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Ten ERs In Colorado Tried To Curtail Opioids And Did Better Than Expected

Kaiser Health News:States - February 23, 2018

DENVER — One of the most common reasons patients head to an emergency room is pain. In response, doctors may try something simple at first, like ibuprofen or acetaminophen. If that wasn’t effective, the second line of defense has been the big guns.

“Percocet or Vicodin,” explained ER doctor Peter Bakes of Swedish Medical Center, “medications that certainly have contributed to the rising opioid epidemic.”

Now, though, physicians are looking for alternatives to help cut opioid use and curtail potential abuse. Ten Colorado hospitals, including Swedish in Englewood, Colo., participated in a six-month pilot project designed to cut opioid use, the Colorado Opioid Safety Collaborative. Launched by the Colorado Hospital Association, it is billed as the first of its kind in the nation to include this number of hospitals in the effort.

The goal was for the group of hospitals to reduce opioids by 15 percent. Instead, Dr. Don Stader, an ER physician at Swedish who helped develop and lead the study, said the hospitals did much better: down 36 percent on average.

“It’s really a revolution in how we approach patients and approach pain, and I think it’s a revolution in pain management that’s going to help us end the opioid epidemic,” Stader says.

The decrease amounted to 35,000 fewer opioid doses than during the same period in 2016.

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The overall effort to limit opioid use in emergency departments is called the Colorado ALTO Project; ALTO is short for “alternatives to opioids.”

The method calls for coordination across providers, pharmacies, clinical staff and administrators. It introduces new procedures, for example, like using non-opioid patches for pain. Another innovation, Stader said, is using ultrasound to “look into the body” and help guide targeted injections of non-opioid pain medicines.

Rather than opioids like oxycodone, hydrocodone or fentanyl, Stader said, doctors used safer and less addictive alternatives, like ketamine and lidocaine, an anesthetic commonly used by dentists.

Lidocaine was by far the leading alternative; its use in the project’s ERs rose 451 percent. Ketamine use was up 144 percent. Other well-known painkillers were used much less, like methadone (down 51 percent), oxycodone (down 43 percent), hydrocodone (down 39 percent), codeine (down 35 percent) and fentanyl (down 11 percent).

Lidocaine was the most commonly used alternative in the Colorado Opioid Safety Collaborative pilot project. Hospitals used a multifaceted approach to reduce reliance on opioid painkillers. (John Daley/CPR News)

Claire Duncan is a clinical nurse coordinator in the Swedish Medical Center's emergency department. (John Daley/CPR News)

“We all see the carnage that this opioid epidemic has brought,” Stader said. “We all see how dangerous it’s been for patients, and how damaging it’s been for our communities. And we know that we have to do something radically different.”

Claire Duncan, a clinical nurse coordinator in the Swedish emergency department, said the new approach has required intensive training. And there was some pushback, more from patients than from medical staff.

“They say ‘only narcotics work for me, only narcotics work for me.’ Because they haven’t had the experience of that multifaceted care, they don’t expect that ibuprofen is going to work or that ibuprofen plus Tylenol, plus a heating pad, plus stretching measures, they don’t expect that to work,” she said.

The program requires a big culture change, encouraging staff to change the conversation from pain medication alone to ways to “treat your pain to help you cope with your pain to help you understand your pain,” Duncan said.

Emergency medical staff are all too familiar with the ravages of the opioid epidemic.

They see patients struggling with the consequences every day. But Bakes, the ER doctor at Swedish, said this project has changed minds and allowed health care professionals to help combat the opioid crisis they unwittingly helped to create.

“I think that any thinking person or any thinking physician, or provider of patient care, really felt to some extent guilty, but … powerless to enact meaningful change,” Bakes said.

Patient Ashley Copeland talks to her mother, Sue Iverson, in the Swedish Medical Center emergency department. Copeland was treated for a severe headache with a nerve blocking anesthetic, but no opioid painkillers. She was discharged and advised to use over-the-counter meds for pain. (John Daley/CPR News)

Dr. Peter Bakes is an emergency medicine doctor at Swedish Medical Center. (John Daley/CPR News)

The pilot project has proven so successful that Swedish and the other emergency departments involved will continue the new protocols and share what they learned. Stader said the Colorado Hospital Association will help spread the word about opioid safety and work toward its adoption statewide by year’s end.

“And I think if we did put this in practice in Colorado and showed our success that this would spread like wildfire across the country,” Stader said.

The 10 hospitals that collaborated on the project include Boulder Community Health, Gunnison Valley Health, Sedgwick County Health Center, Sky Ridge Medical Center, Swedish Medical Center, UCHealth Greeley Emergency and Surgical Center, UCHealth Harmony Campus, UCHealth Medical Center of the Rockies, UCHealth Poudre Valley Hospital and UCHealth Yampa Valley Medical Center.

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

Podcast: KHN’s ‘What The Health?’ The Long Wait Ends For Short-Term Plan Rules

Kaiser Health News:HealthReform - February 22, 2018

The Trump administration finally released a long-awaited rule that would allow significant expansion of health insurance policies that do not meet all the requirements of the Affordable Care Act, both in terms of what they cover and how much they charge.

The administration says it wants to broaden the availability of so-called short-term insurance plans to give people who buy their own insurance more choices of lower-cost coverage. Critics say that the plans would draw the healthiest people out of the plans that meet the ACA’s requirements, driving up premiums for those who remain in that market.

And in the wake of last week’s tragic school shooting in Florida, attention is once again turning to the issue of a long-standing federal funding ban on most gun-related public health research.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Margot Sanger-Katz of The New York Times and Julie Appleby of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • The Trump administration’s proposal for short-term insurance plans may offer some less expensive coverage options, but those plans have a history of leaving patients on the hook if they develop health problems.
  • Federal health officials estimated that as many as 200,000 people now buying ACA plans might instead move to buy the short-term plans being proposed. But many analysts suspect the number could be much higher — and that will mean the prices could rise dramatically in the ACA marketplace plans and cost the federal government more money for the premiums it subsidizes.
  • Idaho’s proposal to allow plans that don’t meet ACA requirements is being watched closely, but federal officials have not yet tipped their hands about how they will react.
  • Although Congress has restricted funding for federal research into gun violence, studies are going forward by other academic researchers.
  • A growing divide among consumers is raising concerns. People who buy their own insurance are more frustrated as their costs continue to go up while they see others getting coverage paid for by the ACA subsidies or the expansion of Medicaid.
  • Democrats are seizing on the growing concerns over price among people who buy their own insurance to propel talks about establishing a way for more people to be covered by Medicare or Medicaid.
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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’ “As Some Got Free Health Care, Gwen Got Squeezed: An Obamacare Dilemma,” by Abby Goodnough.

Margot Sanger-Katz: HuffPost’s “The Liberal Establishment Suddenly Sounds Very Ambitious On Health Care,” by Jonathan Cohn.

Julie Appleby: Vox.com’s “Idaho’s Brazen Plan To Unravel Obamacare, Explained,” by Dylan Scott.

Stephanie Armour: The Washington Post’s “Bad Beside Manner: Bank Loans Signed In The Hospital Leave Patients Vulnerable,” by Shefali Luthra of Kaiser Health News.

To hear all our podcasts, click here.

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

 

Couple Makes Millions Off Medicaid Managed Care As Oversight Lags

Kaiser Health News:Marketplace - February 22, 2018

CHULA VISTA, Calif. — Norma Diaz and her husband, Joseph Garcia, have dedicated their careers to running a nonprofit health insurer that covers some of California’s neediest residents.

For three decades, they have worked for a Medicaid managed-care plan, Community Health Group, serving nearly 300,000 poor and disabled patients in San Diego County under a state contract funded entirely by taxpayers. They’ve earned above-average ratings for patient care.

And in the process, they’ve made millions of dollars.

Together, Diaz and Garcia made $1.1 million in 2016 and received more than $5 million since 2012, according to the health plan’s tax returns and company data. Diaz’s compensation as CEO exceeded the pay of several peers at bigger plans in 2016.

Garcia, married to Diaz since 1997, is an outside consultant who serves as chief operating officer. Their health plan, with $1.2 billion in annual revenue, had a profit margin of 19 percent in 2016, the highest of any Medicaid insurer in California and more than six times the industry average.

“This is not only a conflict of interest but egregious overpayments,” Frank Glassner, chief executive of Veritas Executive Compensation Consultants in San Francisco, said after hearing of the payments from a reporter and reviewing the tax returns. “It’s the family-and-friends plan.”

The arrangement at this midsize California health plan raises broader questions about government oversight as states award billions of dollars in public money to private plans to cover patients on Medicaid, the federal-state insurance program for the poor.

Evidence is mounting that Medicaid’s rapid expansion under the Affordable Care Act has far outstripped the government’s ability to monitor the taxpayer money it turns over to insurers. In California, for instance, some health plans have reaped outsize profits, so large the state is now trying to claw back billions in overpayments, a recent Kaiser Health News investigation found.

Medicaid enrollment has soared to 74 million Americans, from 58 million before the ACA rollout. About 75 percent of them are assigned to plans like Community Health

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Group, which receive a flat monthly fee per person to handle their medical care.

Increasingly, states have embraced managed care in hopes of controlling Medicaid costs. Insurers could see further growth as the Trump administration and Congress seek to cut federal spending on Medicaid and shift more of the fiscal burden onto states.

These managed-care contracts can be highly lucrative for the companies involved and their executives, like Diaz and Garcia. Any money left over after spending on medical care and administration is profit or “surplus,” depending on whether the plan is nonprofit.

Federal auditors have warned for years about lax oversight of Medicaid money, a task that primarily falls to states. A 2017 report found that even as managed care has grown in importance, states have fallen behind in collecting essential data from plans.

In the past year alone, government auditors and consultants criticized Illinois, Kansas and Mississippi for poor supervision of Medicaid insurers. Illinois auditors said the state didn’t properly monitor $7.1 billion paid to Medicaid plans in fiscal year 2016, leaving the program unable to determine what percentage of money went to medical care as opposed to administrative costs or profit.

An examination of Community Health Group in California points to systemic flaws in oversight.

Related Financial Documents

Community Health Group’s 990s:
2015
2014
2013
2012

Joseph Garcia’s compensation:
COO salary survey
consulting agreement

For instance, California officials said they do not examine the companies’ public tax filings. As a social welfare nonprofit, Community Health does not pay taxes, but it is required to file returns with the federal government, known as 990s, which provide basic information about operations and finances.

In a review of Community Health’s recent returns, KHN discovered that the company falsely denied — on the 2015 and 2016 forms — that it was doing business with a family member.

In response, the insurer immediately said that was an error and it was amending the returns to reflect its relationship with Garcia. The company had disclosed the relationship in earlier years.

California’s Medicaid agency, in a statement, said insurers are allowed to set their own conflict-of-interest policies. Asked specifically about Community Health Group, it referred further questions back to the health plan.

Likewise, the state’s chief insurance regulators at the Department of Managed Health Care said in a statement that insurers are not required to submit information on executive compensation and the state does not set standards for that. They do review the pay of outside contractors.

Diaz and Garcia, sitting together at a conference table in the CEO’s office on a recent weekday, said they were proud of their long record of helping disadvantaged people. The couple insists there’s nothing wrong with mixing work and family.

Community Health Group, with $1.2 billion in annual revenue, had a profit margin of 19 percent in 2016, the highest of any Medicaid insurer in California and more than six times the industry average. (Chad Terhune/California Healthline)

Diaz, 56, said her husband reports not to her but to a fellow executive, the associate CEO, and his consultant’s role was approved by the health plan’s board. “I don’t feel for me it’s a conflict of interest because he was here for many years long before we ever got married, so we got used to a working relationship,” she said.

Garcia, 66, served as the company’s on-staff chief operating officer for about 15 years and then switched in 2011 to the role of consultant (acting as COO), which ultimately raised his pay. He said the couple has never tried to hide their personal relationship from the state or anyone else.

“I understand from the outside someone might say ‘Oh my God. That’s a conflict.’ But it’s not. It’s irrelevant that I’m her husband,” he said. “I don’t see how it’s a misuse of public funds. The expense for a chief operating officer would be made no matter what, and my compensation is fair.”

His total compensation reached $487,386 in 2016, according to the insurer. From 2012 to 2016, the health plan paid him a total $2.3 million.

