollees who were referred to the state Department of Workforce Services to help with job training followed through and accessed services.

At New Health Office, ‘Civil Rights’ Means Doctors’ Right To Say No To Patients

The Trump administration is embarking on a sweeping effort to redefine civil rights in health care, with critics accusing the Department of Health and Human Services of sidestepping the rights of patients to soothe a far smaller constituency: conservative nurses, hospitals and other caregivers.

The department’s Office for Civil Rights (OCR) has been greatly strengthening and expanding protections for health care providers who have religious- or conscience-based objections to procedures such as abortion. By way of explanation, officials cite 36 complaints OCR received from, or on behalf of, those working in the health care system from President Donald Trump’s election through early January of alleged affronts to religious beliefs and moral convictions — up from 10 such complaints it had fielded since 2008.

What officials did not mention is that those 36 complaints pale against the more than 30,000 total complaints that OCR received during 2017, according to the agency’s latest budget request; most involved alleged breaches of privacy or discrimination against patients.

“Times are changing,” Roger Severino, OCR’s director, said in a speech in January. “And we are institutionalizing a change in the culture of government, beginning with HHS, to never forget that religious freedom is a primary freedom; that it is a civil right; that it deserves complete enforcement and respect.”

During the Obama administration, OCR operated under a two-pronged, patient-centric mission: to protect civil rights and health information privacy. The office focused on a part of the Affordable Care Act known as Section 1557, which, for the first time, barred providers who receive federal funding from discriminating on the basis of gender identity.

But the new, wide-ranging proposal to strengthen conscience protections at OCR involves the creation of a division, hiring of staff and re-evaluation of which civil rights it will protect.

Overseen by Severino, who has deep ties to the religious right, the makeover appears radical, one that critics worry will jeopardize the care of pregnant women and transgender individuals, as well as others who could be denied certain procedures. Officials spent months quietly rethinking policies and plans for enforcement, Severino has said, preparing to remake the office as a guardian of objections to abortion, sterilization and physician-assisted death, for example.

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“Administrations are able to come in and put their own stamp and agenda on how they see policy. And that is politics. That is politics as usual,” said Mary Alice Carter, executive director of a new watchdog group called Equity Forward. “But the core issue here is we have individuals coming in who fundamentally don’t believe in the very mission they’re serving.”

“They are coming in with the agenda of burning it down,” she said.

Trump’s selection of Severino — a former Justice Department lawyer who most recently researched religious issues at the conservative Heritage Foundation — signaled the changes in store. In 2016, he co-authored a paper that argued OCR’s interpretation of Section 1557 as barring discrimination based on gender identity threatened health care providers who “as a matter of faith, moral conviction, or professional medical judgment, believe that maleness and femaleness are biological realities to be respected and affirmed, not altered or treated as diseases.”

In an interview, Severino said the goal is to achieve “parity” in civil rights, enforcing existing laws passed by Republicans and Democrats alike to ensure those with moral objections are not excluded from the health care field.

In January, Severino unveiled the agency’s Conscience and Religious Freedom Division, which will have equal standing with OCR’s existing Civil Rights and Health Information Privacy divisions, right down to getting its own staff and a director. Previously, conscience complaints from health care providers were reviewed alongside other discrimination complaints by the Civil Rights Division.

Last week, an HHS spokesperson said the office had received at least 40 more conscience-related complaints from providers in the weeks since the division opened, part of what the spokesperson characterized as “a clear surge” in such complaints under the Trump administration.

Under the proposed rule outlining HHS’ plans, the division would collect and investigate complaints filed by health care professionals and entities, in addition to reviewing the policies of HHS and its partners to make sure they comply with a slew of conscience-protection laws. If any recipient of federal funding is found to have violated the law, HHS “would consider all legal options.” That could include cutting off federal funds, taking back previously allocated funds or even referring the culprit to federal law enforcement officials.

That means a hospital that forces a nurse to participate in a vasectomy against her religious objections to sterilization, for instance, could risk having its federal funding revoked. But beyond objections to abortion and sterilization in particular — which have some explicit protections under federal law — it is murky which complaints HHS would deem valid. For example, it is unclear whether conscience-protection laws would shield a primary care doctor who refused to prescribe pre-exposure prophylaxis, or PrEP, which drastically lowers the risk of contracting HIV and is often used by gay men.

Severino rejected the notion that his office is elevating the concerns of a small group of conservative, Christian health care providers above others. In an interview, he argued HHS is early in the normal regulatory process and will work out the practicalities of how to balance the rights of providers with the rights of those they have sworn to treat as it reviews comments from the public and finalizes its proposal.

“We’re about increasing access for everybody,” Severino said. “And part of increasing access for all is making sure we have a diverse set of providers for people.”

Hinting at the scope of the changes in store, officials filed notices in January rewriting OCR’s mission statement to emphasize conscience and religious freedom and empowering Severino to implement related laws.

Jocelyn Samuels, a former Justice Department civil rights lawyer who led OCR under Obama, said the office’s latest efforts suggest officials are setting the stage for an unprecedented expansion in the ability of providers to deny care.

The recent changes, she said, “presage a commitment to invest more resources in protecting people’s rights to deny care than promoting expansions of access to care.”

Already, OCR has reversed decisions of its Obama-era predecessor. In 2016, for example, OCR concluded that a California law requiring that health insurance plans include coverage for elective abortions did not violate the Weldon Amendment — a measure barring federal funding to those that discriminate against professionals or institutions for not providing, or otherwise assisting patients in obtaining, abortions.

In a call with members of the conservative Federalist Society in February, Severino said OCR no longer stood by that 2016 decision.

OCR has also said it will not enforce Section 1557’s protections based on gender identity — the same protections Severino railed against in his 2016 paper — as well as its protections based on “termination of pregnancy.” Officials have attributed that decision to an injunction by a federal judge.

Asked whether the conscience-protection efforts would shield those who object to hormone therapy or other treatments for transgender patients, Severino told Federalist Society members the office was abiding by the judge’s injunction “to the fullest extent.” He added that he had never heard of anyone citing conscience-protection laws in such a case.

In the waning days of George W. Bush’s presidency in 2008, HHS introduced a rule that would prohibit discrimination against those who refuse to perform abortion or other procedures on religious or moral grounds, as well as established a way to file related complaints to OCR. The Obama administration replaced it with a more narrowly tailored rule.

However, the big-picture efforts by the Trump administration have gone further than that Bush administration rule — a point underscored by a note in the proposed rule that explicitly grants OCR “full enforcement authority over a significantly larger universe of Federal statutes” protecting religious- and conscience-based objections than the 2008 rule.

Some have greeted the change with open arms, praising HHS for abandoning what Severino called the “outright hostility” of the Obama years.

Said Everett Piper, the president of Oklahoma Wesleyan University, an evangelical Christian school that sued to be exempted from the Affordable Care Act’s requirement that employer insurance plans cover contraceptives: “I just want to say how good it is to be here thanking Health and Human Services and the Office of Civil Rights rather than suing them.”

While Talk About Opioids Continues In DC, Addiction Treatment Is In Peril In States

Kaiser Health News:States - March 05, 2018

Opioids were on the White House agenda Thursday — President Trump convened a summit with members of his administration about the crisis. And Congress authorized funds for the opioid crisis in its recent budget deal — but those dollars aren’t flowing yet, and states say they are struggling to meet the need for treatment.

The Oklahoma agency in charge of substance abuse has been told by the state’s legislature to cut more than $2 million from this fiscal year’s budget.

“Treatment dollars are scarce,” said Randy Tate, president of the Oklahoma Behavioral Health Association, which represents addiction treatment providers.

It’s like dominoes, Tate said. When you cut funding for treatment, other safety net programs feel the strain.

“Any cuts to our overall contract,” he said, “really diminish our ability to provide the case management necessary to advocate for homes, food, shelter, clothing, primary health care and all the other things that someone needs to really be successful at tackling their addiction.”

In just three years, Oklahoma’s agency in charge of funding opioid treatment has seen more than $27 million dollars chipped away from its budget — thanks to legislative gridlock, slashed state taxes and a drop in oil prices (with the additional loss in state tax revenue that resulted).

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Jeff Dismukes, a spokesman for Oklahoma’s Department of Mental Health and Substance Abuse Services, says the already lean agency has few cost-cutting options left.

“We always cut first to administration,” he said, “but there’s a point where you just can’t cut anymore.”

The agency may end up putting off payments to treatment providers until July — the next fiscal year. Tate says that could be devastating.

“Very thinly financed, small rural providers are probably at risk of going out of business entirely — up to and including rural hospitals,” he said.

Getting treatment providers to open up shop in rural areas is really hard, even in good times, and more financial uncertainty could make that problem worse. In the meantime, according to an Oklahoma state commission’s opioid report, just 10 percent of Oklahomans who need addiction treatment are getting it.

That statistic is similar in Colorado. And as 2018 began, Colorado’s escalating opioid crisis got worse, when the state’s largest drug and alcohol treatment provider, Arapahoe House, shut its doors.

The facility provided recovery treatment to 5,000 people a year. Denise Vincioni, who directs another treatment center, the Denver Recovery Group, says other facilities have scrambled to pick up the patients.

Most of Arapahoe’s clients were on Medicaid. Autumn Haggard-Wolfe, a two-time Arapahoe House client who is now in recovery, worries the facility’s closing will have dire consequences, especially for people who need inpatient care, as she did.

“I feel like the only other option right now in therapy would be jail for people,” she said, “and people die in there from withdrawing.”

Arapahoe House’s CEO blamed its closure on the high cost of care and poor government reimbursement for services.

The mother of Colorado state lawmaker Brittany Pettersen struggled with addiction, and was treated at Arapahoe House. Pettersen says treatment centers rely on a crazy quilt of funding sources and are chronically underfunded — often leaving people with no treatment options.

“We have a huge gap in Colorado,” Pettersen said, “and that was before Arapahoe House closed.”

She is pushing legislation in the state to increase funding for treatment. But to get tens of millions of dollars in federal matching funds, Colorado lawmakers need to approve at least $34 million a year in new state spending.

That price tag may simply be too high for some lawmakers. But either way, she added, “It’s going to take a lot to climb out of where we are.”

Colorado did get new federal funds to fight the opioid crisis through the 21st Century Cures Act, passed in December of 2016, but it was just $7.8 million a year for two years — divvied up among a long list of programs.

This story is part of a partnership that includes StateImpact Oklahoma, Colorado Public Radio, NPR and Kaiser Health News.

User-Friendly Or Error-Ridden? Debate Swirls Around Website Comparing Nursing Homes

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Earlier this year, the state Department of Public Health launched a new website, Cal Health Find, intended to help people compare the quality of nursing homes and other health care facilities.

Now, California nursing home advocates are calling on the state to take it down, saying the new site is incomplete, inaccurate and “a huge step in the wrong direction.”

The state describes the website as a user-friendly replacement for its previous tool, the Health Facilities Consumer Information System. Among other things, state officials say the new site allows consumers to compare up to three facilities at a time, improves compliance with the Americans with Disabilities Act and offers language translation tools.

But the nonprofit organization California Advocates for Nursing Home Reform says those extras are of  little use because the content itself is wrong. The group complains of inaccurate complaint counts for problematic nursing homes and missing links to inspection reports filed before 2016.

“Choosing the right nursing homes can be a life-and-death decision,” said Michael Connors, an advocate with the organization. “This site should help them avoid places that are likely to neglect them. Right now, it will do the opposite.”

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State officials argue that the site is a work in progress that is being refined, with updates to complaint counts coming this week. The new site cost about $437,000 to build and operate, officials said.

“The department has acknowledged and identified the source of the problem [with complaint counts] and has already implemented a correction plan,” Corey Egel, a spokesman for the California Department of Public Health, said in a written statement. “The department believes Cal Health Find improves the user experience. … We find no reason to remove the site while we correct errors.”

