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Assisted Living Kicks Out The Frail ’Cause ‘We Can’t Take Care Of You Any Longer’

Kaiser Health News:Marketplace - September 06, 2018
Navigating Aging

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

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The phone call came as a shock. Your aunt can’t transfer into memory care; we have to discharge her from this facility, a nurse told Jeff Regan. You have 30 days to move her out.

The next day, a legal notice was delivered. Marilou Jones, 94, who has dementia, was being evicted from Atria at Foster Square, an assisted living facility in Foster City, Calif. The reason: “You are non-weight bearing and require the assistance of two staff members for all transfers,” the notice said.

Regan was taken aback: After consulting with Atria staff about his aunt’s deteriorating health, he and Jones’ husband, William, 88, had arranged for her to be transferred to a dementia care unit at the facility. A room had been chosen, and furniture bought. But now, Atria was claiming it couldn’t meet her needs after all.

This action isn’t unusual. Across the country, assisted living facilities are evicting residents who have grown older and frail, essentially saying that “we can’t take care of you any longer.”

Evictions top the list of grievances about assisted living received by long-term care ombudsmen across the U.S. In 2016, the most recent year for which data are available, 2,867 complaints of this kind were recorded — a number that experts believe is almost surely an undercount.

Often, there’s little that residents or their families can do about evictions. Assisted living is governed by states, and regulations tend to be loosely drafted, allowing facilities considerable flexibility in determining whom they admit as residents, the care they’re prepared to give and when an eviction is warranted, said Eric Carlson, directing attorney at Justice in Aging, a legal advocacy organization.

While state regulations vary, evictions are usually allowed when a resident fails to pay facility charges, doesn’t follow a facility’s rules or becomes a danger to self or others; when a facility converts to another use or closes; and when management decides a resident’s needs exceed its ability to provide care — a catchall category that allows for considerable discretion.

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Unlike nursing homes, assisted living facilities generally don’t have to document their efforts to provide care or demonstrate why they can’t provide an adequate level of assistance. In most states, there isn’t a clear path to appeal facilities’ decisions or a requirement that a safe discharge to another setting be arranged — rights that nursing home residents have under federal legislation.

It’s very frustrating “because state regulations don’t provide sufficient protections,” said Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care.

Sometimes, evictions are prompted by a change in ownership or management that prompts a re-evaluation of an assisted living center’s policies. In other cases, evictions target residents and family members who complain about not getting adequate assistance.

Amy Delaney, a Chicago elder law attorney, tells of a client in her late 80s with dementia admitted to an upscale assisted living community. When her two daughters noted deficiencies in their mother’s care, managers required them to hire a full-time private caregiver for $10,000 a month, on top of the facility’s fee of $8,000 a month.

One day, a daughter went to visit, saw staff napping and took pictures on her cellphone, which she sent to the facility administrator with a note expressing concern. “A few days later, she got a call telling her that her mom had become combative and needed to be taken to the hospital for psychiatric treatment,” Delaney said.

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The daughters went to the facility and took their mother to one of their homes. “They found another assisted living facility for her a few weeks later,” Delaney said, noting that she found no record of behavioral issues in the woman’s record when the daughters contemplated suing.

“We see this regularly: An assisted living [facility] will say your mom isn’t looking well, we’re sending her to the hospital to be re-evaluated, and then, before she can return, they’ll say we’ve determined her care level exceeds what we can provide and we’re terminating her agreement,” said Crystal West Edwards, an elder law attorney in New Jersey.

Assisted living operators argue that transfers are often necessary when residents’ health deteriorates and that good communication about changing needs is essential.

“We believe providers should be upfront with consumers about their care abilities [and limitations] and encourage a robust, ongoing conversation with residents and loved ones about their needs — especially as they evolve,” wrote Rachel Reeves, a spokeswoman for the National Center for Assisted Living, in an email.

Atria Senior Living, which operates assisted living communities in more than 225 locations in 27 states and seven Canadian provinces, declined to comment on the circumstances of Jones’ eviction. In an email, a spokesman explained that “we conduct regular assessments, in accordance with state law, to ensure residents are receiving the appropriate level of care and to determine whether we can continue to meet their needs.”

In Jones’ case, Regan said his uncle William was told by a marketing manager that his wife could “age in place” at Atria at Foster Square since a wide range of services — assisted living, memory care and hospice care — were available there.

The couple was willing to pay a considerable amount for their move to the upscale community in July 2017: an $8,000 one-time entrance fee, $10,000 monthly for a two-bedroom apartment, $500 a month to have medications administered, and extra charges for help with transfers, being escorted to meals and more frequent bathing, among other kinds of assistance, that sometimes totaled $2,300 a month.

But Jones was becoming weaker. “My biggest mistake was not getting her into memory care sooner, where she would have received more attention,” Regan said.

In the weeks before Atria’s eviction decision, Jones had fallen several times, been hospitalized for an irregular heartbeat, and started on a new blood thinner medication.

After Atria’s action, “I lost all confidence in them,” Regan said. Within two weeks, he found another community, Sunrise of Belmont, for his aunt, who moved into memory care, and his uncle, who moved into his own apartment — at a combined cost of nearly $20,000 a month.

While his aunt is now receiving good care, his uncle was shaken by the move and is depressed and having difficulty adjusting, Regan said.

Elder law attorneys and long-term care ombudsmen recommend several strategies. Before moving into an assisted living community, “ask careful questions about what the facility will and won’t do,” said Carlson of Justice in Aging. What will happen if Mom falls or her dementia continues to get worse? What if her incontinence worsens or she needs someone to help her take medication?