Under his consulting agreement, Garcia is paid $275 an hour and can make as much as $572,000 annually, according to documents obtained by KHN through a public records request. The health plan had requested the information be kept confidential, but the state released it.

In September, regulators at the managed-care department asked Community Health Group how Garcia’s pay was determined. The company submitted a pay range for chief operating officers that it said was drawn from industry surveys.

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Community Health said it picked the maximum figure in the range, $442,863, to reflect Garcia’s “many years of experience in health plan operations.” It then increased his pay range by 30 percent because it said Garcia doesn’t receive benefits. The plan called his current salary — which in 2016 fell below the maximum allowed — “both fair and competitive.”

An agency spokesman said the state’s review of the matter is closed.

In early 2012, the insurer hired a new executive as COO, but he left the following year. Garcia stayed on as a consultant during that time at roughly $400,000 annually, then resumed his COO duties. His current consulting agreement runs through 2021.

“We don’t want to lose Joseph. He has a tremendous amount of knowledge,” said Albert Vitela, a retired San Diego police detective who is the plan’s co-founder and chairman.

As for Diaz, she has received $2.8 million in salary, benefits and other compensation over the five years ending in 2016. Her 2016 pay of $604,502 exceeded that of the CEO of the Inland Empire Health Plan in Southern California, which has four times the enrollment.

(Story continues below.)

Last year, federal auditors examined compensation for the 133 top paid executives at managed-care organizations in seven states, focused on health plans that get more than half of their revenue from Medicaid.

For 2015, the top executives earned $314,278, on average — more than double what state Medicaid directors earned, according to the report. Auditors didn’t find major differences in pay between for-profit and nonprofit Medicaid plans.

Executive compensation has risen as Community Health Group recorded hefty profits.

State officials had raised the rates paid to Medicaid plans in anticipation of the Affordable Care Act rollout in 2014, but the costs for newly insured patients weren’t as high as predicted. After the KHN investigation into insurer profits published in November, California’s Medicaid director, Jennifer Kent, vowed to recoup billions of dollars in excessive payments from insurers in coming months.

From 2014 to 2016, Community Health Group recorded profits of $344.2 million, according to state data obtained and analyzed by Kaiser Health News. Diaz said her insurer expects to return more than $100 million to the Medicaid program.

Robert Stern, a government ethics expert and former general counsel of California’s Fair Political Practices Commission, welcomed the scrutiny of Medicaid profits. But he said the business practices at Community Health Group suggest there is much more to be done.

“Taxpayer money should be spent as wisely as possible,” Stern said. “It’s not their money. It’s our money.”

Do you have a Medicaid managed care story? Contact Senior Correspondent Chad Terhune at cterhune@kff.org or via Signal at 657-226-0625

Bad Bedside Manna: Bank Loans Signed In The Hospital Leave Patients Vulnerable

Kaiser Health News:Marketplace - February 21, 2018

Laura Cameron, then three months pregnant, tripped and fell in a parking lot and landed in the emergency room last May — her blood pressure was low and she was scared and in pain. She was flat on her back and plugged into a saline drip when a hospital employee approached her gurney to discuss how she would pay her hospital bill.

Though both Cameron, 28, and her husband, Keith, have insurance, the bill would likely come to about $830, the representative said. If that sounded unmanageable, she offered, they could take out a loan through a bank that had a partnership with the hospital.

The hospital employee was “fairly forceful,” said Cameron, who lives in Fayetteville, Ark. “She certainly made it clear she preferred we pay then, or we take this deal with the bank.”

Hospitals are increasingly offering “patient-financing” strategies, cooperating with financial institutions to offer on-the-spot loans to make sure patients pay their bills.

Private doctors’ offices and surgery centers have long offered such no- or low-interest financing for procedures not covered by insurance, like plastic surgery, or to patients paying themselves for an expensive test or procedure with a fixed price.

But promoting bank loans at hospitals and, particularly, emergency rooms raises concerns, experts say. For one thing, the cost estimates provided — likely based on a hospital’s list price — may be far higher than the negotiated rate ultimately paid by most insurers. Sick patients, like Cameron, may feel they have no choice but to sign up for a loan since they need treatment. And the quick loan process, usually with no credit check, means they may well be signing on for expenses they can ill afford to pay.

The offers may sound like a tempting solution for scared, vulnerable patients, but they may not be such a great bargain, suggests Mark Rukavina, an expert in medical debt and billing at Community Catalyst, a Boston-based advocacy group.

His point: “If you pay zero percent interest on a seriously inflated charge, it’s not a good deal.”

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How The Loans Work

Between higher deductibles and narrower networks, patients are paying larger portions of their medical bills. The federal government estimates consumers spent $352.5 billion out-of-pocket on health care in 2016.

But many patients have trouble coming up with cash to pay bills of hundreds or even thousands of dollars, meaning hospitals are having a harder time collecting what they believe they are owed.

To solve their problem, about 15 to 20 percent of hospitals are teaming up with lenders to offer loans, said Bruce Haupt, CEO of ClearBalance, a loan servicing company. He, along with many other analysts, expects that percentage to grow.

The process begins with a hospital estimate of a patient’s bill, which takes insurance coverage into account. A billing representative then lays out payment plans for the patient, often while he or she is still being treated.

A Survival Manual On Medical Credit

Consumers — especially those whose insurance doesn’t cover a particular procedure, doctor or treatment — can end up on the hook for hundreds or thousands of dollars in medical bills. How do you make sure you’re getting a good financing deal? Here’s advice from the experts.

Wait. Don’t commit to a payment plan until you’re home and recovered. A loan may be the best option, but it’s hard to make a good decision under pressure.

Do your research. There are also charities that specialize in medical bill payment, and other organizations that may help. Nonprofit hospitals are legally required to provide financial assistance for certain low-income patients — figure out if you qualify.

Find out what Medicare, which covers elderly and disabled people, pays for the same treatment. Don’t pay above that amount.

A patient can then sign up for a loan, often without a credit check. Patients write smaller monthly checks to the lender, who has paid the hospital, while keeping a designated percentage of the bill as a fee.

Proponents view financing as a useful alternative to medical credit cards, which can surprise users with high interest rates. The partnerships are tempting for hospitals since they offload the need to administer monthly payment plans and collection efforts.

Federal law requires lenders be transparent about the loan terms, a protection that extends to consumers entering these health care arrangements. That means disclosure of interest rates, other fees and the payment schedule.

Even so, said Gerard Anderson, a Johns Hopkins health policy professor and an expert on health care pricing, “it’s an often gentler version of asking you to pay up.”

But an on-the-stretcher sell leaves patients little opportunity for due diligence.

“What’s the charge they’re using to determine what’s a reasonable amount to pay?” Anderson added.

Cameron was suspicious of the $830 estimate of her bill, since she had good coverage from her job at the University of Arkansas. She and her husband had extensive experience with the health care system and its costs. No one had ever asked her to pay upfront, even when her husband owed tens of thousands for cancer treatment.

“It just felt so uncomfortable to us that they would try to push us through a bank, which is designed to make a profit,” Cameron said.

A Growth Business With Risk Of Default

At Florida-based Orlando Health, which works with ClearBalance, loans typically range from $3,000 to $7,000, said Michele Napier, the health system’s chief revenue officer. The highest debt a patient has taken on — about $13,000 — was because of a high-deductible plan, she said.

“All of a sudden a catastrophic event occurs, and to have $13,000 in the bank account is a lot to ask,” she said. “They’re able to spread those payments.”

Though Laura Cameron and her husband have insurance, a hospital employee told them that an emergency room bill after a then-pregnant Laura was treated for a fall would likely total about $830. The employee said that if they couldn’t afford that, they could take out a loan through a bank that had a partnership with the hospital. The Camerons declined the offer. (Charlie Kaijo for Kaiser Health News)

Low-income patients without insurance likely will not need loans to finance large bills,because they should quality for aid from the hospital, or be treated as charity care, Napier said.

It’s a conversation that starts at registration, she added. “If a patient shares with us that they have no resources or limited resources to pay, we will provide information on our financial assistance and other programs including screening them for Medicaid.”

The idea is to foster open conversations about cost and help patients and doctors weigh their options, both financial and medical, said Rick Gundling, a senior vice president at the Healthcare Financial Management Association, a trade group.

“The patient may say, ‘Hey, do I need to do this knee surgery now? Can we wait until I save up, or do I have other options, like physical therapy?’” he said. “The doctor may say … let’s look at other options.”

But the loans can be a band-aid solution, leading vulnerable patients to sign up to pay far more than they should, said Kathleen Engel, a research professor of law at Boston-based Suffolk University and an expert in consumer credit and mortgage finance.

“The hospital potentially is charging the patient the full, what I would call ‘whack rate’ for their care,” she said. “They try to collect the debt.”

Since many of these loans come without credit checks or affordability tests, the odds are higher that a loan could be financially unwise, experts warn.

At ClearBalance, loans average about $1,700, Haupt said. In practice, that means some patients are financing $150 bills, while others have them for as large $50,000.

Default rates vary across the country, with the highest default rates — up to 1 in 5 patients — in places such as Texas and Louisiana. In other areas, closer to 6 or 7 percent of patients ultimately cannot pay off their loans.

“Some of these people are destined to default,” Engel said. “If you have to get a loan for $500 for medical care, that means you are really living at the margins.”

Cameron declined the loan — and chose not to hand over any other form of payment. She wanted to wait until she received her insurance statement.

In the end, the couple owed only $150, the copayment for an ER visit. “It felt to us like it could screw someone over who wasn’t aware about how to work that system,” she said, though she admitted to feeling intimidated as she lay on the stretcher.

She added: “It can be scary feeling like you owe someone money.”

Trump Administration works to give relief to Americans facing high premiums, fewer choices

HHS Gov News - February 20, 2018

In direct response to President Trump’s October 2017 Executive Order, the Departments of Health and Human Services (HHS), Labor, and the Treasury (the Departments) issued a proposed rule today that is intended to increase competition, choice, and access to lower-cost healthcare options for Americans. The rule proposes to expand the availability of short-term, limited-duration health insurance by allowing consumers to buy plans providing coverage for any period of less than 12 months, rather than the current maximum period of less than three months. The proposed rule, if finalized, will provide additional options to Americans who cannot afford to pay the costs of soaring healthcare premiums or do not have access to healthcare choices that meet their needs under current law.

“Americans need more choices in health insurance so they can find coverage that meets their needs,” said Health and Human Services Secretary Alex Azar. “The status quo is failing too many Americans who face skyrocketing costs and fewer and fewer choices. The Trump Administration is taking action so individuals and families have access to quality, affordable healthcare that works for them.”

Short-term, limited-duration insurance, which is not required to comply with federal requirements for individual health insurance coverage, is designed to provide temporary coverage for individuals transitioning between healthcare policies, such as an individual in between jobs, or a student taking a semester off from school. Access to these plans has become increasingly important as premiums have more than doubled between 2013 and 2017 in health plans on the Federal Health Insurance Exchange. And half of the counties in America have only one insurance carrier to choose from.

“Americans who find themselves between jobs or simply can’t afford coverage because prices are too high will be helped by President Trump’s Healthcare for All Executive Order,” said Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma. “In a market that is experiencing double-digit rate increases, allowing short-term, limited-duration insurance to cover longer periods gives Americans options and could be the difference between someone getting coverage or going without coverage at all.”

This announcement builds on the President’s October 2017 Executive Order 13813, “Promoting Healthcare Choice and Competition Across the United States,” which directs the Departments to consider proposing regulations or revising guidance to expand the availability of short-term, limited-duration insurance and allow it to cover longer periods. The Departments published a final rule in 2016, which restricted short-term, limited-duration insurance to less than three months. Key stakeholders, including state regulators, have expressed concerns that the current limit could cause harm to some consumers, limit consumer options, and have little positive impact on the risk pools in the long run. Today’s proposed rule would address these concerns by reverting to the previous definition of short-term, limited-duration insurance which permits coverage for nearly a full 12 months.

A fact sheet on today’s proposed rule can be found here:  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-02-20.html.

The link to the proposed rule can be found here:  https://www.federalregister.gov/documents/2018/02/21/2018-03208/short-term-limited-duration-insurance.

Trump Administration Proposes Rule To Loosen Curbs On Short-Term Health Plans

Kaiser Health News:HealthReform - February 20, 2018

Insurers will again be able to sell short-term health insurance good for up to 12 months under a proposed rule released Tuesday by the Trump administration that could further roil the marketplace.