Deborah Pacyna, a spokeswoman for the California Association of Health Facilities, which represents nursing homes, said her organization also has shared some concerns about the data with the state, but she declined to give further details. She added that some nursing homes were complaining that pictures from Google Earth did not accurately reflect their facilities, instead showing only the street or a back parking lot. She repeated the state’s assertion that the site is a work in progress.

Connors said she remains skeptical that the state is taking the problems seriously.

The state’s old website is still up, although it refers people to the new site. A comparison of its data with that available on Cal Health Find showed marked discrepancies.

For example, the state’s old website shows that 90 complaints were made against Lake Merritt Healthcare Center in Oakland in 2017. The new website shows only 34 for the same year. Similarly, while the old website lists 49 complaints against San Diego Healthcare Center in 2017, the new website lists only 13.

Officials offered a complex explanation for the discrepancies, including that the new site contained more records so that it was updating more slowly than the old one. Also, they said, the old site erroneously counted some deficiencies more than once.

People searching the new website will find no links next to individual nursing homes for citations made before 2016 – those links are still there but, according to the patient advocates, buried on the new site.

So, the advocates say, an individual considering Oakpark Healthcare Center in Tujunga, for example, may miss the serious Class AA citation from September 2015 that was more readily evident on the old website. That citation determined that the nursing home failed to identify and treat a gangrenous wound on a resident’s heel, leading to her death.

Need A Medical Procedure? Pick The Right Provider And Get Cash Back

Kaiser Health News:Insurance - March 05, 2018

Laurie Cook went shopping recently for a mammogram near her home in New Hampshire. Using an online tool provided through her insurer, she plugged in her ZIP code. Up popped facilities in her network, each with an incentive amount she would be paid if she chose it.

Paid? To get a test? It’s part of a strategy to rein in health care spending by steering patients to the most cost-effective providers for non-emergency care.

State public employee insurance programs were among the early adopters of this approach. It is now finding a foothold among policymakers and in the private sector.

Scrolling through her options, Cook, a school nurse who is covered through New Hampshire’s state employee health plan, found that choosing a certain facility scored her a $50 check in the mail.

She then used the website again to shop for a series of lab tests. “For a while there, I was getting a $25 check every few weeks,” said Cook. The checks represented a share of the cost savings that resulted from her selections.

Lawmakers in nearby Maine took the idea further, recently enacting legislation that requires some private insurers to offer pay-to-shop incentives, part of a movement backed by a conservative foundation to get similar measures passed nationally.

Similar proposals are pending in a handful of other statehouses, including Virginia, West Virginia and Ohio.

“If insurance plans were serious about saving money, they would have been doing this stuff years ago,” said Josh Archambault, a senior fellow at the Foundation for Government Accountability, a limited-government advocacy group based in Naples, Fla., that promotes such “right-to-shop” laws. “This starts to peel back the black box in health care and make the conversation about value.”

Still, some economists caution that shop-around initiatives alone cannot force the level of market-based change needed. While such shopping may make a difference for individual employers, they note it represents a tiny drop of the $3.3 trillion spent on health care in the U.S. each year.

“These are not crazy ideas,” said David Asch, professor of medicine, medical ethics and health policy at the Penn Medicine Center for Health Care Innovation in Philadelphia. But it’s hard to get consumers to change behavior — and curbing health care spending is an even bigger task. Shopping incentives, he warned, “might be less effective than you think.”

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If they achieve nothing else, though, such efforts could help remove barriers to price transparency, said Francois de Brantes, vice president at the Health Care Incentives Improvement Institute, a nonprofit that designs benefit programs.

“I think this could be quite the breakthrough,” he said.

Yet de Brantes predicts only modest savings if shopping simply results in narrowing the price variation between high- and low-cost providers: “Ideally, transparency is about stopping folks from continuously charging more.”

Among the programs in use, only a few show consumers the price differences among facilities. Many, like the one Cook used, merely display the financial incentives attached to each facility based on the underlying price.

Advocates say both approaches can work.

“When your plan members have ‘skin in the game,’ they have an incentive to consider the overall cost to the plan,” said Catherine Keane, deputy commissioner of administrative services in New Hampshire. She credits the incentives with leading to millions of dollars in savings each year.

Several states require insurers or medical providers to provide cost estimates upon patients’ requests, although studies have found that information can still be hard to access.

Now, private firms are marketing ways to make this information more available by incorporating it into incentive programs.

For example, Vitals, the New Hampshire-based company that runs the program Cook uses, and Healthcare Bluebook in Nashville offer employers — for a fee — comparative shopping gizmos that harness medical cost information from claims data. This information becomes the basis by which consumers shop around.

Crossing Network Lines

Maine’s law, adopted last year, requires insurers that sell coverage to small businesses to offer financial incentives — such as gift cards, discounts on deductibles or direct payments — to encourage patients, starting in 2019, to shop around.

A second and possibly more controversial provision also kicks in next year, requiring insurers, except HMOs, to allow patients to go out-of-network for care if they can find comparable services for less than the average price insurers pay in network.

Similar provisions are included in a West Virginia bill now under debate.

Touted by proponents as a way to promote health care choice, it nonetheless raises questions about how the out-of-network price would be calculated, what information would be publicly disclosed about how much insurers actually pay different hospitals, doctors or clinics for care and whether patients can find charges lower than in-network negotiated rates.

“Mathematically, that just doesn’t work” because out-of-network charges are likely to be far higher than negotiated in-network rates, said Joe Letnaunchyn, president and CEO of the West Virginia Hospital Association.

Not necessarily, counters the bill’s sponsor, Del. Eric Householder, who said he introduced the measure after speaking with the Foundation for Government Accountability. The Republican from the Martinsburg area said “the biggest thing lacking right now is health care choice because we’re limited to our in-network providers.”

Shopping for health care faces other challenges. For one thing, much of medical care is not “shoppable,” meaning it falls in the category of emergency services. But things such as blood tests, imaging exams, cancer screening tests and some drugs that are administered in doctor’s offices are fair game.

Less than half of the more than $500 billion spent on health care by people with job-based insurance falls into this category, according to a 2016 study by the Health Care Cost Institute, a nonprofit organization that analyzes payment data from four large national insurers. The report also noted there must be variation in price between providers in a region for these programs to make sense.

Increasingly, though, evidence is mounting that large price differences for medical care exist — even among rates negotiated by the same insurer.

The price differences are so substantial it’s actually scary,” said Heyward Donigan, CEO of Vitals.

At the request of Kaiser Health News, Healthcare Bluebook ran some sample numbers for a Northern Virginia ZIP code, finding the cost of a colonoscopy ranged from $670 to $6,240, while a knee arthroscopy ranged from $1,959 to $20,241.

Another challenge is the belief by some consumers that higher prices mean higher quality, which studies don’t bear out.

Even with incentives, the programs face what may be their biggest challenge: simply getting people to use a shopping tool.

Kentucky state spokeswoman Jenny Goins said only 52 percent of eligible employees looked at the shopping site last year — and, of those, slightly more than half chose a less expensive option.

“That’s not as high as we would like,” she said.

Still, state workers in Kentucky have pocketed more than $1.6 million in incentives — and the state said it has saved $11 million — since the program began in mid-2013.

Deductibles, the annual amounts consumers must pay before their insurance kicks in and are usually $1,000 or more, are more effective than smaller shopping incentives, say some policy experts.

In New Hampshire, it took a combination of the two.

The state rolled out the payments for shopping around — and a website to look for best prices — in 2010. But participation didn’t really start to take off until 2014, when state employees began facing an annual deductible, said Deputy Commissioner Keane.

Still, the biggest question is whether these programs ultimately cause providers to lower prices.

Anecdotally, administrators think so.

Kentucky officials report they already are witnessing a market response because providers want patients to have an incentive to choose them.

“We do know providers are calling and asking, ‘How do I get my name on that list’ [of cost-effective providers]?” said Kentucky spokeswoman Goins. “The only way they can do that is to negotiate.”

Readout of Secretary Azar’s Visit to Brigid’s Path

HHS Gov News - March 03, 2018

HHS Secretary Alex Azar traveled on Friday to Dayton, Ohio, to visit Brigid’s Path, a facility for mothers and infants struggling with opioid dependence, and hear from young people and others affected by the opioid crisis.

Secretary Azar visited with a mother in recovery and her infant, who was born with neonatal abstinence syndrome and is being cared for at Brigid’s Path. He then participated in a roundtable with young people who have been affected by the crisis, including a young woman who had lost both parents to addiction; a young woman who lost her brother to an overdose; and two high schoolers who designed an app to raise awareness about opioid addiction and treatment options.

The roundtable was led by Judge Anthony Capizzi, who runs a family drug court in Montgomery County, where Brigid’s Path is located, and included U.S. Representative Mike Turner, who represents Montgomery County; Jill Kingston, founder of Brigid’s Path; Cyndi Swafford, a foster mother who has adopted opioid-affected children; and Jewell Good, Director of Montgomery County Child Services. Participants individually highlighted the need for wraparound services and recovery supports for those struggling with opioid addiction, as well as challenges that the opioid crisis has presented for the foster care and child services systems.

Following the roundtable, Secretary Azar, Jill Kingston, and Cyndi Swafford held a press conference, where Secretary Azar emphasized President Trump’s personal commitment to the struggle against opioid addiction and noted HHS efforts to advance treatment of neonatal abstinence syndrome in particular.

The visits were a part of an ongoing effort by HHS to visit with communities on the frontlines of the opioid epidemic, and followed Thursday’s opioids summit at the White House.

Updates from the Department are also available at:

Secretary Azar - @SecAzar

HHS - @HHSgov

HHS Media - @HHSMedia

Congress Races The Clock In Quest To Bring Stability To Individual Insurance Market

Congress is running out of time if members want to come up with legislation to stabilize the individual insurance market.

While Republicans and Democrats still feud over the fate of the Affordable Care Act, a bipartisan group of senators and House members has been working since last summer on measures to keep prices from rising out of control and undermining the individual market where people who don’t get insurance through work or the government buy policies.

They hope to attach a package of fixes to what should be the year’s final temporary spending bill, due in late March.

The lawmakers are up against not just the legislative clock, but also the insurance companies’ timeline. Insurers have until summer to decide if they want to continue to sell policies in the ACA marketplaces, but many start making preliminary decisions as early as April.

In the absence of congressional action, insurers say premiums will go up in 2019 due to the uncertainty — raising costs for consumers and the government.

It is by no means clear whether any package could gain the votes needed in the House and Senate. Most Republicans are loathe to be seen “fixing” Obamacare, although opinion polls clearly show they will be blamed for problems with the law going forward.

The bipartisanship extends beyond Capitol Hill. Last week five governors (three Democrats, one Republican and one Independent) released a blueprint for a health system overhaul that includes several of the stabilization ideas under consideration in Congress.

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About 18 million people buy their own policies, both inside and outside the ACA insurance marketplaces.

Lawmakers are looking at two primary fixes, although they could be combined.

One, pushed by Sens. Susan Collins (R-Maine) and Bill Nelson (D-Fla.), is called “reinsurance.” It is a way to guarantee the insurance companies do not face large losses. The idea is that if insurers don’t have to worry about covering the expenses for their highest-cost patients, they can keep premiums lower for everyone.

The ACA actually had a temporary reinsurance program from 2014 to 2016. It was intended to help insurers get started in a market where sick people were able to buy their own insurance for the first time. Prior to the law, most insurers did not cover many people with preexisting health conditions. If they did, it was at an extremely high cost.

Since the federal program ended, several states, including Minnesota and Alaska, have adopted, with some success, their own reinsurance programs in an attempt to hold premiums down.

The other proposal, negotiated by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), would guarantee insurers federal reimbursement for so-called cost-sharing reduction subsidies. Those are discounts that the ACA requires insurers to provide to their lower-income enrollees to help reduce their deductibles and other out-of-pocket costs. President Donald Trump cut off federal reimbursement of those payments in October.