Review the facility’s admissions agreement carefully, ideally with the help of an elder law attorney or experienced geriatric care manager. Carefully check the section on involuntary transfers and ask about staffing levels. Have facility managers put any promises they’ve made to you in writing.

If a resident receives an eviction notice — typically 30 days in advance — don’t move out right away. If the facility says it can no longer manage someone’s care needs, bring in a physician to evaluate whether assisted living is still a viable option, said Anthony Chicotel, staff attorney at California Advocates for Nursing Home Reform. Try negotiating with the facility if you can suggest a solution to the concern managers are raising.

File a complaint with your local long-term care ombudsman’s office, which will trigger an investigation and usually slow down the process, said Joseph Rodrigues, the state long-term care ombudsman in California. Ombudsmen represent residents’ interests in disputes and can help advocate on your behalf, he noted.

Consider bringing the matter to landlord-tenant court or civil court in your area — a legal option available when other avenues for appeal are not available. Or ask for a “reasonable accommodation of the resident’s needs under the federal Fair Housing Act.”

Staying in place and waiting for the facility to initiate legal action will buy you time, which should be your goal. Don’t rush to move into another facility without checking and making sure it will be a better fit, now and in the future, Chicotel said.

Also consider whether you want to stay at the current facility. “Do you really want to be someplace that doesn’t want you?” said Jason Frank, a Maryland elder law attorney. For most clients, he said, the answer is no.

Finally, consider adjusting your expectations. “Success for some families is ‘I bought three years of good care for Mom in assisted living’ and now she’s moved along in her illness and it’s time for skilled nursing care,” said Judith Grimaldi, an elder law attorney in New York City.

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

States Looking To Tax Opioids Pin Hopes On November Elections

Kaiser Health News:States - September 06, 2018

After almost slapping a tax on makers of opioid pills earlier this year, Minnesota lawmakers are set to try again when they meet in January.

The drug manufacturers that helped create the opioid addiction crisis should help fix it, said state Sen. Chris Eaton, whose daughter died of an overdose.

“I’m definitely going to pursue it” in the next legislative session, said Eaton, a Democrat. “Whether it has a chance or not kind of depends on the election.”

Lawmakers in at least 10 other states intend to consider opioid taxes in upcoming legislative sessions. Many pin their hopes on the November midterm elections.

If Democrats retake governorships and legislatures this fall, lawmakers and policy analysts predict other states would be more likely to follow New York, whose groundbreaking opioid tax to raise $100 million a year took effect July 1.

November results “are absolutely going to drive some of this,” said Tara Ryan, vice president of state government affairs for the Association for Accessible Medicines, which represents makers of generic medications and opposes opioid taxes. “If the Democrats take the elections, like some people say they will, it could definitely change the votes.”

California, Delaware, Iowa, Kentucky, Maine, Massachusetts, Montana, New Jersey, Tennessee and Vermont are all eyeing renewed attempts to pass opioid taxes, officials in those states say. The proceeds would mostly pay for addiction treatment and prevention.

“We’ll be back come January,” said Tim Ashe, president pro tempore of the Vermont Senate, which overwhelmingly passed a tax measure this year that faded in the House and was opposed by the state’s Republican governor, Phil Scott, who is up for re-election.

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New York’s law taxes manufacturers and distributors according to an opioid medication’s strength and will direct proceeds toward addiction treatment, prevention and education. The tax is expected to amount to roughly a dime per lower-strength opioid pill and higher for more powerful ones.

“I think it’s a good idea,” said Andrew Kolodny, an opioid-policy researcher at Brandeis University and frequent critic of the pharma industry. “The human and economic costs of these meds are enormous.”

Adding to the momentum is frequent support from Republicans, who are normally reluctant to tax businesses.

“I’m probably the No. 2 or 3 most conservative individual in the legislature, and I’m standing up there proposing a[n opioid] sales tax,” said Montana Republican Sen. Roger Webb.

But an industry backlash is growing. An association representing pharmaceutical distributors sued in July to block the New York law, arguing that those businesses were unfairly targeted.

Pharma’s main trade group has also fought hard against such measures, arguing they drive up the cost of medicine and unfairly penalize patients with chronic pain.

“We do not believe levying a tax on prescribed medicines that meet legitimate medical needs is an appropriate funding mechanism for a state’s budget,” said Priscilla VanderVeer, spokeswoman for the Pharmaceutical Research and Manufacturers of America, or PhRMA.

New York’s law prohibits passing the tax on to consumers and other purchasers such as insurance companies, but enforcing that could be tricky, according to legal experts.

The Association for Accessible Medicines opposes all opioid taxes but especially objects to that measure because it taxes drugs per pill rather than according to revenue. That puts most of the burden on makers of cheap generics and largely spares brand-name sellers, whose marketing helped fuel the addiction crisis, Ryan said.

Drugmakers will prove to be tough opponents regardless of electoral outcomes, said Regina LaBelle, a visiting fellow at Duke-Margolis Center for Health Policy who worked on drug strategy in the Obama White House.

“These types of taxes face an uphill battle in state legislatures as powerful forces, including industry and industry-funded groups, ally against them,” she said. Pharma-funded chronic-pain patients can be a powerful lobby, she said.

Surging mortality rates caused by fentanyl, heroin and other illegal opioids give pharma companies a chance to deny blame, even if many of those victims became addicted through prescription pills, LaBelle said.

Drug overdoses killed more than 70,000 people last year, a record, according to new, preliminary estimates from the Centers for Disease Control and Prevention.