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“We want to open up affordable alternatives to unaffordable Affordable Care Act policies,” said Health and Human Sservices Secretary Alex Azar. “This is one step in the direction of providing Americans health insurance options that are more affordable and more suitable to individual and family circumstances.”

The directive follows an executive order issued in October to roll back restrictions put in place during the Obama administration that limited these plans to three months. The rule comes on the heels of Congress’ approval of tax legislation that in 2019 will end the penalty for people who opt not to carry insurance coverage.

The administration also issued separate regulations Jan. 4 that would make it easier to form “association health plans,” which are offered to small businesses through membership organizations.

Together, the proposed regulations and the elimination of the so-called individual mandate by Congress could further undermine the Affordable Care Act marketplace, critics say.

Seema Verma, who now heads the Centers for Medicare & Medicaid Services, which oversees the marketplaces, told reporters Tuesday that federal officials believe that between 100,000 and 200,000 healthy people now buying insurance through those federal exchanges would switch to the short-term plans, as well as other people who are now uninsured.

The new rule is expected to entice younger and healthier people from the general insurance pool by allowing a range of lower-cost options that don’t include all the benefits required by the federal law — including plans that can reject people with preexisting medical conditions.

In addition, according to the proposed rule, the plans would not be required to sell to everyone, so people with medical problems may not be able to get this coverage.

“It will undermine the individual market risk pool,” said Kevin Lucia, research professor and project director at Georgetown University’s Health Policy Institute.

Over time, those remaining in ACA plans will increasingly be those who qualify for premium tax credit subsidies and the sick, who can’t get an alternative like a short-term plan, predicts Lucia and other experts. That, in turn, would drive up ACA premiums further.

“If consumers think Obamacare premiums are high today, wait until people flood into these short-term and association health plans,” said industry consultant Robert Laszewski. “The Trump administration will bring rates down substantially for healthy people, but woe unto those who get a condition and have to go back into Obamacare.”

Supporters said the rules are needed because the ACA plans have already become too costly for people who don’t receive a government subsidy to help them purchase the coverage. “The current system is failing too many,” said Verma.

And, many supporters don’t think the change is as significant as skeptics fear.

“It simply reverts back to where the short-term plan rules were prior to Obama limiting those plans,” said Christopher Condeluci, a benefits attorney who also served as tax counsel to the U.S. Senate Finance Committee.

But in their call with reporters, CMS officials noted that the proposed rule is seeking comment on guaranteeing the renewability of these short-term plans. That would be different than prior practice.

The comment period for the proposed rule runs for 60 days.

Short-term plans had been designed as temporary coverage, lasting for a few months while, for instance, a worker is between jobs and employer-sponsored insurance. They provide some protection to those who enroll, generally paying a percentage of hospital and doctor bills after the policyholder meets a deductible.

They are generally less expensive than ACA plans, because they cover less. For example, they set annual and lifetime caps on benefits, few cover prescription drugs, and most exclude coverage for maternity care, preventive care, mental health services or substance abuse treatment.

Most require applicants to pass a medical questionnaire — and they can also exclude coverage for preexisting medical conditions.

The plans are appealing to consumers because they are cheaper than Obamacare plans. They are also attractive to brokers, because they often pay higher commissions than ACA plans. Insurers like them because their profit margins are relatively high — and are not held to the ACA requirement that they spend at least 80 percent of premium revenue on plan members’ medical care.

Extending short-term plans to a full year could be a benefit to consumers because they must pass the health questionnaire only once. Still, if a consumer develops a health condition during the contract’s term, that person would likely be rejected if he or she tried to renew.

Both supporters and critics of short-term plans say consumers who do develop health problems could then sign up for an ACA plan during the next open enrollment because the ACA bars insurers from rejecting people with preexisting conditions.

“We’re going to have two different markets, a Wild West frontier called short-term medical … and a high-risk pool called Obamacare,” said Laszewski.

KHN senior correspondent Phil Galewitz contributed to this article.

Reducing Red Tape For Traveling Nurses

Kaiser Health News:States - February 20, 2018

Lauren Bond, a traveling nurse, has held licenses in five states and Washington, D.C. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires.

The 27-year-old got into travel nursing because she wanted to work and live in other states before settling down. She said she wished more states accepted the multistate license, which minimizes the hassles nurses face when they want to practice across state lines.

“It would make things a lot easier — one license for the country and you are good to go,” said Bond, who recently started a job in California, which does not recognize the multistate license.

The license, known as the Nurse Licensure Compact (NLC), was launched in 2000 to address nursing shortages and enable more nurses to practice telehealth. Under the agreement, registered nurses licensed in a participating state can practice in other NLC states without needing a separate license. They must still abide by the laws that govern nursing wherever their patients are located.

About half of the states joined the original compact, which was modeled on the portability of a driver’s license. Some states that declined to sign on cited a major flaw: The agreement didn’t require nurses to undergo federal fingerprint criminal background checks.

Last month, the National Council of State Boards of Nursing launched a new version of the NLC that requires those checks. Twenty-nine states have passed legislation to join the new agreement.

Jim Puente, who oversees the compact for the council, said he expects even more states to sign the agreement now that criminal background checks are required. He noted that nine states have legislation pending to join.

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Among states participating in the new nurse licensing compact are Iowa, Kentucky, Tennessee, Delaware, Idaho and Arizona.

California does not plan to join the new compact, largely because of concern about maintaining state training and quality standards. The state, like many others, already requires nurses to undergo background checks. Washington, Oregon and Nevada are among the other states that do not accept the multistate license.

Proponents of the nurse licensing agreement — both the old and new versions — argue that it helps fill jobs in places where there aren’t enough nurses and enables nurses to respond quickly to natural disasters across state lines.

“The nurse shortage tends to wax and wane regionally, so being able to move nurses where the needs are is really, really important,” said Marcia Faller, chief clinical officer at AMN Healthcare, a San Diego-based medical staffing company that employs Bond. The multistate license “really helps with that mobility … to deliver care to patients across state lines.”

Similar cross-state agreements exist for physicians, psychologists, emergency medical technicians and physical therapists.

In some states, the multistate nursing license is helpful because it streamlines the process for nurses doing case management or telehealth, said Sandra Evans, executive director of the Idaho Board of Nursing. Getting nurses to work in the rural areas of Idaho is a challenge, and hospitals often rely on telemedicine in places where the closest health care facility might be in Montana, she said.

Before Idaho joined the original NLC in 2001, nurses doing telehealth or case management needed numerous licenses to work across state lines, but now they “can travel virtually — electronically or telephonically — to help their clients,” she said.

Joey Ridenour, executive director of the Arizona State Board of Nursing, said one of the biggest advantages of the compact for her state is that it allows authorities to share information and collaborate with other states to investigate and discipline problem nurses. “We are able to take action faster,” she said.

Opponents of the compact argue that states have different standards, course requirements and guidelines and that nurses licensed in one state may lack the necessary knowledge or experience to practice in another one.

“The ability to control the standards of training and quality are of some concern to us,” said Linda McDonald, president of United Nurses and Allied Professionals union in Rhode Island, which participated in the original NLC but hasn’t signed on to the new one. “We want them trained in Rhode Island. We want them licensed in Rhode Island.”

Nurses in California have similar concerns. “We really want to make sure that nurses who are entering our state and taking care of our patients are competent and qualified,” said Catherine Kennedy, a Sacramento-area nurse who is secretary of the California Nurses Association. Some traveling nurses haven’t been, she added.

Kennedy said California does not have difficulty recruiting nurses, even without the compact, because of the state’s relatively high salaries and strict nurse-to-patient ratios in hospitals.

Research has shown that California’s minimum nurse staffing requirements, which were the first in the nation, can reduce workloads and burnout, improve the quality of care and make it easier for hospitals to retain their nurses.

Lauren Bond, a traveling nurse who has a temporary position at UCLA Medical Center, Santa Monica, has held licenses in five states and the District of Columbia. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires. (Courtesy of Robert Hernandez/UCLA Health)

Massachusetts, which has never participated in the nurse licensing compact, requires nurses licensed there to take courses on treating victims of domestic violence and sexual assault, said Judith Pare, director of the division of nurses for the Massachusetts Nurses Association. If the state allowed out-of-state nurses to practice in Massachusetts without getting a license there, they wouldn’t necessarily have that training, she noted.

Bond, the traveling nurse, said additional courses don’t make her more qualified to do her job. “Across the board, wherever you go to nursing school, everybody comes out with a similar experience,” said Bond, who works at UCLA Medical Center in Santa Monica. “Then most of the training you are going to do is on the job.”

Jenn Stormes works as a nurse and formally cares for her 18-year-old son, who has a severe seizure disorder and developmental disabilities. Stormes is licensed in Colorado, which participates in the multistate compact.

She has been able to use that license in some states. But she has also had to get several individual licenses so she can continue serving as her son’s nurse in other states where the family travels for medical care. Stormes estimated she has spent about $2,000 on licenses.

“It took me over a year to get all these licenses,” she said. “I had to prove to every state the same education, the same experience, the same fingerprints. I think it is a duplication of efforts and is a waste of everybody’s time and money.”

Anthem Calls On Eye Surgeons To Monitor Anesthesia During Cataract Surgery

Kaiser Health News:Insurance - February 20, 2018

If you need cataract surgery, your eye surgeon may have to do double duty as your anesthetist under a new policy by health insurer Anthem. In a clinical guideline released this month, the company said it’s not medically necessary to have an anesthesiologist or nurse anesthetist on hand to administer and monitor sedation in most cases.

Some ophthalmologists and anesthesiologists say the policy jeopardizes patient safety, and they are calling on Anthem to rescind it.

“The presence of anesthesia personnel is one of the key ingredients in the patient safety and effectiveness of cataract surgery today,” said Dr. David Glasser, an ophthalmologist in Columbia, Md., who is secretary for federal affairs at the American Academy of Ophthalmology, a professional group for eye physicians and surgeons. “An ophthalmologist cannot administer conscious sedation and monitor the patient and do cataract surgery at the same time.”

Anthem, which offers commercial insurance plans in 14 states, said anesthesia needs vary and so should coverage. According to a statement from the company, “Anthem’s Medical Policy and Technology Assessment Committee, a majority of whom are external physicians, reviewed the available evidence addressing the use of general anesthesia and monitored anesthesia care for cataract surgery. According to the literature reviewed, there is no one definitive approach regarding the use of anesthesia for cataract surgery and patient-specific needs should be taken into consideration as well as potential risk of harm to individuals who are sedated during surgical procedures.”

Medicare, the health care program for people age 65 and older, covers cataract surgery, including anesthesia services.

A cataract, typically related to aging, is caused by protein deposits on the lens of the eye that make it cloudy and can distort vision. During a cataract operation, the surgeon makes an incision in the surface of the eye with a laser or blade and then uses a tool to break up the clouded lens, pull it out and replace it with an artificial one.

Cataract surgery is common. More than half of Americans have either had a cataract or had cataract surgery by the time they reach age 80, according to the National Eye Institute.

Surgery is typically performed on an outpatient basis and takes less than an hour. Though drowsy while sedated, patients are generally conscious during the procedure and can hear what’s said to them and speak if necessary.

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Eye surgeons often have an anesthesiologist or a nurse anesthetist present to administer intravenous drugs to help keep the patient relaxed and ensure they don’t move during the operation as well as monitor their vital signs and adjust medication as necessary.

Anthem’s new policy states that this type of monitored anesthesia care is medically necessary only if the patient is under 18 years old, or is unable to cooperate or communicate because of dementia or other medical conditions, can’t lie flat, has known problems with anesthesia, or if a complex surgery is anticipated.

But some ophthalmologists and anesthesiologists disagree.

“I wouldn’t even consider doing a cataract surgery without an anesthesiologist or nurse anesthetist in the room,” said Dr. David Aizuss, an eye surgeon who is president-elect of the California Medical Association. “If you’re working inside the eye it’s a very confined space, and if the patient gets agitated and starts moving around you have to get the equipment out of the eye very quickly.”

Although Anthem posted the new policy online, providers are seeking clarification from the company about the timing of its implementation in their states, physicians said.

Until then, some practices are taking no chances. At the Freedom Vision Surgery Center in Encino, Calif., where Aizuss practices, Anthem patients who come in for cataract surgery are asked to pay $400 out-of-pocket upfront for anesthesia services.