Senate Majority Leader Mitch McConnell (R-Ky.) pledged to Collins in exchange for her vote on the GOP tax plan in December that he would support bringing both bills to the floor for debate.

That has not happened, although in a statement, Collins said she is “continuing to have productive discussions” with Senate and House leaders about both bills.

Meanwhile, a lot has changed, including new questions about whether the fixes would work.

For starters, state insurance regulators managed to find a workaround for Trump’s sudden cancellation of the federal cost-sharing payments. Most states allowed insurers to offset the loss of these funds by increasing the premiums for the “silver” level plans that determine how much help enrollees get to pay those premiums. So the increases end up being paid by the federal government anyway, through higher premium subsidies. The result is that most people who get government help pay the same (or, in some cases, less), while insurers are effectively being paid back for the discounts, albeit through a different mechanism.

That means, however, if the cost-sharing reduction payments were reinstated for 2018, as the original legislation called for, insurers would have to give the excess money back to the government.

Analysts agree that would only add to the confusion.

Restoring the federal payments for this year, said Joseph Antos of the conservative American Enterprise Institute, “does not lower premiums this year, so it does absolutely no good to the average person.”

Some advocates have suggested that Congress should guarantee the payments for 2019 and 2020. But Antos said that “also makes no sense, because the insurers would then think ‘Are we going to go through this again?’”  They might raise premiums even more to make up for the uncertainty.

Antos  — and many other analysts — agree that restoring or creating a new reinsurance program would likely do more to control premium increases.

Reinsurance “will protect premiums for the people who are actually most subject to them,” said Sherry Glied, a former Obama administration health official now at New York University. She was referring to those in the individual market who do not get government help and have been footing large premium increases for the past several years. That’s because having protection against the largest bills would allow insurers to lower premiums across the board.

Then there are the political considerations.

Many Republicans in Congress have called the cost-sharing reduction payments in particular a “bailout” to the insurance industry, and are resistant to reinstate the payments.

Republicans seem more amenable to the idea of reinsurance, because they consider it a type of “high risk pool,” which they have been pushing for years. House Speaker Paul Ryan said at an event in Wisconsin in January that “I think there might be a bipartisan opportunity there to get risk pools, risk mechanisms.”

But Republicans have made clear they want something in return for what could be considered a “fix” to the health law they despise.

Health and Human Services Secretary Alex Azar was careful to say in a meeting with reporters last week that the Trump administration has no formal position yet on the stabilization efforts.  But, he said, “I think it would need to be part of an entire set of reforms there that we would want to see.” That would likely include more flexibility for states to opt out of some of the health law’s coverage requirements.

The delay has made Democrats more demanding, too. The repeal of the ACA’s penalties next year for people who don’t have insurance has changed the situation dramatically, said Sen. Murray.

“As I have made clear, the bipartisan bill I originally agreed on with Chairman Alexander will not make up for this latest round of Republican health care sabotage,” she said in a statement. “In fact, there are changes that now need to be made to our bill to ensure it meets its intended goals of keeping premiums down and stabilizing markets.”

But while Congress decides if it will take action, insurers are warning that doing nothing will lead to still higher premiums.

Premium rates for a “benchmark” silver plan could rise by 27 percent in 2019, the Blue Cross Blue Shield Association said earlier this month.

Congressional action on reinsurance and cost-sharing, the association predicted, would help push premium rates 17 percent below this year’s levels.

“Health plans are looking for certainty in the market,” said Justine Handelman, senior vice president in the association’s policy shop.

Ideally, Congress would include the funding in measures adopted in February or March, said Handelman, who spoke with reporters during a briefing at the association’s Washington, D.C., headquarters: “Most plans are filing premium rates by April.”

Kaiser Health News senior correspondent Julie Appleby contributed to this story.

As Surgery Centers Boom, Patients Are Paying With Their Lives

The surgery went fine. Her doctors left for the day. Four hours later, Paulina Tam started gasping for air.

Internal bleeding was cutting off her windpipe, a well-known complication of the spine surgery she had undergone.

But a Medicare inspection report describing the event says that nobody who remained on duty that evening at the Northern California surgery center knew what to do.

How a push to cut costs and boost profits at surgery centers led to a trail of death.

A team of journalists based in California, Indiana, New Jersey, Florida, Washington, D.C., and Virginia worked to tell this story in a partnership between Kaiser Health News and USA TODAY Network.

Christina Jewett is a senior correspondent for Kaiser Health News. Mark Alesia is an investigative reporter for the Indianapolis Star.

Reporters pored through thousands of pages of court records and crisscrossed the U.S. to talk to injured patients or families of the deceased.

For more than a year, using federal and state open-records laws, reporters gathered more than 12,000 inspection records and 1,500 complaint reports, as well as autopsies and EMS documents and medical records, together forming the foundation for this report.

In desperation, a nurse did something that would not happen in a hospital.

She dialed 911.

By the time an ambulance delivered Tam to the emergency room, the 58-year-old mother of three was lifeless, according to the report.

If Tam had been operated on at a hospital, a few simple steps could have saved her life.

But like hundreds of thousands of other patients each year, Tam went to one of the nation’s 5,600-plus surgery centers.

Such centers started nearly 50 years ago as low-cost alternatives for minor surgeries. They now outnumber hospitals as federal regulators have signed off on an ever-widening array of outpatient procedures in an effort to cut federal health care costs.

Thousands of times each year, these centers call 911 as patients experience complications ranging from minor to fatal. Yet no one knows how many people die as a result, because no national authority tracks the tragic outcomes. An investigation by Kaiser Health News and the USA TODAY Network has discovered that more than 260 patients have died since 2013 after in-and-out procedures at surgery centers across the country. Dozens — some as young as 2 — have perished after routine operations, such as colonoscopies and tonsillectomies.

Reporters examined autopsy records, legal filings and more than 12,000 state and Medicare inspection records, and interviewed dozens of doctors, health policy experts and patients throughout the industry, in the most extensive examination of these records to date.

The investigation revealed:

  • Surgery centers have steadily expanded their business by taking on increasingly risky surgeries. At least 14 patients have died after complex spinal surgeries like those that federal regulators at Medicare recently approved for surgery centers. Even as the risks of doing such surgeries off a hospital campus can be great, so is the reward. Doctors who own a share of the center can earn their own fee and a cut of the facility’s fee, a meaningful sum for operations that can cost $100,000 or more.
  • To protect patients, Medicare requires surgery centers to line up a local hospital to take their patients when emergencies arise. In rural areas, centers can be 15 or more miles away. Even when the hospital is close, 20 to 30 minutes can pass between a 911 call and arrival at an ER.
  • Some surgery centers are accused of overlooking high-risk health problems and treat patients who experts say should be operated on only in hospitals, if at all. At least 25 people with underlying medical conditions have left surgery centers and died within minutes or days. They include an Ohio woman with out-of-control blood pressure, a 49-year-old West Virginia man awaiting a heart transplant and several children with sleep apnea.
  • Some surgery centers risk patient lives by skimping on training or lifesaving equipment. Others have sent patients home before they were fully recovered. On their drives home, shocked family members in Arkansas, Oklahoma and Georgia discovered their loved ones were not asleep but on the verge of death. Surgery centers have been criticized in cases where staff didn’t have the tools to open a difficult airway or skills to save a patient from bleeding to death.

Most operations done in surgery centers go off without a hitch. And surgery carries risk, no matter where it’s done. Some centers have state-of-the-art equipment and highly trained staff that are better prepared to handle emergencies.

But Kaiser Health News and the USA TODAY Network found more than a dozen cases where the absence of trained staff or emergency equipment appears to have put patients in peril.

A Struggle To Save A Woman's Life

Rekhaben Shah trusted her care to a surgery center.

It may have cost her her life, her family’s lawsuit contends.

Explore the interactive here

And in cases similar to Tam’s, upper-spine surgery patients have been sent home too soon, with the risk of suffocation looming.

In 2008, a 35-year-old Oregon father of three struggled for air, pounding the car roof in frustration while his wife sped him to a hospital. A Dallas man collapsed in his father’s arms waiting for an ambulance in 2011. Another Oregon man began to suffocate in his living room the night of his upper-spine surgery in 2014. A San Diego man gasped “like a fish,” his wife recalled, as they waited for an ambulance on April 28, 2016.

None of them survived.

Spinal surgery patient McArthur Roberson, 60, lost more than a quart of blood during the operation and struggled to breathe after surgery, his family claimed in a lawsuit. He died on the way home.

If he “had been observed in a hospital overnight,” said Dr. Daniel Silcox, an Atlanta spine surgeon and expert for the family in their lawsuit, “his death would not have occurred.”

The surgery center denied wrongdoing in the case, which reached a confidential settlement in 2017.

Many in the health care field — from doctors to private insurance companies to Medicare — have dismissed the mounting deaths as medical anomalies beyond the control of physicians.

USA TODAY Network and KHN reporters contacted 24 doctors and surgery center administrators about patient deaths and none would answer questions about what went wrong, citing patient privacy laws, or referring reporters to attorneys. Responding to lawsuits around the nation, surgery centers have argued that fatal complications were among the known outcomes of such surgeries. Two centers blamed patients for negligence in their own demise.

KHN On CBS This Morning

CBS This Morning interviewed KHN’s Christina Jewett about her reporting for this investigation.

Watch It Here

Bill Prentice, chief executive of the Ambulatory Surgery Center Association, declined to speak about individual cases but said he has seen no data proving surgery centers are less safe than hospitals.

“There is nothing distinct or different about the surgery center model that makes the provision of health care any more dangerous than anywhere else,” Prentice said. “The human body is a mysterious thing, and a patient that has met every possible protocol can walk in that day and still have something unimaginable happen to them that has nothing to do with the care that’s being provided.”

However, Dr. Kenneth Rothfield, board member of the Physician-Patient Alliance for Health & Safety, said many surgery centers and physicians push the envelope on how much can be done in outpatient centers.

“It’s important to realize that surgery centers are not hospitals,” he said. “They have different resources, different equipment.”

At a hospital, doctors and nurses … know how they are going to respond. These guys at the surgery centers are walking on a tightrope with no safety net.

Attorney Glenn Ellis

The explosive growth of surgery centers — which receive $4.1 billion a year from Medicare — has taken place under circumstances some medical experts consider unseemly.

Federal law allows surgery center doctors — unlike others — to steer patients to facilities they own, rather than the full-service hospital down the street. In some cases, doing so could increase the risk to a patient, but double a physician’s profits.

Prentice said physician ownership of surgery centers is a good thing.

“The physicians who practice there are responsible for everything that happens in that surgery center from the moment the patient walks out of their car in the parking lot to the moment they leave,” he said.

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But several studies have shown that surgery center doctors who are owners perform operations more frequently. And in lawsuits across the country, surgery center doctors have been accused of taking risks with patients.

Even some who’ve made their living in the surgery center industry have expressed concerns. Dr. Larry Teuber, a South Dakota neurosurgeon who worked as an executive in the surgery center industry for 22 years, said he has watched surgery center owners take on increasingly complex — and lucrative — orthopedic and spinal surgeries, undercutting a nearby hospital’s profits for their own gain.

“When you’re making money doing [complex surgeries] you get on a slippery ethical slope,” Teuber said. “The money overshadows everything.”

“I cry every night. I still miss him,” says Carmen Carrasquillo, Pedro Maldonado’s widow. Maldonado, 59, went to Ambulatory Care Center in New Jersey to have his upper digestive tract scoped. He was discovered unresponsive 10 minutes after the seven-minute procedure, according to his widow’s lawsuit. (Amy Newman/The Record)

The History

The first surgery center in the U.S. opened in Phoenix in 1970, a place “squeezed between neighborhood shops and a Baptist church,” where, for $90, a child could receive an incision to relieve pressure on the inner ear, The Arizona Republic reported at the time.