Dozens of cities, counties and states have sued opioid makers and distributors, arguing the companies downplayed the dangers of addictive pills and ignored signs they were being abused on a massive scale. Often compared to litigation against tobacco companies in the 1990s, the cases could produce billions of dollars in government revenue to fight addiction and overdose.

But that could take years. Through opioid taxes and related measures, states could quickly supplement addiction-prevention funds made available by Washington, which many consider inadequate and unpredictable.

Members of Congress have pushed more opioid legislation this summer, but the House’s package so far has no clear path to becoming law.

Federal funding “is a drop in the bucket,” said Patrick Diegnan, a Democratic New Jersey state senator who backed an opioid tax this year. “We really basically have to put in place the infrastructure for treatment. It will cost a lot of money.”

Minnesota’s proposed opioid tax had bipartisan support this year, passing the state Senate by a huge margin. But under heavy pressure from drug companies, a measure in the Republican-controlled house failed at the end of the legislative session in May.

In the governor’s race this fall, Tim Walz, a Democratic congressman, faces Jeff Johnson, a county commissioner who upset former Gov. Tim Pawlenty in the Republican primary.

Minnesota recently got Washington’s permission to bill Medicaid, the state and federal program designed for low-income people, for psychiatric hospital stays for those with intense addiction-treatment needs.

But none of the moves so far will furnish resources adequate to relieve the crisis, argue patient advocates. Many see an element of justice in making opioid companies contribute.

“Why is it important for the drug industry to pay reparations?” said Lexi Reed Holtum, executive director of the Steve Rummler Hope Network, a Minnesota advocacy group named for her fiancé, who died of an overdose in 2011. “No matter what, this is going to go on for decades to come.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Watch: What Is Sepsis?

Kaiser Health News:Marketplace - September 05, 2018

Fatal Shock Read Main Story

What exactly is sepsis, and why is it so dangerous?

Sepsis happens as the body tries to fight off an infection. The body releases chemicals into the bloodstream to battle the invading germs — which can lead to a severe drop in blood pressure. That can damage vital organs and, in severe cases, cause them to shut down.

That’s known as septic shock, and it can be fatal.

Who is most vulnerable? And what are the signs of sepsis? KHN explains in this video.

KHN’s coverage of end-of-life and serious illness issues is supported in part by the Gordon and Betty Moore Foundation.

Look-Up: Infection Risk Factors At Nursing Homes Near You

Kaiser Health News:Marketplace - September 05, 2018

Click here to see a mobile-friendly version of this tool.

Avoidable Sepsis Infections Send Thousands Of Seniors To Gruesome Deaths

No one tracks sepsis cases closely enough to know how often these severe infections turn fatal. But the toll — both human and financial — is enormous, finds an investigation by KHN and the Chicago Tribune.

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Click here to download KHN’s full data set.

Data analysis by KHN data editor Elizabeth Lucas and KHN senior correspondent Fred Schulte. Data visualizations by KHN producer Caitlin Hillyard.

Avoidable Sepsis Infections Send Thousands Of Seniors To Gruesome Deaths

Kaiser Health News:Marketplace - September 05, 2018

Shana Dorsey first caught sight of the purplish wound on her father’s lower back as he lay in a suburban Chicago hospital bed a few weeks before his death.

Her father, Willie Jackson, had grimaced as nursing aides turned his frail body, exposing the deep skin ulcer, also known as a pressure sore or bedsore.

“That was truly the first time I saw how much pain my dad was in,” Dorsey said.

The staff at Lakeview Rehabilitation and Nursing Center, she said, never told her the seriousness of the pressure sore, which led to sepsis, a severe infection that can quickly turn deadly if not cared for properly. While a resident of Lakeview and another area nursing home, Jackson required several trips to hospitals for intravenous antibiotics and other sepsis care, including painful surgeries to cut away dead skin around the wound, court records show.

Dorsey is suing the nursing center for negligence and wrongful death in caring for her dad, who died at age 85 in March 2014. Citing medical privacy laws, Lakeview administrator Nichole Lockett declined to comment on Jackson’s care. In a court filing, the nursing home denied wrongdoing.

The case, pending in Cook County Circuit Court, is one of thousands across the country that allege enfeebled nursing home patients endured stressful, sometimes painful, hospital treatments for sepsis that many of the lawsuits claim never should have happened.

My father was like my best friend. Most people go to their mom to talk and tell all their secrets, and for me it was my dad.

Shana Dorsey

Year after year, nursing homes around the country have failed to prevent bedsores and other infections that can lead to sepsis, an investigation by Kaiser Health News and the Chicago Tribune has found.

No one tracks sepsis cases closely enough to know how many times these infections turn fatal.

Pinpointing Sepsis Risk, By Site

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Explore infection risk factors at nursing homes in your state. This tools tracks infection-related deficiencies and staffing levels for nursing homes that take Medicare and/or Medicaid.

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However, a federal report has found that care related to sepsis was the most common reason given for transfers of nursing home residents to hospitals and noted that such cases ended in death “much more often” than hospitalizations for other conditions.

A special analysis conducted for KHN by Definitive Healthcare, a private health care data firm, also suggests that the toll — human and financial — from such cases is huge.

Examining data related to nursing home residents who were transferred to hospitals and later died, the firm found that 25,000 a year suffered from sepsis, among other conditions. Their treatment costs Medicare more than $2 billion annually, according to Medicare billings from 2012 through 2016 analyzed by Definitive Healthcare.

In Illinois, about 6,000 nursing home residents a year who were hospitalized had sepsis, and 1 in 5 didn’t survive, according to Definitive’s analysis.