Professional groups representing California eye physicians and anesthesiologists have written to Anthem requesting the policy be rescinded. In addition, the California Medical Association has lodged complaints with state regulators.

This isn’t the first time Anthem has come under scrutiny for changes to its clinical guidelines that some have charged help the company’s bottom line at patients’ expense. Last year, the company announced it would no longer pay for emergency department visits it later determined were not emergencies. Then in September it said it would no longer pay for imaging tests like MRIs in many cases if patients got them at hospital-owned centers rather than independent imaging centers.

Last week, Modern Healthcare reported that the company said it was modifying its ER rule so that certain types of visits would always be paid for, including those by patients who are directed to the emergency department by their provider or have recently had surgery.

Some safety experts said they were concerned about Anthem’s new policy, even for routine cataract surgeries.

“If you’re putting a knife in my eye, that’s not routine for me,” said Leah Binder, president and CEO of the Leapfrog Group, a nonprofit organization that advocates for improved safety and quality at hospitals. Noting that anesthesiologists and nurse anesthetists were pioneers in the patient safety movement, she said there are better ways for Anthem to save money than shutting them out of the operating room.

“How about identifying the surgeons who have the highest complication rates, and letting patients know about them?” she suggested.

Listen: Got A Sky-High Bill? Don’t Write The Check.

Kaiser Health News:Marketplace - February 16, 2018

Have you gotten a medical bill that sounds way too expensive or is just downright confusing? Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News, says don’t be intimidated — and don’t just pay that bill. Call, discuss and negotiate, instead.

And if you are up for it, share your bill and your experience with KHN and NPR. On Friday, Rosenthal and NPR Morning Edition Host Steve Inskeep discussed the launch of “Bill Of The Month,” a crowdsourced investigation.

Listen below.

‘Bill Of The Month’: A College Student’s $17,850 Drug Test

Kaiser Health News:Insurance - February 16, 2018

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

Full Story

Investigation: A $17,850 Bill For A Simple Urine Test Stuns Texas Student

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In her late 20s and attending college in Texas, Elizabeth Moreno suffered from debilitating back pain caused by a spinal abnormality. “I just could not live with the pain,” she said. “I couldn’t get dressed by myself, I couldn’t walk across my house, let alone to class, and nothing, no drug that had been prescribed to me, even dulled the pain.”

Moreno says she also tried chiropractic medicine and acupuncture, but they didn’t make the pain go away. Finally, a doctor at the student health center referred her to an orthopedic specialist who performed tests and concluded a disc was blocking nerves down her legs and needed to be removed. Moreno’s father, a retired Ohio doctor who had seen many failed back surgeries over his career, agreed it was the best course.

In late 2015, Moreno had the operation in Houston, which she described as “a complete success.” She gave it little thought when the surgical office asked her to leave a urine sample for a drug test.

Then the bill came.

Patient: Elizabeth Moreno, then 28, a student at Texas State University in San Marcos.

Total bill: $17,850 for a urine test in January 2016

Service provider: Sunset Labs LLC of Houston

Medical treatment: Moreno had a disc removed from her back in December 2015. Her surgeon prescribed an opioid painkiller, hydrocodone. At a follow-up office visit in mid-January 2016, the staff asked her to leave a urine sample, which she figured was routine. In March 2017, over a year later, the lab sent her a bill for $17,850 for testing her urine for a slew of drugs, including cocaine, methadone, anti-anxiety drugs and several other drugs she had never heard of.

(Story continues below.)

What gives: Urine drug testing has exploded over the past decade amid alarm over rising opioid overdose deaths. Many doctors who prescribe the pills rely on the urine tests to help reduce drug abuse and keep patients with chronic pain safe. Yet the tests have become a cash cow for a burgeoning testing industry, and critics charge that unneeded and often expensive ones are sometimes ordered for profit rather than patient care. Doctors can decide whether to test patients who take opioids for short periods, such as after an operation. Moreno’s surgeon would not discuss her urine test — why he ordered it and why the sample was tested for so many substances.

After having surgery to remove a disc from her back, Elizabeth Moreno gave it little thought when the surgical office asked her to leave a urine sample for a drug test. But then came the bill for the urine test: $17,850. (Julia Robinson for KHN)

Three experts contacted by Kaiser Health News questioned the need for such extensive testing and were shocked to hear of the lab’s prices. They said these tests rarely cost more than $200, and typically much less, depending on the complexity and the technology used. Some doctors’ offices use a simple cup test, which can detect several classes of drugs on the spot and could be purchased for about $10. Bills can climb higher when labs run tests to detect the quantity of specific drugs and bill for each one, as the lab did here.

The experts KHN interviewed said that the lab’s prices for individual tests were excessive, such as charging $1,700 to check for amphetamines or $425 to identify phencyclidine, an illegal hallucinogenic drug also known as PCP. They also criticized a charge of $850 for two tests to verify that her urine sample had not been adulterated or tampered with.

Moreno’s insurer, Blue Cross and Blue Shield of Texas, refused to pay any of the bill, arguing that the lab was out-of-network and thus not covered. Had it chipped in, it would have covered the service at $100.92, according to an explanation of benefits the insurance company sent to Moreno.

Sunset Labs says its list prices were “in line” with its competitors in the area. It also said doctors treating pain agree extensive urine testing is “the best course of action” and that a lab “is not in the position” to question tests ordered by a doctor.

Related Story: Pain Hits Long After Surgery When Doctor’s Daughter Is Stunned By $17,850 Urine Test

Resolution: Fearing damage to his daughter’s credit rating, Moreno’s father, Dr. Paul Davis, paid the lab $5,000 in April 2017 to settle the bill. A retired doctor, he also has filed a formal complaint about the bill with the Texas attorney general’s office, accusing the lab of “price gouging of staggering proportions.” The lab’s attorney said he was not aware of the complaint. A Texas attorney general’s spokesperson confirmed to KHN that the office had received complaints about the lab, but declined further comment.

The takeaway: When a physician asks for a urine or blood sample, always ask what it’s for. Insist that it be sent to a lab in your insurance network.

Source: AG complaint; interviews

In An Effort To Curb Drug Costs, States Advance Bills To Prod Feds On Importation

Kaiser Health News:States - February 16, 2018

Norm Thurston is a “free-market guy” — a conservative health economist in Republican-run Utah who rarely sees the government’s involvement in anything as beneficial.

But in a twist, the state lawmaker is now pushing for Utah to flex its muscle to spur federal action on ever-climbing prescription drug prices.

“This is something that a red state like Utah could do. I don’t think this is a partisan issue,” Thurston said. “Those outrageous cost increases are not the result of the free market.”

The approach: Let the state contract with wholesalers in Canada, importing cheaper prescriptions from up north and distributing them to the state’s health care system.

Other states — Vermont, West Virginia and Oklahoma, among them — are following similar paths, pushing legislation that would seek permission from the Trump administration to launch their own plans to import drugs from Canada.

For years, American consumers have tried to buy cheaper drugs from their northern neighbor, sometimes packing into buses for day trips to Canadian pharmacies, or patronizing American stores that help them order drugs from abroad. But the practice is illegal.

The states want to change that, and set up a formal process that nets broader savings. The idea is for the state health department to set up a wholesale program that buys drugs from Canada and resells them to local pharmacies and hospitals. Individual states would be responsible for ensuring that the medications are safe and that importing them does save money.

“This statute is putting pressure on the federal government to take a harder look at these questions,” said Rachel Sachs, an associate law professor at Washington University of St. Louis, who researches drug price regulations. “The state legislatures can say, ‘Look, we’re doing everything we can, but we do need the federal government to help us out on this.’”

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The federal government has been slow to act on this issue, and skeptics say a 30-page Trump administration memo on drug pricing released late last week would likely have only limited impact.

But states, whose budgets for Medicaid and state employee health programs are squeezed by these costs, are moving forward.

In Vermont alone, drug spending has gone up by 35 percent from 2010 to 2015, the most recent year for which data are available.

Backers of the state plans say the strategy is a no-brainer that could save hundreds of millions of dollars. They discount concerns about drug safety, arguing that drugs from Canada are made by reputable companies, often in the same facilities and by the same firms that sell them in the U.S. — but at much higher prices.

“We would be bringing in drugs intended for the Canadian market, and therefore at Canadian pricing,” Thurston said. “One would assume if we could come up with a program that meets the recommendations of federal law, what justification would the [Health and Human Services] secretary have for saying no?”

The state measures follow model legislation developed by the National Academy for State Health Policy that uses a framework put in place by the 2003 federal law that created the Medicare Part D program. That law says the U.S. Department of Health and Human Services can approve drug importation plans if it is convinced the plans will save money and will not create any public health concerns.

Once passed, these laws task state health departments with overseeing the development of these programs. After the health department settles on the specifics, state officials must negotiate implementation with HHS. That could take years.

It is also likely to be an uphill battle.

In 15 years, HHS has never acted upon the 2003 law by approving any drug importation program.

Last spring, when members of Congress pushed a national bill, a bipartisan group of former Food and Drug Administration commissioners came out in opposition, arguing it would be impossible to verify drug safety absolutely. That bill ultimately failed to garner a majority vote.

It’s unclear where the current administration stands on this issue.

Alex Azar, the newly confirmed HHS secretary, has been coy on the subject — though in a confirmation hearing last fall, he said importing drugs from Canada could create safety concerns. Despite multiple requests, HHS did not provide comment for this story by the publication deadline.

The pharmaceutical industry echoed the cautions about safety.

“The proposals we are seeing in states across the country threaten the safety of patients and families and will not deliver the savings they promise,” said Priscilla VanderVeer, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America (PhRMA).

In the states, though, backers say their bills address that concern.

And other analysts argued that, regardless, safety of Canadian drugs isn’t a real issue.

“A lot of the drugs used in the United States and in Canada are made in the same plants, in countries like India or Europe,” said Michael Law, a pharmaceutical policy expert and associate professor at the University of British Columbia’s Center for Health Services and Policy Research. “The U.S. FDA and other regulatory agencies rely on other agencies’ inspections — the idea that Canadian drugs are these dangerous drugs is a red herring.”

A bigger question, he said, is the amount of savings these bills would generate.

Thurston pointed to Utah state analyses that suggest the state could save $70 million in the private sector, and another $20 million to $30 million in state-funded insurance programs. If approved, he said, the state would target 15 to 20 drugs to import — insulin, for instance, because it is bought in large quantities, or expensive drugs that treat hepatitis C or HIV.

Others expressed skepticism.

For one thing, the true price of prescription drugs isn’t always clear. There’s the list price — and generally, those are much higher in the United States. But insurance plans often negotiate rebates, or discounts, from the drug company — meaning they can end up paying far less than what’s advertised. Those discounts aren’t public, making it much harder to compare prices between the two countries.

The drug industry would also likely employ strategies to counter importation.

Pharmaceutical companies, Law noted, stand to lose if American states are importing cheaper drugs. That could motivate them to tamp down how many prescriptions they sell in Canada, or find other ways to discourage Canadian wholesalers from participating.

“My guess is any Canadian distributor to engage in that would find their [medication] supply dwindle quickly, because the drug companies would stop supplying,” he said. “The supplier systems in the United States would probably find it hard to get a [Canadian drug] supply in the long term.”

That’s certainly a real concern, said Claire Ayer, a Vermont state senator and Democrat who chairs her legislature’s Health and Welfare Committee.

“We can’t tell drug companies or wholesalers what to do in Canada,” she added.

VanderVeer said PhRMA could not speculate on how individual drug companies may react to importation.

Still, these state efforts could spur the federal government to take action, Sachs suggested — even if it’s unclear how large an impact importation would have.

“Importation will not solve all the problems — and I don’t think states see it as such,” she said. “But it could be a useful way to put pressure on a federal government and White House that has thus far largely been inactive on this topic.”

Pain Hits After Surgery When A Doctor’s Daughter Is Stunned By $17,850 Urine Test

Kaiser Health News:Insurance - February 16, 2018

After Elizabeth Moreno had back surgery in late 2015, her surgeon prescribed an opioid painkiller and a follow-up drug test that seemed routine — until the lab slapped her with a bill for $17,850.

A Houston lab had tested her urine sample for a constellation of legal and illicit drugs, many of which, Moreno said, she had never heard of, let alone taken.

“I was totally confused. I didn’t know how I was going to pay this,” said Moreno, 30, who is finishing a degree in education at Texas State University in San Marcos and is pregnant with twins.