The pioneering doctors, John Ford and Wallace Reed, didn’t see why patients needed to be hospitalized for such minor surgeries.

Taking the procedures out of hospitals reduced the cost for patients and insurers because surgery centers don’t require the same level of staffing or lifesaving equipment.

(Story continues below.)

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Medicare helped drive the expansion of surgery centers when it began paying for procedures in 1982.

Then in 1993, Congress encouraged doctors to open surgery centers by exempting them from the second Stark Law, which prevents doctors from steering patients to other businesses they own.

Doctors-turned-entrepreneurs drove early growth, urging their patients to give the centers a chance. Seeing lucrative elective surgeries moving away, hospitals increasingly bought centers of their own. Last year, insurance giant UnitedHealth Group spent $2.3 billion buying a national surgery center chain.

The centers have been popular with patients, who enjoy the convenience and personalized care. Doctors say they like the ease of planning operations without unexpected trauma surgeries upending the schedule. And surgery centers have thrived even as hospitals have battled to contain the spread of infections.

Today, there are 5,616 Medicare-certified centers. The expansion has come despite lingering safety concerns. In 2007, Medicare noted that surgery centers “have neither patient safety standards consistent with those in place for hospitals, nor are they required to have the trained staff and equipment needed to provide the breadth of intensity of care. …” Some procedures are “unsafe” to be handled at surgery centers, the report concluded.

Medicare advised the centers to transfer patients to hospitals when emergencies arise. Only a third of surgery centers participate in a voluntary effort to report how often that happens. They sent at least 7,000 patients to the hospital in the year that ended in September 2017, a KHN analysis of surgery center industry data shows. Not all survive the trip.

In the 21st century in the USA, a doctor doing a surgery on a patient has to call 911? Give me a break. … It’s just absolutely ignorant.

Robin Long

They include James Long, 56, who had no pulse when an ambulance came to the Colorado surgery center where he’d undergone more than five hours of lower-spine surgery in 2014, according to the center’s medical records provided to the family’s attorney.

The state reviewed the case and cited no deficiencies. Jen Kenitzer, the Minimally Invasive Spine Institute administrator, said the center has “extensive procedures in place to respond quickly and appropriately” in emergencies.

Yet Long’s loved ones remain troubled by the case.

“In the 21st century in the USA, a doctor doing a surgery on a patient has to call 911?” said Robin Long, his ex-wife, who did not sue the center. “Give me a break. … It’s just absolutely ignorant.”

Rekhaben Shah, 67, died following a colonoscopy at Oak Tree Surgery Center in Edison, N.J. Shah was the glue that kept her family together. “We lost everything,” daughter Neha Shah says. (Amy Newman/The Record)

Preparation Under Par

Patients enter hospitals with heart attacks, gunshot wounds and traumatic injuries. There, doctors and nurses become skilled at saving lives in emergencies.

Doctors in surgery centers may excel at the procedures they perform most often. But the centers aren’t always prepared and sometimes struggle in a crisis, according to a  review of Medicare records and more than 70 lawsuits.

Health inspectors working on behalf of Medicare have discovered 230 lapses in rescue equipment or training regulations at surgery centers since 2015.

A center in California had empty oxygen tanks. One operating on children in Arkansas didn’t have a pediatric tracheotomy set to restore breathing; another lacked pediatric defibrillator pads to shock hearts back into rhythm.

In an ongoing lawsuit against her and the center, anesthesiologist Dr. Yoori Yim testified that she came up empty-handed on Dec. 23, 2015, when grappling to find the right-sized airway tube to save a patient who had stopped breathing.

Rekhaben Shah, 67, had come to Oak Tree Surgery Center in Edison, N.J., for a simple colonoscopy.

Yim tried a variety of methods to help Shah breathe, with limited success. From the moment Shah stopped breathing on the operating table, 33 minutes passed before a paramedic effectively inserted a breathing tube, according to medical and EMS records.

A photograph of Rekhaben Shah holds a special place on the altar of Kaushal Shah, Rekhaben’s son. (Amy Newman/The Record)

Paramedics responding to the center’s 911 call had to use a video GlideScope to see inside the patient’s throat, equipment the surgery center didn’t have, court testimony says.

By then it was too late. Shah was removed from life support at a nearby hospital on Christmas Day.

Neither Yim nor the center returned calls for comment. In court records, an expert for the surgery center said Shah’s airway was obstructed and it was cleared around the time the paramedics arrived. He said the GlideScope is not required in New Jersey, nor would it likely have made a difference. An expert for Yim, however, said her actions were appropriate and if a GlideScope had been at the center, “we would probably not be discussing this case at all.”

When emergency crews arrive, surgery centers are not always prepared to receive them.

In Yim’s case, paramedics testified that she refused to move away from Shah and allow them to attempt lifesaving measures.

In Florida, paramedics who rushed to a surgery center after its usual operating hours hit a locked door while a patient inside gasped for breath. The 55-year-old remains in a vegetative state.

In 2016, paramedics arrived at West Lakes Surgery Center in Iowa as staff tried to revive 12-year-old Reuben Van Veldhuizen after he experienced complications during a tonsillectomy, according to a Medicare inspection report.

One paramedic told state inspectors she had to ask who was in charge of the resuscitation efforts. No one replied, the inspection report says.

The boy made it to the hospital 37 minutes after the surgery center staff called 911. There, he was pronounced dead.

The family filed suit, alleging that the center and anesthesiologist erred in giving the boy an anesthetic that carries a warning about cardiac arrest risk in young boys.

At their home in Oskaloosa, Iowa, Scott and Sandy Van Veldhuizen sit on a bench given to them by families of children who played sports with their son Reuben. (Michael Zamora/The Des Moines Register)

A football and a pinwheel are among the decorations on Reuben's grave at Evergreen Cemetery in Leighton, Iowa. (Michael Zamora/The Des Moines Register)

In court records responding to the lawsuit, the surgery center and anesthesiologist said Reuben’s death was a result of “pre-existing conditions, acts of others, or conditions over which (Defendants) had no control or responsibility.”

Yet lawyers who sue the centers and scrutinize their internal records say they often see deadly delays in care.

Pedro Maldonado, 59, went to Ambulatory Care Center in New Jersey to have his upper digestive tract scoped. He was discovered unresponsive 10 minutes after the seven-minute procedure, according to his widow’s lawsuit.

It took surgery center staff 25 more minutes to start CPR, according to a lawsuit that Philadelphia attorney Glenn Ellis filed on behalf of Maldonado’s widow. Twenty-seven more minutes passed before Maldonado was wheeled into an ER, the widow’s ongoing suit alleges. Maldonado never regained consciousness.

Reached by phone, a center administrator declined to comment. In a legal filing, the center denied claims of wrongdoing.

“At a hospital, doctors and nurses … know how they are going to respond,” Ellis said. “These guys at the surgery centers are walking on a tightrope with no safety net.”

Pedro Maldonado, 59, of Vineland, N.J., went to Ambulatory Care Center on March 26, 2015, for an examination of his upper digestive system. According to his widow’s lawsuit against the center, he was unresponsive 10 minutes after the procedure and transferred to a hospital, where he remained in a coma and died on April 3. The suit alleges he was not an appropriate candidate for a procedure at the center. The center denied the claims in court records, arguing that Maldonado’s injuries were “caused by pre-existing conditions over which this defendant had no control.” (Amy Newman/The Record)

Conveyor Belt Of Care

While the thrum of a hospital continues through the night, some surgery center doctors keep banker’s hours. That means patients whose surgeries end later in the day are sometimes left in the care of one or two nurses for up to 23-hour stays. Some patients have been sent home to grapple with complications on their own.

Sondra Wallace went to the Surgery Center of Oklahoma in early 2017 for a sinus procedure.

After the procedure, doctors saw her blood-oxygen level sinking. They realized she had had a reaction to the anesthesia and at 2 p.m. gave her a drug to reverse the effects, an ongoing lawsuit filed by her husband says.

Then, an hour later, they sent her home with her husband, Larry, the lawsuit says.

It was 3 p.m. on the Friday before Presidents Day weekend.

“I just think they wanted to start their three-day weekend,” said daughter Casey Podoll.

Larry Wallace alleges in the suit that the center gave him no hint that Sondra had a reaction to the anesthesia.

Sondra Wallace, 58, a junior high school English teacher from Altus, Okla., died Feb. 17, 2017. Wallace (left), pictured with her daughter, Casey Podoll, had difficulty breathing before the Surgery Center of Oklahoma discharged her after a sinus surgery. (Courtesy of Casey Podoll)

So, Wallace thought nothing of her napping in the back seat as he drove for more than two hours through Oklahoma pastures on his way home. When he arrived, he discovered his wife cold in the back seat. She was pronounced dead at Jackson County Memorial Hospital at 6:30 p.m. that day.

“They didn’t give any indication … that there were any red flags whatsoever,” Podoll said.

Craig Buchan, attorney for the Surgery Center of Oklahoma, said Wallace met discharge criteria and her cause of death has not been determined. He said the center did not close any earlier “than often occurs after the last patient is discharged.”

Cecilia Aldridge said she also felt as if the staff at a surgery center was rushing her out the door, after her 2-year-old daughter’s tonsil surgery in Arkansas in 2015.

A lawsuit filed by the parents said the surgery center “discharged Abbygail too early because a snow storm was moving into the area.”

Abbygail turned blue in the car on the way home. Her mother said she raced into an emergency room, shouting for help, her toddler in her arms.

“She never woke up,” Aldridge said tearfully in an interview.

Abbygail’s parents now question whether the surgery center ever should have been willing to treat their daughter.

Risky Patients

Because surgery centers have less safety equipment and staffing than hospitals, industry leaders stress the importance of selecting patients healthy enough to fare well. Their predictions, though, are not always correct.

Abbygail, who loved her hand-me-down blanket and the film “Frozen,” had sleep apnea, an irregular heartbeat and was very heavy for her age, according to the lawsuit.

Sleep apnea increases the risk of serious complications in surgery and the night after, medical research shows. Given her condition, Abbygail “should have been admitted [to a hospital] and monitored post-procedure,” said Dr. Charles Cote, a retired Harvard pediatric anesthesiology professor who was not involved in the family’s lawsuit.

Abbygail Chance, 2, suffered from an irregular heartbeat and sleep apnea, conditions that made her a high-risk patient for a tonsillectomy, according to her mother’s lawsuit. Still, she was referred to Executive Park Surgery Center in Fort Smith, Ark., which discharged her before she woke up fully from her procedure, her mother alleged in the lawsuit. She turned blue on her way home, and her mother took her to an emergency room. She died three days later on Feb. 19, 2015. (Courtesy of the Chance family)

The lawsuit says Abbygail’s risk factors “were documented and known by the Defendants,” including the doctor. It said the toddler should have been operated on “in an inpatient setting under hospital care and monitored overnight.”

Dr. Michael Marsh performed Abbygail’s tonsillectomy at Executive Park Surgery Center in Fort Smith, Ark.

The surgery center’s lawyer declined to comment. The doctor’s lawyer did not return email and voice messages. In court documents responding to the lawsuit, Marsh and the center denied wrongdoing.

In the court filing, Marsh said the toddler’s injuries were “the natural progression” of her illness. Executive Park Surgery Center said in a court filing that “no action on their part … was a proximate cause of any damages or injury.” The case was settled.

In at least 25 cases, surgery centers opened their doors to ailing and fragile patients who died after simple procedures, such as tonsillectomies, retinal repairs or colonoscopies, KHN and USA TODAY Network found.

Medicare asks surgery centers to assess each patient’s risk, but inspectors flagged 122 surgery centers in 2015 and 2016 alone for lapses in risk assessments. Some centers failed to gauge risk at all. Others overlooked their own policies.

Doctors can use an anesthesia risk assessment to screen out fragile patients — healthy patients get a score of 1, and a score of 5 means a person is nearly dead.