“This is an enormous public health problem for the United States,” said Dr. Steven Simpson, a professor of medicine at the University of Kansas and a sepsis expert. “People don’t go to a nursing home so they can get sepsis and die. That is what is happening a lot.”

The costs of all that treatment are enormous. Court records show that Willie Jackson’s hospital stays toward the end of his life cost Medicare more than $414,000. Medicare pays Illinois hospitals more than $100 million a year for treatment of nursing home residents for sepsis, mostly from Chicago-area facilities, according to the Medicare claims analysis.


Sepsis is a bloodstream infection that can develop in bedridden patients with pneumonia, urinary tract infections and other conditions, such as pressure sores. Mindful of the dangers, patient safety groups consider late-stage pressure sores to be a “never” event because they largely can be prevented by turning immobile people every two hours and by taking other precautions. Federal regulations also require nursing homes to adopt strict infection-control standards to minimize harm.

Yet the failures that can produce sepsis persist and are widespread in America’s nursing homes, according to data on state inspections kept by the federal Centers for Medicare & Medicaid Services. Many of the lawsuits allege that bedsores and other common infections have caused serious harm or death. The outcome of these cases is not clear, because most are settled and the terms kept confidential.

Cook County, where the private legal community is known to take an aggressive approach to nursing homes, has more of these suits than any other metro area in the U.S., KHN and the Tribune found by reviewing court data.

State inspectors also cite thousands of homes nationally for shortcomings that have the potential to cause harm. Inspections data kept by CMS show that since 2015 94 percent of homes operating in Illinois have had at least one citation for conditions that increase the risk of infection. These citations include care related to bedsores, catheters, feeding tubes and the home’s overall infection-control program.

“Little infections turn to big infections and kill people in nursing homes,” said William Dean, a Miami lawyer with more than two decades of experience suing nursing homes on behalf of patients and their families.

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Much of the blame, regulators and patient advocates say, lies in poor staffing levels. Too few nurses or medical aides raises the risks of a range of safety problems, from falls to bedsores and infections that may progress to sepsis or an even more serious condition, septic shock, which causes blood pressure to plummet and organs to shut down.

Staffing levels for nurses and aides in Illinois nursing homes are among the lowest in the country. In the six-county Chicago area, 78 percent of the facilities’ staffing levels fall below the national average, according to government data analyzed by KHN.

Matt Hartman, executive director of the Illinois Health Care Association, which represents more than 500 nursing homes, acknowledged low staffing is a problem that diminishes the quality of nursing care.

Hartman blamed the state’s Medicaid payment rates for nursing homes — about $151 a day per patient on average — which he said is lower than most other states. Medicaid makes up about 70 percent of the revenue at many homes, he said.

Last October, CC Care LLC, an Illinois nursing home group that specializes in treating mentally ill patients on Medicaid, filed for bankruptcy, arguing that the state’s “financial troubles have been disastrous for all nursing homes.”

In a July court filing, CC Care creditors’ committee argued that the company couldn’t stay afloat relying on Illinois Medicaid payments, which it called “slow, erratic and significantly less than what we are due.”

Pat Comstock, executive director of the Health Care Council of Illinois, said nursing homes she represents “are operating in an increasingly difficult environment in Illinois, yet they continue to prioritize delivering the best care possible to residents in a safe and secure setting.”

A Festering Complaint

Shana Dorsey remembers her father as a quiet but friendly man. He worked as a uniformed bank security guard and picked up extra cash fixing neighbors’ cars in an empty lot adjacent to his West Side apartment building. He was a stickler for detail, who relished teaching his granddaughter the state capitals and was always ready to lend a hand to help his daughter, who now works for a Chicago property management firm.

Willie Jackson(Courtesy of Shana Dorsey)

But age and declining health caught up with the Army veteran, who by his early 80s began to exhibit signs of dementia and moved into an assisted living apartment.

Dorsey knew her dad needed more specialized care when she found him sitting in his favorite peach recliner in his apartment, unable to get up and incontinent.

He required more intense medical and personal care as his kidney disease worsened and he became more confused, medical records show. In his last 18 months of life, he cycled in and out of hospitals eight times for treatment of septic bedsores and other infections, according to court records.

The Chicago law firm representing Dorsey, Levin & Perconti, provided KHN and the Tribune with medical records and additional court filings that cover Jackson’s care.

Jackson had two pressure sores in late November 2012 when he was first admitted to Lakeview nursing center from the Jesse Brown VA Medical Center in Chicago, according to lawyers for his daughter.

These wounds healed, but in late September 2013, Jackson spiked a fever and had an infected sore in his lower back that exposed the bone, causing what Dorsey’s lawyers called “significant pain.”

The nursing home transferred Jackson to Presence St. Joseph Hospital in Chicago, where surgeons cut away the dead skin and administered antibiotics. At that time, the sore was as wide as a grapefruit and had “copious purulent drainage, foul smell and bleeding,” Dorsey’s lawyers argue. Tests confirmed sepsis, and the wound had grown so deep that it infected the sacral bone in his back, a condition known as osteomyelitis, the lawsuit said.

In November 2013, Dorsey moved her father to another nursing home. He required three more hospital visits before Dorsey made the difficult decision to place Jackson in hospice care. He died March 14, 2014, from “failure to thrive,” according to a death certificate.

In her suit, Dorsey, 39, argues that Lakeview nursing staff knew Jackson was at “high risk” for bedsores because of his declining health. Yet the home failed to take steps to prevent the injuries, such as turning and repositioning him every two hours, according to the suit. That didn’t happen about 140 times in August 2013 alone, Dorsey’s lawyers said.