Related: ‘Bill Of The Month’: A College Student’s $17,850 Drug Test

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Do you have an exorbitant or baffling medical bill? Join the KHN and NPR’s Bill-of-the-Month Club and tell us about your experience. We’ll feature a new one each month.

Submit Your Bill

Her bill shows that Sunset Labs LLC charged $4,675 to check her urine for a slew of different types of opioids: $2,975 for benzodiazepines, a class of drugs for treating anxiety, and $1,700 more for amphetamines. Tests to detect cocaine, marijuana and phencyclidine, an illegal hallucinogenic drug also known as PCP or angel dust, added $1,275 more.

The lab also billed $850 to test for buprenorphine, a drug used to treat opioid addiction, and tacked on an $850 fee for two tests to verify that nobody had tampered with her urine specimen.

Total bill: $17,850 for lab tests that her insurer, Blue Cross and Blue Shield of Texas, refused to cover, apparently because the lab was not in her insurance network. The insurer sent Moreno an “explanation of benefits” that says it would have valued the work at just $100.92.

Moreno’s father, in a complaint to the Texas attorney general’s office about the bill, identified the Houston surgeon who ordered the costly test as Dr. Stephen Esses. His office told Kaiser Health News the surgeon would have no comment.

Bill Of The Month

Understanding A $17,850 Urine Test

Read More

Sunset Labs is part of a network of pain clinics and other medical businesses founded by Houston anesthesiologist Phillip C. Phan, according to Texas secretary of state filings and court records. Court records say Phan’s companies also own the facility where Moreno had her operation.

Three experts interviewed by KHN said the lab grossly overcharged; they also doubted the need for the test.

“This just blows my mind,” said Jennifer Bolen, a former federal prosecutor and lab and pain management consultant. “It’s very high and incredibly out of the norm.”

Dan Bowerman, a medical fraud expert, called the lab bill “outrageous” and “unconscionable” and said it should have prompted an investigation.

“Sounds real fishy,” added Charles Root, a veteran industry adviser. He wondered if the lab had “misplaced the decimal point,” because such a test should cost a few hundred dollars, tops.

The lab disagrees.

Sunset’s billings “are in line with the charges of competing out-of-network labs in the geographical area,” lab attorney Justo Mendez said in an emailed statement.

Mendez said pain doctors agree that extensive urine testing is “the best course of action” and that a lab “is not in the position” to question tests ordered by a doctor.

Urine testing for patients with chronic pain has grown explosively over the past decade amid a rising death toll from opioid abuse. Pain doctors say drug testing helps them make sure patients are taking the drugs as prescribed and not mixing them with illegal substances.

Yet the testing boom costs billions of dollars annually and has raised concerns that some labs and doctors run urine tests needlessly — or charge exorbitant rates — to boost profits.

Some insurers have refused to pay, which can leave patients like Moreno threatened with ruinously high bills they had no idea they had incurred.

“Surprise bills larded with unexpected expenses and little explanation inflict sticker shock on vulnerable patients,” said James Quiggle, communications director of the Coalition Against Insurance Fraud, whose members include insurers, consumer groups and government agencies. Quiggle said many “puffed-up bills straddle a fine line between abuse and outright fraud.”

Moreno said her insurance covered the disc removal surgery in December 2015. She said the operation went well and she weaned off the hydrocodone pain pills. To her surprise, on a second return about a month later, the surgeon’s office asked her to leave a urine sample.

“I didn’t think anything of it,” Moreno said of the test. “I said fine, whatever.”

More than a year later, she said, the lab phoned while she was driving and asked her to pay the $17,850 bill. The lab then sent her an invoice, dated March 10, 2017, which states: “[B]ased upon information from your health plan, you owe the amount shown.”

(Story continues below.)

Luckily, her father, Dr. Paul Davis, was visiting her in Texas at the time. Davis, 66, is a retired family practice doctor from Findlay, Ohio.

Davis doubted the need for the test, not to mention what he thought was a sky-high price. He said the University of Findlay, where he helped train physician assistants, gave applicants a basic drug test at a cost of $174, while the local juvenile courts in Ohio paid $10 for a simple drug screen.

Fearing it would ruin his daughter’s credit scores, Davis said, he called Sunset and settled the bill in April 2017 by paying $5,000, which he said he now regrets. The lab sent Moreno a receipt that said it discounted her bill because of “financial need/hardship.”

Asked for comment, Blue Cross spokesman James Campbell said he couldn’t discuss a specific case but noted:

”We are disappointed as well as concerned about transparency whenever [any] member is surprised by an excessive charge for a seemingly routine service or received services that may not have been medically necessary.”

Campbell also said the lab was out-of-network and “we do not control how much they charge for services rendered.” The insurer encourages patients to confirm that all medical care they seek comes from medical providers in the Blue Cross network, he added.

Prices for urine tests can vary widely depending upon complexity and the technology used. Some doctors’ offices use a simple cup test, which can detect several classes of drugs on the spot. These tests rarely cost more than $200, and typically much less.

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Bills climb higher when labs check for levels of multiple drugs and bill for each one, a practice insurers argue is seldom medically justified. But even labs sued by insurers alleging wildly excessive testing typically have billed $9,000 or less, court records show. One insurer sued a lab for charging $1,845 for a drug test, for instance.

Davis said Sunset Labs ignored his requests for a full explanation of the charges. In May, he filed a written complaint about the bill with the Texas attorney general’s office that included a copy of the bill and accused the lab of “price gouging of staggering proportions.”

“Young people just starting out, such as my daughter, may not have the ability to pay and this could result in damaged credit ratings or even bankruptcy,” he wrote.

Davis got a letter back from Attorney General Ken Paxton, who said the office would “review the information.” A spokesperson for Paxton told KHN: “We have received complaints about that business, but we can’t comment on anything else.” Sunset attorney Mendez said the lab is “not aware” of any such complaints.

In an interview, Davis also questioned the need for his daughter’s urine test because she received opioids only for a short period and the results would have had no impact on her treatment. In his complaint to the attorney general, Davis said the surgeon told him he ordered the tests because he feared possible retribution from the state medical licensing board for not testing patients who had been prescribed an opioid. The Texas Medical Board doesn’t require urine tests for patients receiving opioids for short-term pain, said spokesman Jarrett Schneider. That’s a “question of independent medical judgment as to whether the physician believes a drug test should be required,” he said.

Bad Reviews

Sunset Labs has an “F” rating with the Houston Better Business Bureau, which on its website posts an August 2017 complaint from a patient charged $16,150 for a urine test.

“This is not covered under my health insurance so I am expected to pay this excessive bill,” the complaint reads.

A second website that publishes government billing numbers of doctors and medical businesses includes a comment section with more than a dozen negative “reviews,” mostly complaints that the lab slammed patients with thousands of dollars in fees their insurers balked at paying.

In a pair of lawsuits filed in 2015, three doctors seeking to quit working at pain clinics operated by Phan accused the facilities of improper billing practices, including unnecessary urine testing. The doctors said they feared losing their medical licenses unless they severed their ties.

In one suit, Drs. Purvi Patel and Lance LaFleur also alleged that the pain clinics “pressured” doctors to overprescribe medical gear and genetic tests to insured patients “regardless of medical necessity.” The case did not go forward because the doctors did not pursue it. Neither doctor would comment.

In the second legal case, pain specialist Dr. Baominh Vinh said he resigned in April 2015 “based on certain questionable business practices … that are inconsistent with my ethical boundaries.” Vinh also alleged urine testing was overused. In a countersuit against Vinh, the pain clinics called his allegations a “falsehood” to justify violation of his employment contract.

The parties settled in March of last year. Terms are confidential, but a lawyer for the pain clinics said Vinh paid money to the company “and not vice versa.”

FDA Head Vows To Tackle High Drug Prices And Drugmakers ‘Gaming The System’

Kaiser Health News:Insurance - February 15, 2018
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Food and Drug Administration Commissioner Scott Gottlieb said he will do everything “within my lane” to combat high drug prices and that he sees drug companies “gaming the system to try to block competition” in a multitude of ways in the marketplace.

In a wide-ranging interview with Kaiser Health News on Thursday, Gottlieb also said that he wants to speed up the U.S. approval process for generic and “biosimilar” versions of biologic drugs, which are drugs comprised of living organisms, such as plant or animal cells.

“Where we see things that we can address, we’re going to take action,” Gottlieb said, adding that he is most bothered when brand-name companies use tactics to block makers of generics and biosimilars from developing drugs. He deflected questions about whether the FDA approves drugs of questionable value that carry exorbitant prices.

“I think we should have a free market for how products are priced,” Gottlieb said. A free market “provides proper incentives for entrepreneurs who are going to make the big investments needed to innovate. But that system is predicated on a premise that when patents have lapsed you’ll have vigorous competition from generic drugs.”

The FDA, Gottlieb said, worked with the White House on a proposal to bring generics to market faster by ensuring that a 180-day exclusivity period isn’t used by drugmakers to block competition. He said there are “situations where you see deals cut” in which a drugmaker will get the 180-day exclusivity and then be persuaded to sit on it without ever selling the drug — essentially delaying the brand drug from facing generic competition.

Currently, generics makers must buy large quantities of the brand-name product in the U.S. to run their own clinical trials. But the companies that make brand-name medicines, in some cases, are making it very difficult for makers of generics to purchase their drugs, he said.

“They are adopting all kinds of commercial restrictions with specialty pharma distributors and wholesalers” to prevent sales to generic companies, Gottlieb said, adding that not every branded company is using the tactic, but it is “going on across the board.”

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To come up with a generic, a drugmaker needs 2,000 to 5,000 doses for testing, Gottlieb said. He said the companies were willing to pay sticker price but are being blocked in other ways.

The FDA is now exploring whether generics makers could buy the drugs they need in the less-expensive European market without having to do additional work to prove the biologics from Europe are the same — even though the American and European versions are often manufactured in the same plants. Gottlieb wants to get rid of such tests, known as “bridging” studies.

“I have lawyers now looking at this,” Gottlieb said. The FDA has been exploring the issue for a couple of months, he said, and he thinks it may be “hard for us to get there without legislation, but we’re not done yet looking at this; we’re still pressing on this.”

Last fall, Gottlieb said that he wanted to “end the shenanigans” that interfere with competition in the marketplace. Since then, the FDA has released a steady stream of action plans and new guidance that tinkers with the drug development system.

“All of these steps are going to have an impact, and I don’t think there’s one silver bullet,” Gottlieb said. “If anyone [thinks] there is one thing you can do with policy intervention that is going to dramatically change drug prices, that’s not true.”

Instead, he said, there are “layers of things that we can do to try to make sure the system is working.”

The agency has been approving drugs at a fast clip: The FDA’s Center for Drug Evaluation and Research approved a record 46 new drugs in 2017, including treatments for sickle cell disease and Batten disease and new cancer therapies. The list doesn’t include landmark gene and cellular therapies and vaccines that are regulated as biologics.

That rate of approvals has raised concerns about the value and quality of drugs being approved. Specifically, criticism of the FDA’s handling of cancer drugs has increased in recent years.

Although some patient advocates want the FDA to approve new drugs more quickly, others charge that the agency greenlights mediocre cancer drugs that do little to prolong survival or improve quality of life. A 2014 study found that the cancer drugs approved from 2002 to 2014 extended survival by an average of just 2.1 months. For many cancer drugs, there is no evidence showing they prolong life.

Once drugs are on the market, companies can charge whatever the market will bear; prices for cancer therapies now routinely top $100,000 a year.

But Gottlieb said it’s not his job to help insurance companies or government programs decide which drugs to cover. Health systems and insurers “have a difficult time saying no,” Gottlieb said, “so they want to put the regulator in the position of saying no.”

Gottlieb acknowledged that it can be difficult for insurance plans to decide which drugs they should include on their drug list. But insurance plans “ought to have the confidence to make [such decisions] and not say, ‘Well, it’s the job of the federal government to make those decisions for us.’”

Gottlieb defended his agency’s approval of drugs that help the average cancer patient live just two or three extra months, noting that some patients do much better than average on cancer drugs — perhaps living months or even years longer than expected. He also said it would be wrong to make cancer patients wait years to try a drug that has a chance to help them.

“We’re ultimately going to learn why some patients respond really well and some don’t,” he said. If you “try to have all that information upfront when you approve a drug, [you’ll] end up having a development process that is very long and very costly and a lot fewer products will be developed.”