A few states, including Pennsylvania and Rhode Island, bar certain surgery centers from operating on patients with an anesthesia risk score of 4. But most states don’t go that far. They leave such decisions up to doctors.

And some of those decisions have been cited in tragic outcomes. Sabino Sifuentes, 74, had survived triple-bypass surgery. But on March 23, 2015, nine minutes after the start of anesthesia for an eye procedure, he became unresponsive, never to be revived, according to a Medicare inspection report. A nurse anesthetist who reviewed the case at Eye-Q Vision Care’s surgery center in Fresno, Calif., told state health inspectors that Sifuentes should have been given a risk score of 4 and his care was “completely mismanaged,” the inspection report says.

In response to the family’s lawsuit, the surgery center said Sifuentes’ injury was caused by his own negligence and others’.

Five other patients with the same risk score died after routine procedures at surgery centers across the U.S.

Two months before her upper-spine surgery in 2014, Paulina Tam (left) took a cruise to Mexico with her husband, Timothy, and mother-in-law, Irene Tam. After finishing careers as a nurse and an educator, she had planned to travel the world with her husband of 32 years. (Courtesy of the Tam family)

A Widening Niche

Such tragedies rarely find their way into the discussion when Medicare decides whether to approve new procedures at surgery centers.

Take spinal surgery.

Until 2015, Medicare wouldn’t pay for it at surgery centers. Then, the industry’s trade association urged the agency to make the change, and encouraged a letter-writing campaign from surgery centers across the nation.

Letter writers included Dr. Alan Villavicencio, a Colorado surgeon who said he’d been doing such surgeries for 12 years and found that his patients “appreciate the convenience and cost savings.” He did not mention that James Long, 56, had died three weeks earlier at a Lafayette, Colo., surgery center where he is an owner, a review of Colorado health department and medical board records shows.

United Surgical Partners International, a surgery center chain, also weighed in urging even more procedures to be approved, not mentioning a patient death hours after a spine surgery at one of its affiliate centers several months before, according to court records and securities filings. The chain said in a statement that it stands behind its comments in support of the proposal.

Such letters carry weight with Medicare, which approves procedures to be done in surgery centers based on the invasiveness and complexity of the surgery and on input from stakeholders.

Robert Beatty-Walters, a Portland, Ore., attorney who has represented the families of three people who died after surgery center spine procedures, said Medicare’s decision-making process is not even-handed.

“The stakeholders — they call them — during these regulatory proceedings are the profit-makers, not the people who are being provided the service,” he said. “The spine centers just want to have more people come. They make more money. I hate to be that cynical about it, but that’s just what I’ve seen.”

Medicare approved 10 spine-surgery codes to be billed at surgery centers starting in 2015 and added more spinal procedures for 2017. A Medicare spokesman denied a request for a telephone interview. In an email, a spokeswoman said Medicare opened the spine proposal to the public and received no comments suggesting the procedures would pose a threat to Medicare patients. She said the final decision about where a patient will have surgery is up to a doctor and patient.

Bill Prentice, chief executive of the Ambulatory Surgery Center Association, declined to speak about individual cases but said he has seen no data proving surgery centers are less safe than hospitals. (Courtesy of Ambulatory Surgery Center Association)

By 2017, at least 14 patients had died soon after spine operations at surgery centers, according to the KHN/USA TODAY Network investigation.

The 14 spine-surgery deaths have gleaned little recognition in the industry or beyond. Only one made headlines in local newspapers. The rest are documented in places like the Macon, Ga., courthouse or in obscure regulatory reports. And there may be far more because some states, including New York, Illinois and Florida, disclose no details about surgery center deaths.

Paulina Tam’s death at Fremont Surgery Center was a tragic example. At 58, the mother of three had finished careers as a nurse and an educator. Next, she planned to travel the world with her husband of 32 years.

“She was the driving force of the family, the spirit I guess,” said her son, Eric Tam, a doctor in New York City, said. “We didn’t expect the worst to happen.”

The care she received at the center is documented in court records, EMS reports and a Medicare inspection report that concluded that the center “failed to provide a safe environment for surgery.”

Tam’s doctor scheduled her for a procedure to replace two discs in her upper spine on April 7, 2014. Pain from a car crash had bothered her for years. Any such surgery — entering the front of the neck to address pain in the spine — comes with a risk of suffocation, according to the Medicare inspection report.

Yet, with her surgeon and anesthesiologist already gone, the only doctor on-site was a digestive health specialist, the inspection report shows. About four hours after her procedure, Tam told a nurse that her surgical collar felt too tight. Then, that she couldn’t breathe.

Dr. Nancy Epstein, chief of neurosurgical and spine care at New York University Winthrop Hospital, said doing delicate work near the spinal cord, windpipe and esophagus in a same-day surgery center is “pretty revolting.” (Courtesy of NYU Winthrop Hospital)

The nurse called a “code blue” just after 6:30 p.m., records say.

Medical experts say the first step in helping such patients is removing the surgical staples so the pooled blood can disperse, allowing the patient to breathe.

In Tam’s case, staff repeatedly tried and failed to insert a breathing tube through her mouth and into her airway, the inspection report shows. A last-ditch remedy would have been to punch a hole through the front of her throat to restore breathing, but the gastroenterologist later told an inspector that he was “not prepared” to do so.

The inability to perform the suffocation-rescue maneuver, the inspection report says, amounted to the center’s “failure to ensure patient safety.”

From the time a nurse called 911, it took 24 minutes to get Tam to the nearest hospital, EMS records show. She arrived without a pulse and remained on life support overnight, as her children raced to her bedside to say goodbye.

The center did not return calls and denied wrongdoing in the court case. Tam’s surgeon declined to discuss the case but filed pleadings in court saying Tam’s “carelessness and negligence” caused her death. It’s unclear what the defense meant by negligence. The case reached a confidential settlement.

After Tam’s death, the center told Medicare inspectors that a qualified doctor would stay on-site after all upper-spine cases.

Dr. Nancy Epstein, chief of neurosurgical and spine care at New York University Winthrop Hospital, said surgery centers doing delicate work near the spinal cord, windpipe and esophagus in a same-day procedure is “pretty revolting.” But she said the centers are making so much money — “reeling it in hand over fist” that the potential dangers are being ignored.

“Medically, it should not be tolerated,” she said, “but it is.”

Lindy Washburn of The (Bergen County, N.J.) Record and contributed to this report.

Podcast: KHN’s ‘What The Health?’ The ACA Heads Back To Court. Again.

Twenty state attorneys general filed another lawsuit challenging the constitutionality of the Affordable Care Act this week. They charge that when Congress added a provision to the December tax bill that eliminates the tax penalty for not having health insurance, the entire health law was invalidated. Attorneys general were also part of the unsuccessful effort to strike down the law in 2012.

Meanwhile, a key Democratic think tank, the Center for American Progress, has released a health overhaul proposal that tries to bridge the divide among Democrats between the Affordable Care Act and a “Medicare for All” single-payer proposal. Will Democrats get on the same page on health care? Or will they end up as split as Republicans?

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

Among the takeaways from this week’s podcast:

  • If the lawsuit brought by 20 states this week against the Affordable Care Act were to get to the Supreme Court, it would likely be several years down the road, and it’s not clear that the court would still look like it does now.
  • The divide among the states over health policy is growing again and perhaps taking the country back to pre-ACA days.
  • Some Democrats are beginning to wonder if the ACA can work long-term and is resistant to Republican efforts to sabotage it. But they have not yet settled on a plan for a future health care policy that will avoid an intra-party civil war. Email Sign-Up

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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: California Healthline’s “Health Care Revamp At The L.A. County Jails,” by Anna Gorman.

Joanne Kenen: The Atlantic’s “What Are Active-Shooter Drills Doing To Kids?” by James Hamblin.

Margot Sanger-Katz: BuzzFeed News’ “The Inside Story Of How An Ivy League Food Scientist Turned Shoddy Data Into Viral Studies,” by Stephanie M. Lee.

Sarah Kliff: BuzzFeed News’ “Passengers Who Call Uber Instead Of An Ambulance Put Drivers At Risk,” by Caroline O’Donovan.

To hear all our podcasts, click here.

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

Tens of Thousands of Medicaid Recipients Skip Paying New Premiums

When Arkansas lawmakers debated in 2016 whether to renew the state’s Medicaid expansion, many Republican lawmakers were swayed only if some of the 300,000 adults who gained coverage would have to start paying premiums.

This “skin-in-the-game” provision — endorsed by conservatives in Washington and in many statehouses — is designed to make Medicaid recipients value their government health insurance more and lead healthier lives.

It’s “to encourage more personal responsibility,” Arkansas Gov. Asa Hutchinson told reporters in 2016. “We want to incentivize better, healthy living.”

Yet few enrollees are paying the $13 monthly premiums, which apply only to Medicaid recipients whose earnings surpass the poverty level. In 2017, just 20 percent of the 63,000 Arkansas enrollees paid. Medicaid enrollees in Arkansas don’t lose coverage for lack of payment.

Arkansas is not the only state where Medicaid recipients who gained coverage under the Affordable Care Act disregard the new premiums. Tens of thousands of Medicaid enrollees in four other states that added premiums during the past four years— Indiana, Michigan, Iowa and Montana — have also opted not to pay, according to state records.

Under the ACA, states received millions of federal dollars to cover everyone with incomes under 138 percent of the federal poverty level (about $16,700 for an individual today). Previously, Medicaid mainly covered only low-income children, disabled adults and parents.

Premiums, which are routine obligations in private health insurance and Medicare, were not a part of Medicaid until that expansion in 2014. In these five states, conservative lawmakers were hesitant to expand the federal-state program unless they secured fees from nondisabled adults.

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Kentucky has received approval to add premiums in 2018.

“We believe the premiums are important to prepare these beneficiaries for what would be required of them if they move up the economic ladder and get coverage through an employer or the federal marketplace,” said Arkansas Medicaid spokeswoman Amy Webb. “It’s a small amount, especially considering the benefit they are receiving. Under an employer or at the marketplace, they would lose their coverage for failure to pay.”

Advocates for Medicaid say it is not surprising that significant numbers of Medicaid enrollees fall behind on their payments.

“Premiums are a financial barrier for low-income people, even if you are working,” said Rich Huddleston, executive director of Arkansas Advocates for Children and Families. Even the state’s $13 monthly premium is burdensome. “Families have to make tough choices every day about whether they buy food, pay the electric bill, their rent, or pay premiums.”

Still, the experience in the five states shows converting conservatives’ “skin-in-the-game” mantra into practice has many administrative challenges.

Michigan requires Medicaid enrollees with incomes over the poverty level to pay 2 percent of their income in monthly premiums, though the amount could be decreased if they engage in so-called healthy behaviors, such as getting a flu shot or trying to quit smoking.

A survey of enrollees last year in Michigan found nearly 88 percent said the amount they had to pay was “fair,” and 72 percent said they agreed that they would “rather take some responsibility to pay something for their health care than not pay anything.”

But from January through August last year, fewer than half of Michigan Medicaid recipients who owed a premium — about 77,000 of 175,000 — paid it.

And premiums were not the only new obligation that many of these enrollees are failing to meet. The state’s Medicaid expansion also required them to fill out a health risk assessment form with their doctor and promise to improve their health. In return, members could lower their premiums or gain a $50 gift card.

Of the 900,104 beneficiaries who have been enrolled in Medicaid for at least six months, 19 percent have completed this chore, according to state records.

For most enrollees this is voluntary. But enrollees with incomes above 100 percent of the poverty level could lose Medicaid coverage if they don’t fill out the form to attest they will try to improve their health. Michigan particularly is getting tough: Last month it mailed letters to 13,550 beneficiaries informing them that they failed to meet this requirement and there will be consequences. They will be moved off Medicaid and will have to choose a private plan on the Obamacare insurance marketplace or will be automatically enrolled in one in June.