“My father was like my best friend. Most people go to their mom to talk and tell all their secrets, and for me it was my dad,” Dorsey said in a November 2015 deposition.

While Lakeview declined to discuss Jackson’s treatment, it has denied negligence and argued in court filings that its actions were not to blame for Jackson’s death. Lockett, the home’s administrator, said the facility “strictly follows” all regulations to minimize the effects of skin breakdowns that can occur naturally with age.

“We are grateful for the daily opportunity to enhance the lives of seniors and other chronically ill populations in our community,” Lockett said in a statement.

Infection Control

Poor infection control ranks among the most common citations in nursing homes. Since 2015, inspectors have cited 72 percent of homes nationally for not having or following an infection-control program. In Illinois, that figure stands at 88 percent of homes.

Illinois falls below national norms for risks of pressure sores or failure to treat them properly in nursing homes. Inspectors have cited 37 percent of the nation’s nursing homes for this deficiency, compared with 60 percent in Illinois, according to CMS records. Only three states were cited more frequently.

Inspectors in November 2016 cited Alden Town Manor Rehabilitation and Health Care Center in Cicero, Ill., for neglect due to its care of an unnamed 83-year-old man with pressure ulcer sores that went untreated. Gangrene had set in by the time the staff sent him to the hospital, where surgeons ended up amputating his right leg above the knee, according to the inspectors’ report and citation. Alden Town Manor had no comment.

Dean, the Miami lawyer, said that nursing home staffs often miss early signs of infection, which can start with fever and elevated heart rate, altered mental status or not eating. When those symptoms occur, nurses should call a doctor and arrange to transfer the patient to a hospital, but that process often takes too long, he said.

“They don’t become septic on the ambulance ride over to the hospital,” Dean said.

There is little agreement over how much staff should be required in nursing homes. Federal regulations simply mandate that a registered nurse must be on duty eight hours per day, every day. In 2001, a federal government study recommended a daily minimum of 4.1 hours of total nursing time per resident, which includes registered nurses, licensed practical nurses and certified nursing assistants, often referred to as aides. That never became an industry standard or federal regulation, however.

Most states set requirements lower and face industry resistance to raising the bar. A California law requiring 3.5 hours per resident as of this July 1 is drawing intense criticism from the industry, for instance.

In addition, staffing can fluctuate, particularly over the weekends. A recent KHN investigation found that on some days, nursing home aides could be in charge of twice as many residents as normal.

At a minimum, Illinois requires 2.5 hours of direct care daily for residents. Yet federal nursing home payroll data show that at least 1 in 4 Chicago-area nursing home residents live in facilities that aren’t consistently providing that much care, KHN found.

Nationally, each aide is responsible for 10 residents on average; in the six-county Chicago area, the average is 13 residents per aide.

Federal officials have linked inadequate staffing to bedsores and other injuries, such as falls. If left unattended, even a small ulcer or sore can become septic, and once that happens, a patient’s life is in imminent danger.

In October 2014, Milwaukee-based Extendicare denied wrongdoing but paid $38 million to settle a federal False Claims Act lawsuit that accused it of not having enough staff on hand in 33 nursing homes in eight states, including Indiana, and failing to take steps to prevent bedsores or falls.

In other cases, federal officials have alleged that some nursing homes overmedicate residents — which can result in injuries such as falls from beds or wheelchairs and bedsores — rather than staff up to care for them properly.

Little infections turn to big infections and kill people in nursing homes.

William Dean, a lawyer who represents patients and their families

In May 2015, owners of two nursing homes in Watsonville, Calif., agreed to pay $3.8 million to settle a whistleblower lawsuit alleging the homes persistently drugged patients, contributing to infections and pressure sores.

The suit alleged that an 86-year-old man who could barely move after receiving a shot of an anti-psychotic medication lost his appetite and spent most of the day in bed, “was not turned or repositioned and developed additional pressure ulcers.” He ran a 102-degree fever, but the staff failed to notify his doctor for three days, according to the suit.

Hospital doctors later diagnosed the man with sepsis and an infected pressure ulcer. The home did not admit wrongdoing and had no comment.

Personal injury lawyers and medical experts say that poor infection control often sends nursing home residents to hospitals for emergency treatment — and that the stress can hasten death.

Elderly people often “don’t have the ability to bounce back from an infection,” said Dr. Karin Molander, a California emergency room physician and board member of the Sepsis Alliance advocacy group.

That odyssey of multiple, stressful trips to the hospital is a common thread in negligence and wrongful death lawsuits involving sepsis or bedsores. KHN identified more than 8,000 suits filed nationwide from January 2010 to March of this year that allege injuries from failing to prevent or treat pressure sores and other serious infections.

Molander said serious bedsores indicate “someone is being ignored for an extended time period.”

“When we see patients like that we file [patient neglect] complaints with adult protective services,” she said.

Some of these cases led to million-dollar jury verdicts. In 2017, a Kentucky jury awarded $1.1 million to the family of a woman who suffered from bedsores and sepsis in a nursing home. In a second case last year, a jury awarded $1.8 million to a widow who alleged a Utah nursing home failed to turn her husband often enough to prevent bedsores, which led to his death.

Lawyers filed more than 1,400 of the cases from January 2010 to March of this year in Cook County Circuit Court, which tops all metro areas across the country in the KHN sample.

Nursing homes complain that garish billboards to solicit clients are a fixture in Chicago, where many attorney websites also boast of recent million-dollar verdicts from bedsore cases alone.