Gottlieb maintains that the FDA sets a high standard for approving drugs.

“It is important that we have a rigorous bar” for approval, he said, “but a bar that doesn’t impede these products from coming to the market.”

Podcast: KHN’s ‘What The Health?’ What Do The Budget, Idaho And FDA Chief Scott Gottlieb Have In Common?

Kaiser Health News:HealthReform - February 15, 2018

President Donald Trump released his first full budget proposal this week, with many recommended cuts and some major changes to health programs. But Congress has already agreed on most spending levels for next year, so this budget is even more likely to be ignored than a typical presidential budget plan.

Meanwhile, states are trying to cope with last year’s changes to the Affordable Care Act in very different ways. Several states, mostly led by Democrats, are considering whether to set penalties for people who don’t have insurance — a provision of the ACA that Congress repealed in December. Idaho, meanwhile, is offering to let insurers sell plans that don’t cover the ACA’s required set of benefits and discriminate against people with preexisting health conditions.

Plus, Scott Gottlieb, commissioner of the Food and Drug Administration, talks about getting generic drugs to market faster and how the agency is working with Congress on ways to help patients with terminal illnesses get easier access to experimental treatments.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Stephanie Armour of The Wall Street Journal, Paige Winfield Cunningham of The Washington Post and Margot Sanger-Katz of The New York Times.

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Among the takeaways from this week’s podcast:

  • Even though few of the proposals in Trump’s budget are likely to be enacted, it does lay down some important markers for the administration. Those include backing sweeping changes to Medicaid and eliminating many of the ACA’s coverage requirements.
  •  Blue states considering stepping into the void left by Congress’ repeal of the individual insurance mandate penalties have limited time to act. Insurers start making decisions about whether to participate in the individual market in the spring.
  • The FDA’s Gottlieb tells Rovner and KHN’s Sarah Jane Tribble he expects there will be a compromise on Capitol Hill on “right-to-try” legislation that would make it easier for patients with terminal illnesses to gain access to experimental therapies.
  • Idaho is moving forward on its plan to allow insurers to offer policies that do not comply with the requirements of the Affordable Care Act. On Capitol Hill this week, Health and Human Services Secretary Alex Azar would not say whether the federal government will step up to stop them.

Plus, for “extra credit,” in honor of Valentine’s Day, the panelists offer their favorite “Health Policy Valentines” for 2018. You can see more by searching the hashtag #healthpolicyvalentines on Twitter.

Julie Rovner:

"I love you" is three words
"Health care" is two.
"Data" is plural
(I love grammar AND you)#healthpolicyvalentines

— Deborah Roseman (@roseperson) February 12, 2018

Stephanie Armour:

BREAKING: My love for you is as urgent and long as an @ASlavitt news thread. #healthpolicyvalentines 1/

— Joy L. Lee, PhD (@superlegitJoy) February 14, 2018

Paige Winfield Cunningham:

Damn, girl. Are you Kentucky Medicaid? Because you are making me work for you. #healthpolicyvalentines

— Eric Michael Garcia (@EricMGarcia) February 14, 2018

Margot Sanger-Katz:

I thought writing a #healthpolicyvalentines would be easy, but this year, there’s a work requirement.

— Andy Slavitt (@ASlavitt) February 13, 2018

To hear all our podcasts, click here.

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

Idaho Blue Cross Jumps Into Controversial Market For Plans That Bypass ACA Rules

Kaiser Health News:HealthReform - February 14, 2018
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That didn’t take long.

It’s barely been two weeks since Idaho regulators said they would allow the sale of health insurance that does not meet all of the Affordable Care Act’s requirements — a controversial step some experts said would likely draw legal scrutiny and, potentially, federal fines for any insurer that jumped in.

On Wednesday, Blue Cross of Idaho unveiled a menu of new health plans that break with federal health law rules in several ways, including setting premiums based on applicants’ health.

“We’re trying to offer a choice that allows the middle class to get back into insurance coverage,” said Dave Jeppesen, the insurer’s executive vice president for consumer health care.

The firm filed five plans to the state for approval and hopes to start selling them as soon as next month.

The Blue Cross decision ups the ante for Alex Azar, the Trump administration’s new Health and Human Services secretary. Will he use his authority under federal law to compel Idaho to follow the ACA and reject the Blues plans? Or will he allow state regulators to move forward, perhaps prompting other states to take more sweeping actions?

At a congressional hearing Wednesday, even as Blue Cross rolled out its plans, Azar faced such questions.

“There are rules. There is a rule of law that we need to enforce,” Azar said. Observers noted, however, he did not specifically indicate whether the federal government would step in.

Robert Laszewski, a consultant and former insurance industry executive, thinks it should.

“If Idaho is able to do this, it will mean other … states will do the same thing,” he said. “If a state can ignore federal law on this, it can ignore federal law on everything.”

Idaho’s move stirs up more issues about individual insurance market stability.

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Policy experts say that allowing lower-cost plans that don’t meet the ACA’s standards to become more widespread will pull younger and healthier people out of Obamacare, raising prices for those who remain. Supporters say that is already happening, so this simply provides more choices for people who earn too much to qualify for subsidies to help them purchase ACA coverage.

The state’s move to allow such plans, announced in January, drew harsh and swift criticism.

“Crazypants illegal,” tweeted Nicholas Bagley, a law professor at the University of Michigan and former attorney with the civil division of the U.S. Department of Justice, who said that states can’t pick and choose which parts of federal law to follow. Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, pointed out that health insurers could be liable for sharp fines if they are found to be in violation of the ACA.

But both Idaho regulators and Blue Cross officials say they are not worried.

Jeppesen said the ACA gives states regulatory authority “to make sure the market works and is stable,” and the insurer is simply “following what the state has given us guidance” to do.

Other insurers in Idaho are taking a much more cautious approach, telling The Wall Street Journal they are not stepping up immediately to offer their own plans.

Laszewski said they are likely waiting to see what legal challenges develop.

“If I were running an insurance company, there’s no way I would stick my neck out until the high court has ruled in favor of this — and they’re not going to,” he said.

Jeppesen said his company has consulted with legal experts and is moving ahead with confidence. The aim is to bring people back into the market, particularly the young, the healthy and those who don’t get a tax credit subsidy and can’t afford an ACA plan.

For some people — especially younger or healthier applicants — the new plans, which the insurer has named Freedom Blue, cost less per month than policies that meet all ACA rules.

They accomplish that by limiting coverage. If they are allowed to be sold, consumers will need to weigh the lower premiums against some of the coverage restrictions and varying premiums and deductibles, policy experts say.

The plans, for example, will include a “waiting period” of up to 12 months for any preexisting conditions if the applicant has been without coverage for more than 63 days, Jeppesen said.

Additionally, they cap total medical care coverage at $1 million annually. And premiums are based, in part, on a person’s health: The healthiest consumers get rates 50 percent below standard levels, while those deemed unhealthy would be charged 50 percent more.

All those caveats violate ACA rules, which forbid insurers from rejecting coverage of preexisting conditions or setting dollar caps on benefits or higher premiums for people with health problems.

But the rates may prove attractive to some.

Premiums for a healthy 45-year-old, for example, could be as low as $195 a month, according to a comparison issued by the insurer, while a 45-year-old with health problems could be charged $526. In that case, the 45-year old would find a lower price tag — $343 a month — for an ACA-compliant bronze plan.

While Freedom Blues plans cover many of the “essential health benefits” required under the ACA, such as hospitalization, emergency care and mental health treatment, they do not include pediatric dental or vision coverage. One of the five plans does not include maternity coverage.

When compared with one of the Blues’ ACA-compliant plans — called the Bronze 5500 — the new standard Freedom Blue plan’s annual deductibles are a mixed bag.

That’s because they have two separate deductibles — one for medical care and one for drugs. If a consumer took only generic drugs, the new plan would be less expensive, according to details provided by the plan. But with a $4,000 deductible for brand-name drugs, the Freedom Blue plan requires more upfront money before full coverage kicks in than the ACA-compliant plan it was compared with.

Jeppesen said the insurer hopes to attract many of the “110,000 uninsured state residents who cannot afford [ACA] coverage.”

That’s the total number of uninsured people who earn more than 100 percent of the federal poverty level in the state, he said.

Sarah Lueck, senior policy analyst for the Center on Budget and Policy Priorities, cautioned that some of those residents might actually be eligible for subsidies under the ACA, which are available to people earning up to four times as much.

“Many … could be getting subsidies for more comprehensive coverage through the [ACA-compliant state exchange] and would be better off,” Lueck said.

Work-For-Medicaid Lifts Off In Indiana, But Even Fans Fret About Red Tape

Kaiser Health News:States - February 14, 2018

Indiana is one of the states poised to enact work requirements for some citizens with Medicaid coverage — a controversial policy and long-sought goal for Republicans. But advocates for the poor have protested loudly in recent months, saying many will lose coverage or be ensnared by bureaucratic mistakes. KHN’s Sarah Varney reports in collaboration with PBS NewsHour.

Read the full transcript:

Judy Woodruff: Republicans in Washington and around the nation are poised to achieve a long-sought goal: reshaping Medicaid. That’s medical assistance mainly for those with low incomes.

The Trump administration has given the go-ahead to Indiana and other states to require many adult Medicaid recipients to do work or community service in order to qualify.

The idea is popular in Indiana, but some exemptions will be granted for groups like caregivers, students, those in addiction recovery programs.

Still, as special correspondent Sarah Varney reports, advocates for the poor say they are worried that the requirements will jeopardize medical care for more than 30,000 people there.

This story was produced in collaboration with our partner Kaiser Health News.

Sarah Varney: Katie Josway is a songwriter and the front woman for the Indianapolis band Gypsy Moonshine. Over the past few years, she’s been covered by Medicaid. The public insurance program is largely free to patients in other states.

But, in Indiana, Josway pays about $25 a month. If she misses too many payments, the state will drop her insurance.

Katie Josway: I think that it’s fair to expect people to contribute based on their level of income and their ability to do so. So, I think that’s kind of what we do in a society. Right?

Varney: But Josway, who also works as a massage therapist, worries about changes coming to Medicaid in Indiana. And even though she earns about $16,000 a year, near the federal poverty level, she will have to prove that she’s working at least 20 hours a week to stay insured, a tough bet when her hours fluctuate each week.

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Katie Josway: I’m trying to get people to book with me, but if they don’t, then I don’t want to be penalized and potentially lose my insurance as well. Like, that seems really harsh.

And I am concerned about that growing trend of assuming that anyone who is on an assistance program somehow is mooching off the government or doesn’t try hard enough.

Varney: Under former Gov. Mike Pence, now vice president, Indiana became the first state to enact a much more conservative approach to Medicaid.

But the idea of requiring most adults in the program to work was stopped by the Obama administration. Now the Trump White House is allowing Indiana to move ahead.

Seema Verma: What is going on in the Medicaid program today is that we have a very inflexible system.

Varney: The effort is being led by Seema Verma, whom President Trump appointed to lead the Centers for Medicare & Medicaid Services.

Verma once worked for Gov. Pence in Indiana, where she tested out her conservative policies, like coverage lockouts and monthly premiums. Now she’s taking her vision even further, by allowing states to impose work requirements and making smokers pay more for public insurance.

The administration has approved Kentucky and Indiana’s plans and at least eight other states have submitted similar requests. But advocates for the poor have protested loudly in recent months, saying many will lose coverage.

Nationwide, 60 percent of Medicaid recipients already work. And advocates say the ones that don’t usually have a good reason for not having a job, because they’re caregivers, students or in drug recovery.

At the heart of the debate are people like Antonio Berlanga. He’s 60 years old and lives in Clinton, Ind., and spent most of his adult life without health insurance. Indiana first expanded Medicaid coverage to a small number of poor adults in 2008, as the recession decimated the state’s economy.

Then, in 2015, Gov. Pence expanded it even further under the Affordable Care Act to about 442,000 adults. That allowed Berlanga, a janitor at a local church, to enroll in coverage. Now he’s been treated for severe shoulder pain, cirrhosis of the liver and hepatitis C at the Valley Professionals Community Health Center.

Like a lot of Hoosiers, he’s worried about what the changes could mean for him, but he’s willing to do his part.