Dr. Renuka Tipirneni, a researcher with the University of Michigan Institute for Healthcare Policy & Innovation, said it’s unclear if these enrollees will be worse off in the private plans since many will get subsidies to help cover their premium costs. But they may face a larger cost-sharing portion or have to change doctors.

She was surprised by how few people paid their premiums, given the survey findings. “Many people want to pay and want to say they are contributing, but what is the reality of their circumstances?” she asked. The lack of a penalty for not paying, she added, could be a factor.

Michigan officials last year also sent 68,000 Medicaid enrollees who owed premiums a notice that they would garnish any state income tax refunds or lottery winnings. That led about 7,000 recipients to pay. The state last year collected premium money from 19,400 through their tax refunds and another 59 from their lottery winnings, according to a state report.

Arkansas officials also plan to intercept state tax refunds to recoup unpaid premiums, but not until 2019.

Other states have mixed records on collecting Medicaid premiums, according to state reports:

  • In Indiana, about 25,000 Medicaid recipients were kicked off the program from the fall of 2015 to October 2017 for failure to pay — or more than 1 in 3 who owed premiums. The payments range from $1 to $27. Indiana is the only state to lock enrollees out of Medicaid for six months for failure to pay the premium for two months in a row — and about 10,000 recipients fell into that category in 2016. Kentucky recently received federal permission to add a similar lockout provision this year.
  • Iowa disenrolled more than 14,000 Medicaid enrollees from January 2016 to September 2017 for failure to pay a $10 monthly Medicaid premium, though they could re-enroll at any time. More than 40,000 Medicaid enrollees with incomes over 50 percent of the poverty level were subject to a premium in September 2017 and about three-quarters of them had not paid nor completed a health risk assessment form that would have waived the fee.
  • Montana’s Medicaid program dropped 2,884 adults with incomes over the poverty level from coverage in 2017 for failing to pay a premium. The state charges 2 percent of the enrollee’s monthly income. Montana allows those dropped to re-enroll at any time without paying.

ACA’s Popularity Grows, Even As GOP Lauds Change To Requirement To Have Coverage

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Despite President Donald Trump’s boasting that “we have essentially repealed Obamacare,” a new poll shows the Affordable Care Act is more popular than ever. In fact, many people don’t know Congress repealed the ACA’s penalty for not having insurance.

The poll from the Kaiser Family Foundation found 54 percent of Americans had a favorable view of the 2010 health law that expanded health coverage to millions. That was up four points from January, and it’s highest point since the monthly survey began in 2010. (KHN is an editorially independent program of the foundation.)

The survey found 40 percent of respondents were unaware that Congress in January repealed the individual mandate penalty as part of the federal tax overhaul. It takes effect in 2019. About one in five people were aware of the repeal but believed incorrectly that it had taken effect this year.

Only 13 percent of respondents were aware that both the requirement to buy insurance was repealed and that it remains in effect for 2018.

The public’s lack of knowledge about the individual mandate likely reflects the fact that few people are affected by it. The majority of Americans have health coverage or are exempt from the mandate because their income is too low, said Ashley Kirzinger, a Kaiser polling expert.

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“Confusion over the status of the ACA’s individual mandate stems from a lot of different things, but health care policy is complicated and the public generally doesn’t pay attention to details of health policy until it directly impacts them,” she said.

The poll showed the public is also split on what’s motivating states to add a work requirement to Medicaid.

About 41 percent of those surveyed said states were looking to lower government spending while 33 percent believed states were enacting the new requirements to “lift people out of poverty.”

The Trump administration in February approved requests from Indiana and Kentucky to require some non-disabled adults to work as a condition of having Medicaid coverage. At least eight more states are waiting for a green light.

About two-thirds of Americans said states should not put time limits on how long people can be enrolled in Medicaid as long as they qualify, the poll found. Support for lifetime caps was stronger among Republicans (51 percent) than Democrats (16 percent).

A Kaiser poll from June 2017 found that 70 percent of Americans support states imposing work requirements on non-disabled Medicaid adults.

The latest Kaiser poll of 1,193 adults was conducted Feb. 15 – 20 and has a margin of error of +/- 3 percentage points.

Cartoon Mascot Masks Nasty Health Care Feud

Kaiser Health News:Insurance - February 28, 2018
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SACRAMENTO, Calif. – In the age of Black Panther, Thor and Captain America, California’s health insurance plans bring you … A giant, androgynous red heart.

The health insurers debuted their bubbly superhero Tuesday in front of California’s stately Capitol building. The heart, who wore black booties and white, Michael Jackson-esque gloves, had no name. No matter. S/he bopped. S/he waved at school children. S/he flashed the thumbs-up. S/he made the Capitol feel a bit like Disneyland.

Passers-by couldn’t help but giggle at the insurance industry’s mute mascot. And they certainly seemed to have no clue that the anthropomorphized heart was merely the latest PR stunt in an ongoing feud between two health system titans: health insurers and drugmakers.

“It’s very cute. I don’t know exactly what’s going on. … What is happening here exactly?” asked Christine Danho, 25, an administrative assistant who stopped to snap a picture.

In recent years, the two deep-pocketed industries have pointed fingers at each other over the rising cost of prescription drugs, each side accusing the other of ripping off patients who need life-saving medicines.

The California Association of Health Plans, which bankrolled the event, introduced its heart “hero” and “high-priced drug nemesis” with fighting words for drugmakers.

“Pharma has made a practice of swarming the State Capitol with their minions working to keep drug prices sky high,” the lobbying group’s press release proclaimed.

True, drugmaker Pfizer shelled out $732,454 in 2017 to lobby California policymakers on health care, and the California Life Sciences Association, comprised largely of pharmaceutical companies, spent $522,323, according to the California Secretary of State.

But among the top five spenders in health care lobbying last year? The health plan association itself, which doled out about $1.2 million.

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Drugmakers called the health plans out on their own tactics.

“Like a broken record, the insurers continue to blame everyone else for high health care costs when their policies are making lifesaving medicines increasingly more expensive for patients,” said Priscilla VanderVeer, a vice president with Pharmaceutical Researchers and Manufacturers of America (PhRMA).

VanderVeer’s colleague, Nicole Kasabian Evans, was a spokeswoman for the health plans not so long ago, but now she helps run PhRMA’s public relations strategy in California. And she had no qualms about criticizing her former employer’s media strategy.

“Honestly, are they generating any real news out of this event?” Kasabian Evans asked. It’s nothing more than “someone in a costume hand[ing] out tchotchkes,” she declared.

The health plan group said it timed the event to coincide with American Heart Month, and highlighted three heart disease medications on a poster board whose prices have spiked in recent years.

During the first hour of the event, the heart looked lonely, hoping for a little attention. But as the sun warmed the air and an unrelated rally brought people to the Capitol steps, onlookers cozied up to the health plans’ cherry red mascot for photo-ops or grabbed free heart-shaped stress balls.

Eric Wang ran into the heart-shaped mascot while visiting California’s Capitol. He said high drug prices are “something we need to figure out.” (Pauline Bartolone/KHN)

Lila Cervantes posed for a photo with the heart mascot at the Capitol in Sacramento. When it comes to insurers and pharmaceutical companies feuding over health costs, she said, “there’s probably a lot of right and a lot of wrong on both sides.” (Pauline Bartolone/KHN)

Eric Wang, visiting from Los Angeles for a meeting with legislators, said opposing groups need to “work together to figure out a way to make our health care system affordable.”

But it’s unlikely the feud between drugmakers and health insurers will dissipate anytime soon. The federal government is only taking small steps to control drug prices, which means the debate over drug prices will continue to flare in state houses around the country.

“That’s where the fight has shifted,” said Steve Pearson, an expert on medical costs with  the Institute for Clinical and Economic Review. “There’s going to be a lot more money from both industries.”

Lila Cervantes, who was at the Capitol  advocating for higher education funding, posed for a picture with the heart, but she admitted later that she didn’t know much about the war between health insurers and drugmakers.

“There’s probably a lot of right and a lot of wrong on both sides,” Cervantes said. “We gotta’ sometimes take the politics out of it and … do what’s best for the people.”

Never Too Late To Operate? Surgery Near End Of Life Is Common, Costly

Kaiser Health News:Marketplace - February 28, 2018

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

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In this series, “Treatment Overkill,” Kaiser Health News investigates the causes and consequences of medical overtreatment, both for patients and the health care system.

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Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

Stanich, at age 87, had signed a “do not resuscitate” directive, ordering doctors to not revive her should her heart stop, but doctors gave her a defibrillator anyway. (Photo courtesy of Susan Giaquinto)

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Redberg, who at the University of California-San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people over 65 — involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

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Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a 2011 study in The Lancet.

More than 12 percent of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Dr. Eleni Linos has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When Less Is More

Maxine Stanich celebrated her 90th birthday with friends and family in 2010 more than two years after Dr. Rita Redberg had deactivated a defibrillator and discharged her with home hospice service. Stanich, at age 87, had signed a “do not resuscitate” directive, ordering doctors to not revive her should her heart stop, but doctors gave her a defibrillator anyway. (Photo courtesy of Susan Giaquinto)

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors — ever.”

According to the University of Michigan’s National Poll on Healthy Aging, published Wednesday, more than half of adults ages 50 to 80 said doctors often recommend unnecessary tests, medications or procedures. Yet half of those who’d been told they needed an X-ray or other test — but weren’t sure they needed it — went on to have the procedure anyway.

Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Redberg said doctors recently treated her mother for melanoma — the most serious type of skin cancer. After the cancer was removed from her leg, Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.

Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in three to five years. I doubt I’ll be here.”

Dr. Rita Redberg, director of women's cardiovascular services at the University of California-San Francisco Division of Cardiology, tends to her mother, Mae Redberg, in Mae's apartment in Manhattan. (Yana Paskova for Kaiser Health News)

Mae Redberg rests in her apartment in Manhattan. (Photo by Yana Paskova for Kaiser Health News)

Finding Solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

We have a culture that believes in very aggressive care. We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.

Dr. Rita Redberg, director of women’s cardiovascular services at the University of California-San Francisco Division of Cardiology

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.

Schwarze said, “If someone says they can’t tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test —not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another two years and three months, dying at home just after her 90th birthday in 2010.

Ding Dong! The Obamacare Tax Penalty Is(n’t) Dead

Kaiser Health News:HealthReform - February 28, 2018
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Rick, Patrick and Michael recently commented on Covered California’s Facebook page, urging others to ditch health insurance because:

“No more fines or penalties!!! Trump took care of that!! Saved me 700 bucks this year!!!”

“Trump removed the penalty for not having insurance.”

“I’m pretty sure Trump abolished the illegal penalty.”

They’re right — and wrong.

On Dec. 22, President Donald Trump did indeed sign a sweeping tax bill that repeals the Affordable Care Act’s tax penalty by zeroing out the fines.

Opponents of the tax penalty rejoiced, and many, like Rick, Patrick and Michael, assumed it took effect immediately.

Not so. The penalty won’t go away until 2019, and that means you still will owe Uncle Sam if you didn’t have health insurance — or an exemption from the mandate — in 2017. The same holds true for this year.

“There’s just mass confusion out there,” reports Steven Stasoiski, a tax accountant and insurance agent in Seal Beach, Calif.

Some of his clients decided to drop their health insurance this year without consulting him first, thinking they wouldn’t have to pay a penalty next year. “When they file next season … they’re going to be surprised,” he says.

One client, a family of four in Orange County, Calif., decided to go without insurance this year, and will owe about $15,200 next year because of it — roughly the same cost as a bronze-level health insurance plan that would protect them from catastrophic health insurance bills, Stasoiski says.

Under Obamacare, most people must have health insurance or pay a tax penalty. For 2017, the penalty is $695 per adult (up to a family maximum of $2,085), or 2.5 percent of household income, whichever is greater. The penalty for children is half the adult rate ($347.50).