“We see an incredible amount of lawsuits out there,” said Hartman, of the Illinois nursing home association. “We feel we have a target on our backs.”

Trial lawyers counter that nursing homes often try to duck responsibility for poor care by creating complex corporate structures to limit their liability. Yet Hartman derided these suits as “cash cows” for law firms that can rack up six-figure legal fees as cases drag on. The nursing home industry supports tort reforms that would compensate injured persons but also bring a quicker resolution of claims, he said.

“That is something that needs to be fixed in Illinois,” Hartman said.

Avoidable Hospital Transfers

In September 2013, the Centers for Medicare & Medicaid Services said it was working to reduce avoidable transfers from nursing homes to hospitals. CMS had previously called these trips “expensive, disruptive and disorienting for frail elders and people with disabilities.”

The plans came in the wake of a critical 2013 Department of Health and Human Services audit that found Medicare had paid about $14 billion in 2011 for these transfers. Care related to sepsis cost Medicare more than the next three costliest conditions combined, according to the audit.

The auditors have not checked in to see if Medicare has since reduced those costs and have no plans to do so, a spokesman for the HHS Office of Inspector General said.

However, Definitive Healthcare’s analysis of billing data, modeled after the HHS audit, shows little change between 2012 and 2016, both in terms of deaths and costs.

Wendy Meltzer, executive director of Illinois Citizens for Better Care, said that hospital trips caused by treatment for sepsis can be “emotionally devastating” for confused elderly patients.

“It’s not a choice anybody makes. It’s horrible for people with dementia,” Meltzer said. “Some never recover from that. It’s a very real phenomenon and it’s cruel.”

University of Maryland master’s student Chris Cioffi contributed to this report.

This story was jointly produced by Kaiser Health News and the Chicago Tribune by reporters based in Washington, D.C., and Chicago. Fred Schulte is a senior correspondent for KHN and Elizabeth Lucas is data editor. Joe Mahr is a Tribune reporter.

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

California: A Health Care Laboratory With Mixed Results

Kaiser Health News:HealthReform - September 05, 2018

California’s expansion of Medicaid under the Affordable Care Act enabled many low-income HIV patients to get health insurance previously denied to them. Still, those with mental health needs, who had been receiving coordinated care through a separate federal program, suddenly faced gaps in treatment, payment disputes and doctors who had little understanding of life with HIV.

A report on HIV patients is one example in a special California edition of the journal Health Affairs showing that though the state is often a national beacon in health care, some of its innovations fall short of expectations.

The Golden State was a pioneer in embracing the ACA, aiming to enhance the availability, quality and efficiency of health care. But its size and diversity — as well as the unforeseen complications of real-world implementation — have made for some messy experiments.

It is “not a well-controlled laboratory,” said Dylan Roby, an associate professor at the University of Maryland’s School of Public Health. “When you are trying to make things more efficient, there are, of course, going to be these gaps that are created.”

In the case of HIV patients, “individuals who had previously been receiving really integrated, culturally tailored services … were now having to navigate a really complicated landscape,” said Emily Arnold, associate professor at University of California-San Francisco and lead author of the HIV study.

Another Health Affairs article tracked the impact of California’s Medicaid expansion on family planning services for low-income residents. Researchers found that while it left far fewer young women uninsured, it did not boost the proportion who actually received family planning or general health care services.

(Early et al./Health Affairs)

“It was a little bit disappointing,” said Heike Thiel de Bocanegra, associate professor at UCSF and one of the study’s co-authors. “We pushed for access and enrollment and to get everybody on health insurance. Now we have to make sure that they use it and that they use it for preventive services.”

That outcome may be due in part to the fact that California had already invested in family planning services, including for low-income women, according to the study.

California’s increasingly diverse population, willingness to tackle complex health care issues and long history with integrated health care mean it “has learned a lot for itself and also has lessons for the rest of the country,” Alan Weil, Health Affairs’ editor-in-chief, said in an interview.

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Now, Weil said, people are watching California’s discussion of a single-payer health system, which the leading candidate for governor, Democrat Gavin Newsom, has made part of his platform.

The Health Affairs issue also highlights some California successes, including on maternal mortality. The death rate was rising alarmingly and “cut everyone to the core,” leading clinicians and state officials to establish quality measures and follow up on them, said Dr. Elliot Main, medical director of the California Maternal Quality Care Collaborative at Stanford University.

“The status quo was no longer sustainable,” said Main, the lead author of an article about a project to address the rising death rates.

Beginning in 2006, the public health department joined with doctors, hospitals and researchers to study the data, better understand the deaths and teach hospitals how to improve outcomes. While the U.S. maternal mortality rate got worse, California’s dropped nearly in half — from 13.1 maternal deaths per 100,000 live births, on average, for the years 2005 through 2009 to an average of seven per year from 2011 to 2013.

(Main et al./Health Affairs)

In San Diego County, hospitals and clinics tackled another killer: heart disease. Dr. Anthony DeMaria, a professor at University of California-San Diego, said the county’s biggest health care systems worked together on fighting heart disease, which continues to be the leading cause of death in California and the U.S.

They shared data and strategies, used health coaches to work with patients and collaborated with churches. Between 2007 and 2016, hospital admissions due to heart attacks dropped by 22 percent, compared with an 8 percent drop statewide.

“How many cities do you think would be able to get all the competing health care institutions to collaborate on something like this?” asked DeMaria, who co-authored a Health Affairs analysis on the effort. “In most places, it’s like porcupines mating. When they come together, they are very, very cautious.”