Antonio Berlanga: Yes, I just don’t want it for nothing. If I’m still able to do something and give something back, then let’s go. I have still got a heart. I might not be able to, you know, totally do things. But I will do what I can, you know?

Varney: Dr. John Wernert, one of the architects of Indiana’s Medicaid plan, says that’s what he’s heard in every part of the state, that people on Medicaid want to feel like they’re contributing in some way.

Dr. John Wernert: It doesn’t have to be a lot of money for people to feel like they have some ownership and take some responsibility for the administration of their program.

One of the things I can say with confidence as a psychiatrist that has practiced for 30 years is, stigma is real. And there’s a great stigma that folks that are living at or near the poverty level don’t care about their health. Well, that’s completely wrong. They have just not been put in a position where they could take some ownership of that.

Varney: Revenues at Indiana’s hospitals have jumped as more Hoosiers have become insured.

The CEO of Margaret Mary Health, Tim Putnam, hired a company called ClaimAid to enroll uninsured patients into Medicaid and help them comply with Indiana’s complicated rules.

Now they will have to add the work requirements to their checklist. Putnam says the new rules aren’t designed to be punitive.

Tim Putnam: If it was purposefully trying to get people off of HIP, off of Medicaid and onto no coverage at all, that would be a detrimental program for us.

But as it is, it’s trying to get people to get work experience or get some job training to move on and transition to full employment, full insurance.

Varney: But Indiana’s conservative plan has added layers of bureaucracy that has ensnared people like Allen Wilson. He and his wife paid their monthly premium,but a paperwork glitch locked him out of coverage, to the point that his wife started to panic.

Allen Wilson: And she told them two or three times, I think you’re just trying to kill my husband, because he’s going to be too much money out of your pocket.

Varney: And you got stuck with thousands of dollars of bills.

Allen Wilson: Yes, I did. Yes, I did.

Varney: Some 25,000 Hoosiers were disenrolled from Medicaid from 2015 to 2017 because they didn’t pay their premiums. But it’s unclear why. Some may have moved out of state, found jobs with insurance, or even died.

Advocates like Alan Witchey say, now that Indiana is adding a work requirement, bureaucratic mistakes become much more common, especially for vulnerable populations like the homeless.

Alan Witchey: Even though we have been told there’s an exemption for homelessness, we haven’t heard, how is that going to work? What does that look like? How are we going to get it? What proof do you have to provide?

Varney: Those living in isolated rural areas, where jobs are few, have many of the same questions.

Niki Carty moved into her brother’s rented farmhouse here in the town of Dana after getting out of prison in 2015. She was convicted of selling meth, opioids and other drugs. Before prison, she became addicted to fentanyl prescribed by a doctor, and soon her two daughters were hooked on opioids as well.

Now the family is in recovery, and Carty is taking online classes to become an addiction counselor. But even though most students are exempt from the work requirement, Carty worries her courses won’t qualify, and she will be forced to drop out of school and get a dead-end job.

Niki Carty: I am concerned, because I got screwed once before. I really did get screwed.

Varney: In the 1990s, when Indiana forced people on welfare to work, Carty says the state didn’t recognize the classes she was taking then. She quit school and ended up getting injured on the job.

Niki Carty: I look at this way: If I had not had to go to a full-time job where I was being a full-time student then back in the ’90s, I would have never been in that factory to get hit by two forklifts. I mean, 20-some years later, I’m having this surgery, and this is pretty much the results.

Varney: State Rep. Ed Clere, a Republican from New Albany, is one of the few lawmakers raising these kinds of issues at the Statehouse.

I know one of your big concerns is creating more bureaucracy here in Indiana.

Rep. Ed Clere: Right. I think we have to be concerned about that and we need to be realistic. What it’s going to cost to administer this?

Varney: Clere says those added administrative costs will pull money away from medical care. And although he supports the work requirements in theory, he says the new rules are unlikely to improve health outcomes.

Rep. Ed Clere: And, in fact, it may over time take us in the other direction.

Varney: But many here say people who work live healthier lives and the changes will benefit the entire state.

Dr. John Wernert: We’re now starting to move the big battleship in a different direction, more towards what’s needed in our economy and what’s needed in our society now.

Varney: Back in Dana, a world away from the booming economy in Indianapolis, Niki Carty says the message from lawmakers to people like her is pretty clear.

Niki Carty: They think we’re trash, that we’re just garbage to throw away. They’re all worried about the money and all that. And I can understand that. But at the same time, there’s a lot of us that are trying to pick our lives up and put them back together.

Varney: For Carty, that means planning her weekly Narcotics Anonymous meeting with a local pastor. She’s determined, she says, to set her life straight and hopes the upcoming changes to Medicaid won’t get in her way.

For the “PBS NewsHour” and Kaiser Health News, I’m Sarah Varney in Indiana.

The Training Of Dr. Robot: Data Wave Hits Medical Care

Kaiser Health News:Marketplace - February 14, 2018

The technology used by Facebook, Google and Amazon to turn spoken language into text, recognize faces and target advertising could help doctors combat one of the deadliest killers in American hospitals.

Clostridium difficile, a deadly bacterium spread by physical contact with objects or infected people, thrives in hospitals, causing 453,000 cases a year and 29,000 deaths in the United States, according to a 2015 study in the New England Journal of Medicine. Traditional methods such as monitoring hygiene and warning signs often fail to stop the disease.

But what if it were possible to systematically target those most vulnerable to C-diff? Erica Shenoy, an infectious-disease specialist at Massachusetts General Hospital, and Jenna Wiens, a computer scientist and assistant professor of engineering at the University of Michigan, did just that when they created an algorithm to predict a patient’s risk of developing a C-diff infection, or CDI. Using patients’ vital signs and other health records, this method — still in an experimental phase — is something both researchers want to see integrated into hospital routines.

The CDI algorithm — based on a form of artificial intelligence called machine learning — is at the leading edge of a technological wave starting to hit the U.S. health care industry. After years of experimentation, machine learning’s predictive powers are well-established, and it is poised to move from labs to broad real-world applications, said Zeeshan Syed, who directs Stanford University’s Clinical Inference and Algorithms Program.

“The implications of machine learning are profound,” Syed said. “Yet it also promises to be an unpredictable, disruptive force — likely to alter the way medical decisions are made and put some people out of work.

Machine learning (ML) relies on artificial neural networks that roughly mimic the way animal brains learn.

As a fox maps new terrain, for instance, responding to smells, sights and noises, it continually adapts and refines its behavior to maximize the odds of finding its next meal. Neural networks map virtual terrains of ones and zeroes. A machine learning algorithm programmed to identify images of coffee cups might compare photos of random objects against a database of coffee cup pictures; by examining more images, it systematically learns the features to make a positive ID more quickly and accurately.

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Shenoy and Wiens’ CDI algorithm analyzed a data set from 374,000 inpatient admissions to Massachusetts General Hospital and the University of Michigan Health System, seeking connections between cases of CDI and the circumstances behind them.

The records contained over 4,000 distinct variables. “We have data pertaining to everything from lab results to what bed they are in, to who is in the bed next to them and whether they are infected. We included all medications, labs and diagnoses. And we extracted this on a daily basis,” Wiens said. “You can imagine, as the patient moves around the hospital, risk evolves over time, and we wanted to capture that.”

As it repeatedly analyzes this data, the ML process extracts warning signs of disease that doctors may miss — constellations of symptoms, circumstances and details of medical history most likely to result in infection at any point in the hospital stay.

Such algorithms, now commonplace in internet commerce, finance and self-driving cars, are relatively untested in medicine and health care. In the U.S., the transition from written to electronic health records has been slow, and the format and quality of the data still vary by health system — and sometimes down to the medical practice level — creating obstacles for computer scientists.

But other trends are proving inexorable: Computing power has grown exponentially while getting cheaper. Once, creating a machine learning algorithm required networks of mainframe computers; now it can be done on a laptop.

Radiology and pathology will experience the changes first, experts say. Machine learning programs will most easily handle analyzing images. X-rays and MRI, PET and CT scans are, after all, masses of data. By crunching the data contained in thousands of existing scan images along with the diagnoses doctors have made from them, algorithms can distill the collective knowledge of the medical establishment in days or hours. This enables them to duplicate or surpass the accuracy of any single doctor.

Machine learning algorithms can now reliably diagnose skin cancers (from photographs) and lung cancer, and predict the risk of seizures.

Google research scientist Lily Peng, a physician, led a team that developed a machine learning algorithm to diagnose a patient’s risk of diabetic retinopathy from a retinal scan. DR, a common side effect of diabetes, can lead to blindness if left untreated. The worldwide rise in diabetes rates has turned DR into a global health problem, with the number of cases expected to rise from 126.6 million in 2011 to 191 million by 2030 — an increase of nearly 51 percent. Its presence is indicated by increasingly muddy-looking scan images.

Peng’s team gathered 128,000 retinal scans from hospitals in India and the U.S. and assembled a team of 54 ophthalmologists to grade them on a 5-point scale for signs of the disease. Multiple doctors reviewed each image to average out individual differences of interpretation.

Once “trained” on an initial data set with the diagnoses, the algorithm was tested on another set of data — and there it slightly exceeded the collective performance of the ophthalmologists.

Now Peng is working on applying this tool in India, where a chronic shortage of ophthalmologists means DR often goes undiagnosed and untreated until it’s too late to save a patient’s vision. (This is also a problem in the U.S., where 38 percent of adult diabetes patients do not get the recommended annual eye check for the disease, according to the Centers for Disease Control.)

A group of Indian hospitals is now testing the algorithm. Ordinarily, a scan is done, and a patient may wait days for results after a specialist — if available — reads the image. The algorithm, via software running on hospital computers, makes the results available immediately and a patient can be referred to treatment.

Last year, the Food and Drug Administration approved the first medical machine learning algorithm for commercial use by the San Francisco company Arterys. Its algorithm, “DeepVentricle,” performs in 30 seconds a task doctors typically do by hand — drawing the contours of ventricles from multiple MRI scans of the heart muscle in motion, in order to calculate the volume of blood passing through. That takes an average of 45 minutes. “It’s automating something that is important — and tedious,” said Carla Leibowitz, Arterys’ head of strategy and marketing.

If adopted on a broad scale, such technologies could save lots of time and money. But such change is disruptive.

“The fact that we have identified potential ways to gut out costs is good news. The problem is the people who get gutted are not going to like it — so there will be resistance,” said Eric Topol, director of the Scripps Translational Science Institute. “It undercuts how radiologists do their work. Their primary work is reading scans — what happens when they don’t have to do that?”

The shift may not put a lot of doctors out of work, said Topol, who co-authored a piece in JAMA exploring the issue. Rather, it will likely push them to find new ways to apply their expertise. They may focus on more challenging diagnoses where algorithms continue to fall short, for instance, or interact more with patients.

Beyond this frontier, algorithms can provide a more precise prognosis for the course of a disease — potentially reshaping treatment of progressive ailments or addressing the uncertainties in end-of-life care. They can anticipate fast-moving infections like CDI and chronic ailments such as heart failure.

As the U.S. population ages, heart failure will be a rising burden on the health system and on families.

“It’s the most expensive single disease as a category because of the extreme disability it causes and the high demand for care it imposes, if not managed really tightly,” said Walter “Buzz“ Stewart, vice president and chief research officer at Sutter Health, a health system in Northern California. “If we could predict who was going to get it, perhaps we could begin to intervene much earlier, maybe a year or two years earlier than when it usually happens — when we admit a patient to the hospital after a cardiac event or crash.”

Stewart has collaborated on several studies aiming to address that problem. One, done with Georgia Tech computer scientist Jimeng Sun, predicts whether a patient will develop heart failure within six months, based on 12 to 18 months of outpatient medical records.

These tools, Stewart said, are leading to the “mass customization of health care.” Once algorithms can anticipate incipient stages of conditions like heart failure, doctors will be better able to offer treatments tailored to the patient’s circumstances.

Despite its scientific promise, machine learning in medicine remains terra incognita in many ways. It adds a new voice — the voice of the machine — to key medical decisions, for instance. Doctors and patients may be slow to accept that. Adding to potential doubts, machine learning is often a black box: Data go in, and answers come out, but it’s often unclear why certain patterns in a patient’s data point, say, to an emerging disease. Even the scientists who program neural networks often don’t understand how they reach their conclusions.