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You can avoid the penalty if you qualify for one of the health law’s several exemptions. For instance, you may be exempt if you were uninsured for less than three consecutive months of the previous year, if your income is low enough that you’re not required to file a federal tax return or if you belong to a health care sharing ministry.

But if you don’t fit into one of the exemption categories and you were uninsured in 2017, or will be in 2018, you’re probably out of luck, says Alison Flores, a principal tax research analyst at the Tax Institute, the research wing of H&R Block, based in Kansas City, Mo.

“If you have a penalty and you’re due a refund, that penalty reduces your refund,” she says. If you owe a penalty but aren’t owed a refund, and then you decide not to pay the penalty, the Internal Revenue Service may take it out of a future refund, she says.

The IRS says that this year, for the first time, it will reject electronically filed tax returns that don’t address Obamacare tax penalty questions. If you file a paper return and don’t address those questions, your return could be held up and a refund delayed, adds Michael Eisenberg, a certified public accountant with Squar Milner in Encino, Calif.

“They are saying, ‘This is the law, and you have to comply with the law while it’s the law,’” he says. “They are going to enforce the penalties.”

A quick note on the Obamacare-related 1095 tax forms, which will help you prove to the IRS that you had health insurance last year.

Some of you who got insurance last year from employers, on the open market or through government programs such as Medicare or Medi-Cal, may still be waiting for your 1095-B and 1095-C forms. The IRS extended the deadline to March 2 for those forms to be delivered to taxpayers.

But you don’t need them in hand to complete your taxes, which are due on April 17 this year. “You should have other substantiation that you had health insurance,” such as W-2 forms, Medicare cards or explanations of benefits from your insurance company, Flores says.

On the other hand, you must have a correct 1095-A to complete your taxes. If you’re a Covered California enrollee — or buy your insurance through any state or federally run health insurance exchange — you should have received your 1095-A forms by Jan. 31.

If you’re still waiting for yours and you’re a resident of the Golden State, log on to your Covered California account and check your inbox. You should find a copy of your 1095-A there, says agency spokesman James Scullary.

If that still doesn’t help, or if your 1095-A form is incorrect, fill out a dispute form, which you can find under the “Members” tab of the Covered California website at

As always, my most important piece of advice when it comes to Obamacare and taxes is to seek the aid of a tax professional.

If you can’t afford it, multiple programs offer free tax help, including the Volunteer Income Tax Assistance (VITA) program, run by the IRS ( and the AARP Foundation Tax-Aide program (

Following The Fire: Montana Scientists Seize Chance To Scrutinize Smoke Exposure

Kaiser Health News:States - February 27, 2018

Jean Loesch and her family live in Seeley Lake, Mont., which saw the longest and most intense smoke from Montana’s wildfires last summer. Loesch has 10 children, adopted or in her foster care, and they are learning what it’s like to have lingering respiratory problems.

The smoke from the fires was so thick outside, Loesch said, the family couldn’t see the trees across the street, so they stayed inside. It was still really hard to breathe.

“These guys were miserable,” she said. “I think each one of them ended up having to go to the doctor.” Everyone needed inhalers.

The family is typically pretty healthy, but not this year. Loesch got pneumonia and the kids had bloody noses. And now, even with the smoke long gone, the children continue to have trouble with their lungs.

“They’ll wake up hacking,” Loesch said. “They’ve all been sick. I’ve had to take them in for upper-respiratory infections.”

Seeley Lake is in Missoula County, which had several large wildfires that lasted from the end of July through mid-September — weeks longer than usual — and led to the worst season on record for wildfire smoke.

Researchers don’t know a lot about what that kind of extended smoke exposure does to the average person. Most previous studies have focused on indoor wood-burning stoves, urban air pollution and the effects on firefighters.

But the way the smoke piled up and stuck around a whole town this summer was new. Seeley Lake is in a valley. Every day, as the sun set and evening temperatures dropped, cold air traveled down from the mountain and trapped the smoke from the nearby Rice Ridge fire on the valley floor. This phenomenon is called a temperature inversion.

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As the wildfires burned on, and nights grew longer and colder, the inversions grew stronger. Over time, the accumulating smoke made it harder for the sun to break through and warm the ground. That intensified the effect.

The experience was really tough on residents, and it handed scientists an unusual opportunity to learn much more about the health effects of breathing smoke.

Rachel Hinnenkamp, an epidemiologist with the state health department, has been tracking how many people went to emergency rooms complaining of respiratory-related symptoms during the 2017 wildfire season.

For people who live in Missoula and Powell counties, that number more than doubled in 2017 compared with the year before — from 163 in 2016 to 378 in 2017.

“That’s a statistically significant increase,” Hinnenkamp said.

Researchers can’t say whether all those ER visits were directly related to the Rice Ridge Fire, but Hinnenkamp said most visits happened about a month after the air in the region first became heavy with smoke.

The more a person is exposed to polluted air, the worse it is for their health.

“The smoke that we saw this year in Seeley Lake was like nothing we’d ever seen,” said Sarah Coefield, the air quality specialist for the Missoula City-County Health Department. It’s her job to quantify just how bad the air was.

Missoula County Health Department air quality specialist Sarah Coefield tracks smoke moving through western Montana all day. (Nora Saks/Montana Public Radio)

Pollution from wildfire smoke is typically measured as the concentration of fine particulate matter, she explains. The EPA says a daily average concentration of more than 35 micrograms per cubic meter of polluted air is unhealthy.

The county’s air quality monitors max out at 1,000 micrograms. In Seeley Lake last summer, Coefield said, the monitors maxed out 20 times. “So there were 20 hours that we don’t know what the actual number was over a thousand,” she said.

Most public health guidelines aim to protect groups that are the most vulnerable to wildfire smoke in the short term — children, pregnant women, older people and those with chronic heart and lung diseases.

But the off-the-charts summer in Seeley Lake is bad news even for people who aren’t at high risk, said Chris Migliaccio, an immunologist and assistant professor in the University of Montana’s School of Pharmacy.

“Usually these exposures are maybe a couple weeks at high levels,” Migliaccio said. “This was over a month at really unprecedented levels. We have no idea what the long-term effects are.”

He’s part of a team of UM researchers trying to fill in those gaps in knowledge. Working with the county health department, they’ve started tracking a group of Seeley Lake residents, documenting changes in their physical and mental health over time.

One thing Migliaccio predicts the scientists might see is an uptick in respiratory infections — because those fine particulates in wildfire smoke can damage and even kill cells in the lungs that get rid of the harmful substances people inhale. And that leads to more people having a compromised immune system.

“I can’t tell you, ‘You will be susceptible. You will get the flu.’ But because of these exposures, you’re probably at an increased risk,” he said. “We haven’t done these studies. And that’s something we want to follow with this Seeley Lake cohort. Let’s follow them. Let’s see how they do this winter.”

Right now, the biggest hurdle to getting that information is funding. The health scientists are applying for grants to keep their research going. They hope to track people for years, to find out whether the health effects of extended smoke exposure dissipate — or linger.

This story is part of a partnership that includes Montana Public Radio, NPR and Kaiser Health News.

At Some California Hospitals, Fewer Than Half Of Workers Get The Flu Shot

Kaiser Health News:Marketplace - February 27, 2018
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How well are doctors, nurses and other workers at your local hospital vaccinated against the flu?

That depends on the hospital.

According to data from the California Department of Public Health, flu vaccination rates among health care staffers at the state’s acute care hospitals range from a low of 37 percent to 100 percent.

Overall, flu vaccination rates among hospital workers climbed significantly in the past several years — from an average of 63 percent during the 2010-11 influenza season to 83 percent during the 2016-17 season, according to the California Department of Public Health. Vaccination rates for the current season won’t be determined until later this year.
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But that general increase masks some big variations. Monrovia Memorial Hospital in Los Angeles, Los Robles Hospital and Medical Center, East Campus and Thousand Oaks Surgical Center in Ventura each reported that fewer than 40 percent of their health care workers received the flu vaccine last year. Representatives from those hospitals did not return repeated calls for comment.

On the other end of the spectrum, Rady Children’s Hospital in San Diego reported that every single person working there got the vaccine.

Look Up Your Hospital

See flu vaccination rates among health care personnel at general acute care hospitals in California.

California’s flu vaccination policies for hospital workers, and those of many other states, are far from uniform or ironclad. In various states, health care workers have legally challenged hospital requirements for vaccination on religious and secular grounds. And some unions in California and elsewhere oppose a legal mandate, partly for civil rights reasons.

Public health officials themselves have different takes on the legal requirements for hospital workers. The Centers for Disease Control and Prevention lists California and Massachusetts among the handful of states where the flu vaccination is mandated for health care workers. But the states’ laws allow health care workers to opt out by signing a form declining the vaccine. For that reason, officials from those two states said they do not actually consider the vaccine mandatory.

Colorado law requires hospital health care workers to provide proof of immunization or a doctor’s note providing for a medical exemption, and requires that non-immunized workers wear masks. Hospitals that achieve a 90 percent or higher flu vaccination rate are exempt from these rules, however.

In California, state law requires that hospitals offer the vaccine free of charge. Many hospitals offer vaccines to personnel in the cafeteria, and during day and night shifts. “The key to getting more people vaccinated is to make it more easily accessible for people,” said Lynn Janssen, chief of the California Department of Public Health’s associated infections branch.

She also said many California counties and hospitals have required health care workers to either get the flu vaccine or wear a mask, which can help prevent spreading illness to others.

Partly as a result, nearly a third of the state’s hospitals now have flu vaccination rates above 90 percent.

Vaccination rates vary significantly among different categories of hospital workers, however. Hospital employees had an average vaccination rate of 87 percent statewide in 2016-17, while licensed independent practitioners — including some physicians, advance practice nurses and physician assistants who do not receive paychecks from the hospital — had a rate of just 67 percent.
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The CDC recommends that health workers get one dose of influenza vaccine annually, and cites data showing the vaccine in recent years has been to up 60 percent effective — though it was far less so this year. Dr. Bill Schaffner, an infectious diseases professor at Vanderbilt University School of Medicine in Nashville, Tenn., says there are three principal reasons to get vaccinated: to prevent workers from infecting patients, to keep them healthy in order to care for patients and to spare them a bout with the flu.

A 2017 Canadian study, however, suggests that the benefits of health care worker vaccinations have been overstated.

In any case, just because experts say health care personnel should get the vaccine doesn’t mean they will choose to do so.

“In the studies, and also in our experience, it turns out — to everyone’s great surprise — that health care workers are human beings,” Schaffner said. “Some are too busy, some don’t think the flu vaccine is worth it, some don’t like shots. Some are not convinced they can’t get flu from the flu vaccine.” (Experts say they can’t.)

Because of this, Schaffner said, it’s up to hospital leadership to push staffers to get vaccinated. At Vanderbilt University Medical Center, vaccination rates increased from 70 percent to 90 percent once leaders there effectively made the flu vaccine “mandatory,” he said, requiring noncompliant hospital personnel to present vaccine exemption requests to a hospital committee.

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Health officials also encourage patients to ask whether their caregivers are vaccinated.

Jan Emerson-Shea, spokeswoman for the California Hospital Association, said her organization would like the flu vaccine to be mandatory for all health care personnel. Independent physicians have proven an especially challenging group to motivate, she said, since hospitals hold little sway over them.

“I, for the life of me, can’t imagine why a physician wouldn’t want to be vaccinated,” she said. “But they make that choice.”

Yet the California Nurses Association strongly opposes making flu vaccines mandatory, said Gerard Brogan, a registered nurse and spokesman for the union.

He said the union does recommend that providers get the vaccine, but it objects to making vaccination a condition of employment. He said some employees have religious issues or safety concerns about the vaccines and “we think that should be respected as a civil rights issue,” he said.

He also called rules requiring unvaccinated providers to wear a face mask “punitive.”