State health officials, the federal government and insurance plans have also worked together to improve care for chronically ill, low-income seniors who are on both Medicare and Medicaid. They are among the most expensive and complicated patients in the nation and historically have had poorly coordinated care.

California was one of 13 states to implement a pilot project intended to better integrate their medical care and other health-related services. Patients who enrolled in the pilot, known as Cal MediConnect, ultimately reported greater satisfaction with their benefits and quality of care.

At the same time, about half of the eligible participants opted out of enrollment — a significant shortcoming in the experiment.

Despite its successes, California still has significant health disparities and an uneven distribution of health care providers to help reduce them. A Health Affairs study about nurse practitioners underscores the challenge of getting these medical professionals to the populations that need them the most.

Joanne Spetz, a professor at UCSF, found that even though nurse practitioners could help fill gaps in primary care, they and the programs that train them are generally in locations that already have a relatively high number of doctors per patient.

San Francisco, for example, has multiple nurse practitioner education programs, said Spetz, lead author of the article. “That isn’t where the jobs are and where the greatest needs are,” she said.

For California’s complex health challenges, “there is no silver bullet,” said Shana Charles, assistant professor at Cal State-Fullerton. “There are still going to be issues even if you have the best of intentions.”

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

Rudy Giuliani’s Consulting Firm Had Hand In Halting Florida’s Opioid Investigation

Kaiser Health News:Marketplace - September 05, 2018

Six months after hiring former New York City mayor Rudy Giuliani’s consulting firm, Purdue Pharma settled a Florida state investigation that had threatened to expose early illegal marketing of its blockbuster drug OxyContin, company and state records show.

The November 2002 deal was a coup for the drugmaker, which at the time faced growing criticism about overdose deaths and addiction linked to the painkiller. Purdue agreed to pay the state $2 million to help fund a computer database to track narcotics prescriptions and up to $150,000 to sponsor five one-day conferences to educate law enforcement about drug abuse.

In exchange, Florida’s then-attorney general, Robert Butterworth, dropped his marketing investigation, which had uncovered initial evidence that Purdue misled doctors and the public about OxyContin’s safety, state records show.

How America Got Hooked On A Deadly Drug

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Today, as Giuliani makes frequent headlines as President Donald Trump’s personal lawyer in the Russia investigation, the settlement his firm helped secure in Florida is drawing new scrutiny — and mixed opinions.

“This was a missed opportunity,” David Moyé, a former director of economic crimes and health care fraud for the Florida Attorney General’s Office, said of the settlement. “They let them [Purdue] off the hook,” said Moyé, now a lawyer in Tallahassee.

Butterworth agreed to drop any claims “arising out of the sale and marketing” of OxyContin up to Nov. 1, 2002. That happened even though Purdue never paid for the database because state lawmakers balked at supporting it.

On Tuesday, Butterworth told KHN that he realized at the time that a “couple million dollars wasn’t going to solve the problem” caused by what he termed “horrific” marketing of OxyContin. But, he said, “when you are the first state to take this on, you have to start somewhere.”

Now a lawyer in Fort Lauderdale, Butterworth said he regretted that more wasn’t done early on to halt improper marketing of opioids.

“I wish that law enforcement would have taken them out 20 years ago. It is absolutely insane that so many people die each year [from opioids],” he said.

The Florida AG’s marketing investigation remains noteworthy because some of the evidence it unearthed could play a role in an avalanche of lawsuits that now blame Purdue and other opioid makers for fueling the nation’s addiction epidemic.

More than 1,500 of these suits, mostly filed by state and local governments against opioid manufacturers and distributors, seek compensation for the costs of treating addiction.

“We allege the [opioid epidemic] is a consequence of this kind of [marketing] conduct,” said Paul Hanly, co-counsel for a group of lawsuits consolidated in federal court in Cleveland. Addiction treatment costs have “hemorrhaged” over the past 10 years and cost billions of dollars, he said. The drug companies and distributors have denied responsibility in court filings.

Trump earlier this year declared the opioid epidemic a “national emergency,” and suggested last month that the federal government also sue drug companies.

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Giuliani launched his consulting firm, Giuliani Partners LLC, in early 2002. For years, detractors have argued that the ex-mayor traded on the respect and celebrity gained by his leadership after the Sept. 11, 2001, terrorist attacks to help Purdue duck responsibility for misdeeds.

On Aug. 24, two Democratic senators asked the Department of Justice and the Drug Enforcement Administration to investigate Giuliani’s role in a 2007 criminal case against Purdue in Virginia, which accused the company of making false claims about OxyContin’s safety. The request follows a New York Times article that alleged Giuliani’s influence led prosecutors to ease off charges that could have crippled the company.

The 2002 Florida investigation, by taking aim directly at Purdue’s aggressive sales tactics, had posed a significant threat to the company. Released late in 1995, OxyContin topped $1 billion in annual sales by 2002.

The investigation picked up steam in July 2002, less than two months after Purdue announced hiring Giuliani Partners to help it “combat prescription drug abuse and diversion.” The firm’s duties included building support for electronic prescription monitoring plans and developing education programs for law enforcement — the two pillars of the settlement in Florida.

As a sign of its willingness to cooperate with the state, Purdue agreed to turn over its confidential OxyContin marketing plans from 1996 through 2002. Kaiser Health News obtained these reports from the Florida AG and published them in June, with the remaining materials cited here.

Giuliani Partners founding member Daniel Connolly spoke on Purdue’s behalf at a July 23, 2002, meeting with the Florida AG staff, notes of the meeting obtained from the Florida AG’s office show. Connolly had no comment.