“It’s going to make a big difference in how decisions are made — things will become much more data-driven than they used to be,” said John Guttag, a professor of computer science at MIT. Doctors will rely on these increasingly complex tools to make decisions, he said, and “have no idea how they work.” And, in some cases, it will be hard to figure out why bad advice was given.

And while health data are proliferating, the quantity, quality and format vary by institution, and that affects what the algorithms “learn.”

“That is a huge issue with modeling and electronic health records,” Sun said. “Because the data are not curated for research purposes. They are collected as a byproduct of care in day-to-day operations, and utilized mainly for billing and reimbursement purposes. The data is very, very noisy.”

This also means that data may be inconsistent, even in an individual patient’s records. More important, one size does not fit all: An algorithm developed with data from one hospital or health system may not work well for another. “So you need models for different institutions, and the models become quite fragile, you might put it,” Sun said. He is working on a National Institutes of Health grant studying how to develop algorithms that will work across institutions.

And the tide of available medical data continues to rise, tantalizing scientists. “Think about all the data we are collecting right now,” Wiens said. “Electronic health records. Hospitalizations. At outpatient centers. At home. We are starting to collect lots of data on personal monitors. These data are valuable in ways we can’t yet know.”

Consequences for HIPAA violations don’t stop when a business closes

HHS Gov News - February 13, 2018

A receiver appointed to liquidate the assets of Filefax, Inc. has agreed to pay $ 100,000 out of the receivership estate to the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) in order to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Filefax, located in Northbrook, Illinois, advertised that it provided for the storage, maintenance, and delivery of medical records for covered entities. Although Filefax shut its doors during the course of OCR’s investigation into alleged HIPAA violations, it could not escape its obligations under the law.

On February 10, 2015, OCR received an anonymous complaint alleging that an individual transported medical records obtained from Filefax to a shredding and recycling facility to sell on February 6 and 9, 2015. OCR opened an investigation, which confirmed that an individual had left medical records of approximately 2,150 patients at the shredding and recycling facility, and that these medical records contained patients’ protected health information (PHI).

OCR’s investigation indicated that between January 28, 2015, and February 14, 2015, Filefax impermissibly disclosed the PHI of 2,150 individuals by leaving the PHI in an unlocked truck in the Filefax parking lot, or by granting permission to an unauthorized person to remove the PHI from Filefax, and leaving the PHI unsecured outside the Filefax facility.

“The careless handling of PHI is never acceptable,” said OCR Director Roger Severino. “Covered entities and business associates need to be aware that OCR is committed to enforcing HIPAA regardless of whether a covered entity is opening its doors or closing them. HIPAA still applies.”

Filefax is no longer in business. In 2016, a court in unrelated litigation appointed a receiver to liquidate its assets for distribution to creditors and others.  In addition to a $100,000 monetary settlement, the receiver has agreed, on behalf of Filefax, to properly store and dispose of remaining medical records found at Filefax’s facility in compliance with HIPAA.

The resolution agreement and corrective action plan may be found on the OCR website at   http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/Filefax/index.html.

To learn more about non-discrimination and health information privacy laws, your civil rights, and privacy rights in health care and human service settings, and to find information on filing a complaint, visit us at http://www.hhs.gov/hipaa/index.html.

Follow OCR on Twitter at http://twitter.com/HHSOCR.

California’s Regulators To Investigate Aetna’s Medical Coverage Decisions

Kaiser Health News:Insurance - February 13, 2018

Both of California’s health insurance regulators said they will investigate how Aetna Inc. makes coverage decisions, as the lawsuit of a California man who is suing the nation’s third-largest insurer for improper denial of care heads for opening arguments on Wednesday.

The Department of Managed Health Care, which regulates the vast majority of health plans in California, said Monday it will investigate Hartford, Ct.-based Aetna after CNN first reported Sunday that one of the company’s medical directors had testified in a deposition related to the lawsuit that he did not examine patients’ records before deciding whether to deny or approve care. Rather, he relied on information provided by nurses who reviewed the records — and that was how he was trained by the company, he said.

Insurance Commissioner Dave Jones had already told CNN his office would investigate Aetna, which he reconfirmed in a statement Monday.

“If a health insurer is making decisions to deny coverage without a physician ever reviewing medical records, that is a significant concern and could be a violation of the law,” Jones said.

It is unclear how widespread the review of patient claims by non-physicians is in the industry or whether other insurers will feel compelled to revisit their practices.

The California Department of Insurance, which Jones heads, regulates only a small fraction of the state’s health plans, but they include several Aetna policies. He has previously criticized Aetna for “excessive” health insurance rate hikes, though neither his agency nor the managed health care department has the power to stop the increases.

Jones’ investigation of Aetna will review denials of coverage or pre-authorizations during the tenure of the medical director who testified in the California lawsuit, Jay Ken Iinuma, who has since left the company. Insurance department investigators will also look into Aetna’s procedures for managing medical coverage decisions generally.

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The dual investigations come as federal regulators are examining a planned $69 billion purchase of Aetna by pharmaceutical giant CVS — a deal that many experts believe could transform the health care industry.

It’s unclear how the investigations might affect Aetna’s future coverage decisions, or those of other insurers, said Shana Alex Charles, an insurance industry expert and assistant professor at California State University-Fullerton. But she praised the decision to investigate as exactly what insurance regulators should be doing. “Without that strict oversight, corners get cut,” Charles said.

Scott Glovsky, the lawyer representing the California plaintiff, Gillen Washington, said he and his client were “very pleased” by the news that Aetna will be investigated. Speaking Monday, before the managed care department said it would also investigate, Glovsky said his client brought the case “to stop these illegal practices, and we’re looking forward to the insurance commissioner’s investigation so we can make things safer for Aetna patients.”

Washington, of Huntington Beach, had been receiving expensive medication for years to treat a rare immune system disorder known as Common Variable Immune Deficiency.

But in 2014, Aetna denied the college student’s monthly dose of immunoglobulin replacement therapy, saying his bloodwork was outdated. During the appeal process, Washington developed pneumonia and was hospitalized for a collapsed lung.

In recent years, as California Healthline reported last June, patients with similar diseases have faced increasing difficulty getting their insurers to approve treatments, according to clinicians and patient advocates.

In an emailed statement on Monday, Aetna did not directly address the question of case reviews by non-physicians. It said its “medical directors review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees.” It added, “adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process.”

Aetna also noted that it has paid for all of Washington’s treatments since 2014 and continues to do so.

Aetna said in previous documents filed in the lawsuit that it is standard for people with Washington’s immunodeficiency disease to get regular blood tests and that Washington had failed to do so. But Washington’s attorney said his client clearly needed the medication and that Aetna’s action violated its contract with Washington.

Charles, the professor, said she was most surprised by the fact that Iinuma had admitted not only that he hadn’t reviewed Washington’s medical records personally, but also that he had no experience treating his disease. The burden should be on insurers to demonstrate why treatment should be stopped, not on doctors and patients to show why it should be continued, Charles said.

“It’s easy to see the cases as just files and not people standing in front of you,” she said.

At Some Veterans Homes, Aid-In-Dying Is Not An Option

Kaiser Health News:States - February 13, 2018

California voters passed a law two years ago that allows terminally ill people to take lethal drugs to end their lives, but controversy is growing over a newer rule that effectively bans that option in the state’s eight veterans homes.

Proponents of medical aid-in-dying and residents of the Veterans Home of California-Yountville — the largest in the nation — are protesting a regulation passed last year by the California Department of Veterans Affairs, or CalVet, that requires that anyone living in the facilities must be discharged if they intend to use the law.

That’s a position shared by most — but not all — states where aid-in-dying is allowed. As more U.S. jurisdictions consider whether to legalize the practice, the status of terminally ill veterans living in state-run homes will loom large.

“It would be a terrible hardship, because I have no place to go,” said Bob Sloan, 73, who suffers from congestive heart failure and other serious cardiac problems. He said he intends to seek medical aid-in-dying if doctors certify he has six months or less to live.

“I’m not going to be a vegetable,” said Sloan, a Vietnam War-era veteran who moved into the Yountville center five years ago. “I’m not going to end up living in so much pain it’s unbearable.”

A CalVet official said the agency adopted the rule to avoid violating a federal statute that prohibits using U.S. government resources for physician-assisted death. Otherwise, the agency would jeopardize nearly $68 million in federal funds that helps run the facilities, said June Iljana, CalVet’s deputy secretary of communications.

California is not alone. Three other states where aid-in-dying is legal — Oregon, Colorado and Vermont — all prohibit use of lethal medications in state-run veterans homes.

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In Montana, where aid-in-dying is allowed under a state Supreme Court ruling, officials didn’t respond to multiple requests about whether veterans would be able to use the law in the residences. However, Dr. Eric Kress, a Missoula physician who prescribes the lethal medication, says he has transferred patients to hospice, to relatives’ homes, even to extended-stay hotels to avoid conflict.

In Washington, D.C., where an aid-in-dying law took effect last summer, the Armed Forces Retirement Home won’t assist patients in any way. Those who wish to use the law would be referred to an ethics committee for individual consideration, spokesman Christopher Kelly said in an email.

Only Washington state has a policy that allows veterans to remain in government-run residences if they intend to ingest lethal medications.. At least one veteran has died in a state-run home using that law, said Heidi Audette, a spokeswoman for the state’s Department of Veterans Affairs.

Paul Sherbo, a spokesman for the U.S. Department of Veterans Affairs, said the choice is up to the states.

“VA does not mandate how states comply with federal law,” Sherbo said in an email. “There are a number of ways individual states can choose to handle such situations and still be in compliance.”

To date, none of the 2,400 residents of California’s veterans homes has formally requested medical aid-in-dying, said Iljana. That includes the more than 900 residents of the Yountville center, located about 60 miles north of San Francisco.

(iStock/Getty Images)

“We would respectfully and compassionately assist them in transferring to a hospice, family home or other location,” Iljana said in an email. “We will readmit them immediately if they change their minds.”

But Kathryn Tucker, executive director of the End of Life Liberty Project, an advocacy group that supports aid-in-dying, said that CalVet is interpreting the federal regulations too broadly and denying terminally ill veterans the right to choose a “peaceful death” through medical assistance.

“Nothing exists in the federal statute’s language that would prohibit a resident from receiving aid-in-dying services at state homes, so long as they are not provided using federal funds or employees,” she said.

Ed Warren, head of the Allied Council, a group representing veterans at the Yountville site, co-signed a letter to CalVet officials protesting the ruling.

“My point of view is that it is inhumane to expect people in the last stages of dying to go through the hullabaloo of leaving their homes,” he said.

In Washington state, a 60-year-old man diagnosed with terminal chronic obstructive pulmonary disease, or COPD, died in June 2015 after ingesting lethal drugs at the Washington Soldiers Home in Orting, where he lived.

“It was all done very much in the open,” said Chris Fruitrich, a volunteer with the group End of Life Washington, which assisted the man.

There has been no indication that the policy jeopardizes the nearly $47 million the agency receives each year in federal funds, said Audette, the state VA spokeswoman.

In California, additional protests have centered on allegations that CalVet suppressed information about the aid-in-dying law.

Critics at the Yountville home contend that CalVet passed the discharge rule quietly, with little public input. Then the agency refused to broadcast a public meeting about medical aid-in-dying on KVET, the center’s state-run, closed-circuit television station.

Iljana said the Aug. 21 meeting, led by Tucker and Dr. Robert Brody, also a supporter of aid-in-dying, violated state rules that prohibit using public resources to promote political causes.

“Free speech is great and criticizing the government is great, but not using the government’s own resources and paid staff to advocate for a change in the law,” Iljana wrote in an email to prohibit the broadcast.

That decision, however, prompted Jac Warren, 81, who has been KVET’s station manager for eight years, to resign last month in protest, citing censorship.

“What is at issue is whether a state may completely suppress the dissemination of concededly truthful information about entirely lawful activity,” Warren wrote in an email to CalVet.

The hour-long meeting, attended by about 50 people, was not propaganda, Tucker said, but “an educational event with information provided by an attorney and a physician who both specialize in their respective fields in end-of-life care.”

Bob Sloan, who works as an engineer at KVET for a $400 monthly stipend, disagreed with the decision not to broadcast the meeting on the system that serves residents of the Yountville home.

Sloan said he knows other residents who would like to be able to use California’s aid-in-dying law if their illnesses progress.

“The only other option that people have in this state is committing suicide,” he said. “If I can’t find some way of doing it legally, I’ll do it illegally.”

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