“It’s almost like the scarlet letter to shame you,” he said.

He said the masks can frighten patients — a contention made by a New York union as well. In any case, he said, wearing the masks is not especially effective in stopping the spread of flu (although some researchers say otherwise). Instead, he said, employees should be encouraged to wash hands and to stay home when they are sick.

Too often, he said, nurses are asked to come in to work when they are ill. He said he was not able to find any nurses willing to discuss their decision not to get the flu shot.

Refusing To Work For Medicaid May Not Translate To Subsidies For ACA Plan

Kaiser Health News:HealthReform - February 27, 2018

Work requirements for Medicaid coverage. Insurance plans that don’t meet health law standards. Changes to Medicare drug lists. As the ground continues to shift on health care coverage, I answer readers’ queries this week about these three different types of plans.

Q: I’m in a state that is looking into work requirements for Medicaid. At sign-up time, can I simply tell the exchange that I intend to be ineligible for Medicaid by refusing to work and get the premium tax credit to buy a private plan on the insurance marketplace?

Federal health law regulations don’t clearly address the situation you describe, but the short answer is probably not, said policy analysts.

In general, people who are eligible for Medicaid — the federal-state health program for low-income people — or employer coverage can’t qualify for federal tax credits that help pay for premiums on plans sold on the health insurance exchanges.

This year, Kentucky and Indiana became the first states to receive federal approval to require some Medicaid recipients to put in 80 hours each month at a paid job, school or volunteer work, among other activities, to receive benefits. Nearly a dozen other states have made similar requests.

If you refuse to work, does that make you ineligible for Medicaid? The rules aren’t clear, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

States might argue that someone in your situation is eligible for Medicaid, you just have to fulfill the work requirements, said Timothy Jost, an emeritus professor of law at Washington and Lee University in Virginia who is an expert on the health law.

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There are other actions people could take — or fail to take — where this issue might come up. “You could argue that someone is not eligible because they haven’t completed the Medicaid application or provided the required documentation,” Jost said. “There are any number of requirements, but I can’t imagine someone saying they didn’t do those things and so they’re not eligible for Medicaid.”

Whatever the rules, it’s unlikely that many people will be in a position to consider taking this stance. To qualify for premium tax credits, your income must be between 100 and 400 percent of the federal poverty level (about $12,000 to $48,500 for one person in 2018). But you’d also have to be eligible for Medicaid, generally with an income limit of 138 percent of poverty (about $16,750) in states that expanded coverage to adults. In addition, the Medicaid work requirements in your state would have to apply to you.

Q: I lost my job last year and my employer coverage ended in January. I bought a new plan through the marketplace that went into effect last month. I just received policy information, and it states that because the plan does not cover major medical services, I may have to pay additional taxes to the government. I was told that the plan didn’t cover major medical but wasn’t told about any taxes. Will I be fined next year?

It sounds like you bought a plan that doesn’t comply with the Affordable Care Act’s requirements, and if that’s the case you may indeed have to pay a penalty for not having comprehensive coverage when you file your taxes next year.

The tax law repealed the individual penalty for not having health insurance, but that provision doesn’t take effect until 2019. So, for 2018, you may be charged the greater of $695 or 2.5 percent of your household income.

The federal- and state-run marketplaces established by the ACA sell only comprehensive plans that cover 10 essential health benefits, including “major medical” services like hospitalization and prescription drugs.

But some insurance broker websites call themselves marketplaces too, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. These companies may sell other insurance products like short-term or accident coverage alongside comprehensive plans that comply with the law.

Ever since the health law was passed, “There have been opportunistic companies trying to take advantage of consumer confusion to make money,” Corlette said.

If you aren’t happy with your plan, you may still be able to switch. Losing your employer coverage qualifies you for a 60-day special enrollment period to pick a new plan. Since it appears you’re still in that window, you may be able to choose a comprehensive plan.

To ensure you’re using your state’s official marketplace, go to and click on “see if I can change.” That will take you to your state marketplace, even if you live in one of the dozen or so states that run their own exchanges.

Q: I picked a Medicare Part D drug plan that covered all the drugs I take. But as soon as I got my first Novolin R prescription filled, they notified me that they don’t cover it anymore. Can they just switch it like that?

Medicare drug plans can change their list of covered drugs, called formularies. If they’re doing so at the start of the new calendar year, as appears to have happened in your case, the plan may notify you of the change when you fill the prescription for the first time in the new year.  At that time, the plan would typically give you a 30-day “transition” refill so you can switch to another drug that’s on the formulary, according to Juliette Cubanski, associate director of the Program On Medicare Policy at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

If you and your doctor think it’s important that you have Novolin R and not another drug that is similar, you can ask your plan to make an exception to allow you to continue to take the medication.

To go that route, you would need to get your doctor to “make the case for why that formulary drug is not the right drug” for you, said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

HHS announces the availability of $260 million to fund the Title X family planning program

HHS Gov News - February 24, 2018

The U.S. Department of Health and Human Services (HHS) announced the availability of $260 million in a new funding opportunity for the Title X family planning program to help improve and expand quality care. The funding opportunity will assist in the establishment and/or operation of voluntary family planning projects that will offer a broad range of family planning methods and services, including information, education and counseling related to family planning, preconception care, contraception, natural family planning and infertility services.

Recognizing the announcement has been delayed, HHS is committed to ensuring that services continue unabated. Current grantees received notification today inviting them to submit a request for grant extension, so there is no gap in services.

“We encourage all qualified organizations to apply, especially those proposing innovative strategies that would increase the number of clients served and the quality of services provided,” said Assistant Secretary for Health Brett P. Giroir, M.D. “We are committed to ensuring that we provide access to quality family planning services to the women and men who depend on this vital public health program.”  

In particular, this year’s funding opportunity is seeking applicants that offer a broad range of family planning and related health services tailored to the individual needs of the client and that promote optimal health outcomes. As emphasized in the statutory language governing the program, “none of the funds appropriated under this title shall be used in programs where abortion is a method of family planning.”

The funding opportunity further requires that all Title X grantees develop monitoring and reporting policies, consistent with state law, in order to expand assurances that those who enter a Title X service site and who may be victims of child abuse, child molestation, sexual abuse, rape, incest, intimate partner violence or human trafficking, are afforded the help and legal protection to which they are entitled.  For the first time, the funding opportunity requires that all staff are annually trained to respond to such needs.

Further, building on several years of HHS work to streamline the process of applying for Title X grants and ease burdens on applicants, interested organizations can now submit one application that covers multiple geographic service areas, rather than having to submit multiple applications for different service areas.  This year will involve just one annual funding competition, rather than multiple competitions.

This funding announcement covers all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the six Pacific jurisdictions. The awards are expected to be issued in September of this year.

The HHS Office of Population Affairs oversees the Title X family planning program, which currently funds 84 grantees that support nearly 4,000 family planning sites nationwide and provides services to more than 4 million women and men each year. Title X service sites serve a population of mostly female, low-income and young clients. Title X grants are awarded through a competitive process to public and private nonprofit entities. Services funded with Title X grants are provided by state and local public health departments and/or community health, family planning and other private nonprofit agencies.

Applications for the Title X family planning services grants are due at 6:00 PM Eastern Time on Thursday, May 24, 2018. Technical assistance will be provided to those who are interested in applying for grants.

For more information about the Title X program services funding opportunity announcement visit:

To learn more about the Title X program, visit:

To find a family planning clinic in your area, visit:

Evaluations Of Medicaid Experiments By States, CMS Are Weak, GAO Says

Kaiser Health News:States - February 23, 2018
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With federal spending on Medicaid experiments soaring in recent years, a congressional watchdog said state and federal governments fail to adequately evaluate if the efforts improve care and save money.

A study by the Government Accountability Office released Thursday found some states don’t complete evaluation reports for up to seven years after an experiment begins and often fail to answer vital questions to determine effectiveness. The GAO also slammed the federal Centers for Medicare & Medicaid Services for failing to make results from Medicaid evaluation reports public in a timely manner.

“CMS is missing an opportunity to inform federal and state policy discussions,” the GAO report said.

Joan Alker, executive director of the Georgetown University Center for Children and Families, called the report’s findings “troubling but not surprising.”

“It has been clear for some time that evaluations of Section 1115 waivers are not adequate,” she said. “There is some good work going on in this space at the state level, for example in Michigan and Iowa, but as the report makes clear state’s evaluations are often incomplete and not rigorous enough.”

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These experiments are often called “demonstration projects” or “1115 demonstration waivers” — based on the section of the law that allows the federal government to authorize them. They allow federal officials to approve states’ requests to test new approaches to providing coverage. They are used for a wide variety of purposes, including efforts to extend Medicaid to people or services not generally covered or to change payment systems to improve care.

Medicaid demonstration programs often run for a decade or more. Several states that expanded Medicaid eligibility under the Affordable Care Act did so through a demonstration program, including Indiana, Iowa, Arkansas and New Hampshire.

Nearly three-quarters of states have Medicaid demonstration programs, such as those testing providing services through private managed-care firms and requiring enrollees to pay monthly premiums. About a third of the federal government’s $300 billion a year in Medicaid spending goes to these test programs, the GAO said.

The study, requested by top GOP lawmakers including Sen. Orrin Hatch (R-Utah), reviewed demonstration programs in eight states — Arizona, Arkansas, California, Indiana, Kansas, Maryland, Massachusetts and New York.

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In five of these states, money from their Medicaid demonstration program makes up more than half their total federal Medicaid budgets. Nearly all of Arizona’s funding — 99.7 percent — is through a demonstration program.

The use of Medicaid demonstration programs accelerated during the 1990s. But in recent years the experiments have often reflected the political leanings of state officials or the party controlling the White House. Under a demonstration program, the Trump administration this year approved requests from Indiana and Kentucky to enact work requirements for some adult Medicaid enrollees.

The GAO report noted that states often do not complete their evaluation reports until after the federal government renews their demonstration program. For example, Indiana’s Medicaid expansion demonstration program, which charges premiums and locks some enrollees out of coverage for lack of payment, was renewed in February even though a final evaluation report is not yet complete.

GAO said Indiana’s evaluation of its Medicaid expansion won’t look at the effect of the state’s provision that locks out enrollees for six months if they fail to pay premiums.

“GAO found that selected states’ evaluations of these demonstrations often had significant limitations that affected their usefulness in informing policy decisions,” the report said.

Alker said that “more sunshine and data are needed” to assess waivers, “especially as they are clearly the vehicle the Trump administration is now using to pursue its ideological objectives for Medicaid.”

(Story continues below.)

While states typically contract with independent groups to evaluate Medicaid demonstration programs, the federal government sometimes does its own review.

But the GAO investigators found Indiana’s Medicaid agency wasn’t willing to work with the federal contractor out of privacy concerns. That halted efforts for a federal review.

Joel Cantor, director of the Center for State Health Policy at Rutgers University in New Brunswick, N.J., said the demonstration programs have often shifted from their intended purpose because they are designed by lawmakers pushing an agenda rather than as a scientific experiment to find better ways to deliver care.

“Demonstration programs have been used since the 1990s to advance policy agenda for whoever holds power in Washington and not designed to test an innovative idea,” he said.

The evaluations often take several years to complete, he said, because of the difficulty of getting patient data from states. His center has done evaluations for New Jersey’s Medicaid program.

GAO recommended that CMS require states to submit a final evaluation report after the end of the waiver period, regardless of whether the experiment is being renewed, and that the federal agency publicly release findings from federal evaluations in a timely manner. Federal officials said they agreed with the recommendations.

Matt Salo, executive director of the National Association of Medicaid Directors, said the report highlighted a need to modernize the law dealing with Medicaid so that successful experiments are quickly incorporated into the overall program.

“The underlying problem is that the Medicaid statute has fundamentally failed to keep up with the changing reality of health care in the 21st century,” he said. “There’s no way to update the rules to make these changes” a permanent part of the program.