So did Miami attorney Jon Sale, a law school pal of Giuliani’s who remains a close friend. Sale said in a recent interview that Giuliani “most likely” had asked him to represent Purdue in the legal negotiations.

Purdue’s support for the database was among the issues discussed, the meeting notes show. Sale said Purdue hoped the database would allow doctors to check if a patient in their waiting room was receiving opioid prescriptions elsewhere, an abusive practice known as “doctor shopping.”

“Everybody thought it was a wonderful idea,” Sale said in a recent interview.

Former Florida assistant attorney general Dave Aronberg, who worked on the investigation but left before its settlement, agreed.

Aronberg blamed some Republican lawmakers, who saw the database as a threat to patient privacy, for torpedoing the deal. The settlement released Purdue from paying most of the $2 million if legislators did not approve additional funding for the database within two years.

Aronberg said the legislation, which eventually passed more than two years later in 2009, could have saved many lives had the database been set up earlier. Most states now have the computerized systems, though some doubt their effectiveness in curbing opioid overdose deaths and other abuse.

The 2002 settlement, and the political skirmishes over the databank, put the brakes on the AG’s investigation of potentially illegal sales promotions. For instance, an AG’s office investigator interviewed a former Purdue sales manager, who said company executives had directed its sales force to advise doctors that OxyContin was not addictive, according to notes of the interview. Though Purdue gave the state a list of the names and contact information for more than 100 of its sales agents, the same records indicate that the sales manager appears to be the only one interviewed.

Records from the AG’s office show that Purdue also turned over marketing materials that downplayed the risks of addiction from the drug, including a brochure that advised patients, “Fear should not stand in the way of relief of your pain.” Other records included the names of all employees who had helped write product warnings for OxyContin and Purdue’s guidelines for paying commissions to its sales force.

Former fraud director Moyé said that the revelations in these records and other evidence, such as Medicaid billing data that showed some doctors were recklessly prescribing of OxyContin should have prompted Florida officials to demand tougher enforcement, including a hefty fine, and an agreement to cease marketing violations in the future.

“We could have cleaned this up,” Moyé said.

But Hanly, the lawyer now suing opioid makers, noted that the marketing records were later used by the Justice Department in securing Purdue’s criminal convictions in 2007. “It’s not like they didn’t have any consequences,” he said.

Giuliani Partners was not the only high-profile hire at Purdue. It also retained Eric Holder, a former assistant attorney general under President Bill Clinton who went on to serve as attorney general in the Obama administration. In 2004, Holder helped negotiate a $10 million settlement of a lawsuit filed by the West Virginia attorney general, who accused Purdue of deceptive marketing. Holder’s role also has drawn criticism.

But Purdue appears to have placed special trust in Giuliani Partners. In the 2002 press release, Purdue Executive Vice President Michael Friedman said the “management experience, law enforcement background, leadership and integrity of Giuliani Partners and its CEO Rudolph W. Giuliani are tremendous assets to our company.”

Friedman and two other Purdue executives pleaded guilty to criminal charges of “misbranding” OxyContin in the 2007 Virginia case.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

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

Kaiser Health News:HealthReform - September 05, 2018

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

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

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

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

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

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

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

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

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

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

Kaiser Health News:Marketplace - September 04, 2018

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

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

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

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

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

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

(Scheffler et al./Health Affairs)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Antitrust enforcers are now giving such consolidation more scrutiny.

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

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

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

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

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

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

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

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

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

Kaiser Health News:Insurance - September 04, 2018

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

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

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

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

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

1. What is this suit about?

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

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

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

2. Why are Democratic attorneys general defending the law?

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

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

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

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

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

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

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

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

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

4. Is this case purely Republicans versus Democrats?

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

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

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

5. What is Congress doing about this?

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

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

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

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

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

Kaiser Health News:HealthReform - September 04, 2018

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

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

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

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

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

1. What is this suit about?

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

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

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

2. Why are Democratic attorneys general defending the law?

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

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

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

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

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

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

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

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

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

4. Is this case purely Republicans versus Democrats?

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

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

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

5. What is Congress doing about this?

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

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

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

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

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

Kaiser Health News:Marketplace - September 04, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lawmakers Push To Protect Patients And Counter Trump

Kaiser Health News:HealthReform - September 04, 2018

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

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

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

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

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

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

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

Defending the Affordable Care Act

Association Health Plans

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

Short-Term Health Plans

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

Medical Loss Ratio

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

Medi-Cal Work Requirements

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

Consumer Protection

Unloading Homeless Patients 

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

Health Care Providers

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

Abortion Pills On Campus

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

Rape Kit Testing

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

Medication Disposal

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

Hospital Nurse-Patient Ratios

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

Health Care Mergers

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

Drug Prices

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

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

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

Kaiser Health News:Marketplace - August 31, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kaiser Health News:Marketplace - August 31, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To hear all our podcasts, click here.

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

HHS Watchdog To Probe Enforcement Of Nursing Home Staffing Standards

Kaiser Health News:Marketplace - August 30, 2018

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

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

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

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

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

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

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

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

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

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

CMS declined to comment about the new examination.

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

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

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

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

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

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

The Pluses And Minuses Of Allowing Medical Marijuana At School

Kaiser Health News:States - August 30, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kaiser Health News:Insurance - August 29, 2018

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

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

Kaiser Health News:Marketplace - August 29, 2018

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The new study leaves some important questions unanswered.

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

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

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

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

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

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

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

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

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

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

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