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Statement from U.S. Department of Health and Human Services Regarding CDC Director Brenda Fitzgerald

HHS Gov News - January 31, 2018

"This morning Secretary Azar accepted Dr. Brenda Fitzgerald’s resignation as Director of the Centers for Disease Control and Prevention. Dr. Fitzgerald owns certain complex financial interests that have imposed a broad recusal limiting her ability to complete all of her duties as the CDC Director. Due to the nature of these financial interests, Dr. Fitzgerald could not divest from them in a definitive time period. After advising Secretary Azar of both the status of the financial interests and the scope of her recusal, Dr. Fitzgerald tendered, and the Secretary accepted, her resignation. The Secretary thanks Dr. Brenda Fitzgerald for her service and wishes her the best in all her endeavors."

-- HHS Spokesman Matt Lloyd

Statement from HHS Secretary Azar on President Trump’s State of the Union Address

HHS Gov News - January 31, 2018

On Tuesday, Health and Human Services Secretary Alex Azar issued the following statement on President Donald Trump’s State of the Union address:

“I commend President Trump for delivering a speech that celebrated the economic boom we have seen under his leadership, which has brought new opportunity and prosperity to the American people. A healthier economy means a healthier America, and we look forward to more such success in the coming year, including through reforms to make healthcare more affordable and accessible for all Americans.

“The President also deserves tremendous credit for his leadership in addressing the opioid crisis that’s hitting communities all across America. During his first year in office, President Trump has brought a new level of awareness and commitment to this cause, and I look forward to expanding and enhancing our aggressive approach to this scourge of addiction and overdose.”

Background

In 2017 under President Trump, among other actions on the opioid epidemic, HHS:

  • Declared a historic nationwide Public Health Emergency regarding the crisis, bringing a new level of coordination and commitment to the issue;
  • Disbursed more than $800 million in grants to fight the opioid crisis, more than any previous year;
  • Unveiled a comprehensive five-point strategy, encompassing better treatment, prevention, and recovery services; better targeting of overdose-reversing drugs; better data on the epidemic; better research on pain and addiction, and better pain management;
  • Approved new Medicaid waivers for two states to expand access to substance abuse treatment and outlined a streamlined process for more such approvals;
  • Began calculating and releasing from CDC monthly provisional data on drug overdose deaths, shortening what had been up to a two-year lag;
  • Clarified privacy regulations to inform hospitals and doctors that they can share information with patients’ families during crisis situations, such as opioid overdoses;
  • Approved through FDA the first monthly formulation of buprenorphine, a key option for medication-assisted treatment of opioids; and
  • Delinked patient scores of hospital pain management from Medicare reimbursement, helping to align payment policies with clinical best practices and address concerns from providers that the prior policy may have driven overprescribing.

In 2018, HHS will continue work on all five points of the strategy, including through developing a large-scale public awareness campaign regarding the dangers of opioid addiction.

Podcast: KHN’s ‘What The Health?’ The State Of The (Health) Union

Kaiser Health News:Madicaid - January 31, 2018

In his first State of the Union Address, President Donald Trump told the American public that “one of my greatest priorities is to reduce the price of prescription drugs.” But that message could barely begin to sink in before other health news developed: The director of the Centers for Disease Control and Prevention was forced to resign Wednesday after conflict-of-interest reports.

Meanwhile, outside the federal government, Idaho is proposing to allow the sale of individual insurance policies that specifically violate portions of the Affordable Care Act. And three mega-companies — Amazon, Berkshire-Hathaway, and JPMorgan Chase — say they will partner to try to control costs and improve quality for their employees’ health care.

This week’s “What The Health?” panelists are Julie Rovner of Kaiser Health News, Alice Ollstein of Talking Points Memo and Julie Appleby and Sarah Jane Tribble of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • Despite Trump’s strong rhetoric in the State of the Union Address, the president has taken few actions during his first year in office to reduce drug prices.
  • The president touted that Republicans had repealed the health law’s requirement that individuals get health insurance or pay a penalty. But that change in the law doesn’t go into effect until 2019, so his comments could be confusing to some taxpayers.
  • Idaho officials have announced that they are going to allow insurers to issue policies that don’t meet all the criteria of the federal health law. But it’s not clear that insurers are interested in participating in the experiment.
  • “Alexa, send me my Lipitor!” Can Amazon’s announcement that it and two other corporate behemoths are taking on employees’ health care create a new formula for keeping costs down and improving quality? Email Sign-Up

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

Julie Rovner: Kaiser Health News’ “No Car, No Care? Medicaid Transportation At Risk In Some States,” by JoNel Aleccia.

ALSO: JAMA’s “Are Medicaid Work Requirements Legal?” by Nicholas Bagley.

Alice Ollstein: Politico’s “Trump’s Top Health Official Traded Tobacco Stock While Leading Anti-Smoking Efforts,” by Sarah Karlin-Smith and Brianna Ehley.

Julie Appleby: The Atlantic’s “Why We Forget Most of the Books We Read,” by Julie Beck.

Sarah Jane Tribble: The New York Times’ “5-Year-Olds Work Farm Machinery, And Injuries Follow,” by Jack Healy.

To hear all our podcasts, click here.

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

Podcast: ‘What The Health?’ The State Of The (Health) Union

Kaiser Health News:Insurance - January 31, 2018

In his first State of the Union Address, President Donald Trump told the American public that “one of my greatest priorities is to reduce the price of prescription drugs.” But that message could barely begin to sink in before other health news developed: The director of the Centers for Disease Control and Prevention was forced to resign Wednesday after conflict-of-interest reports.

Meanwhile, outside the federal government, Idaho is proposing to allow the sale of individual insurance policies that specifically violate portions of the Affordable Care Act. And three mega-companies — Amazon, Berkshire-Hathaway, and JPMorgan Chase — say they will partner to try to control costs and improve quality for their employees’ health care.

This week’s “What The Health?” panelists are Julie Rovner of Kaiser Health News, Alice Ollstein of Talking Points Memo and Julie Appleby and Sarah Jane Tribble of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • Despite Trump’s strong rhetoric in the State of the Union Address, the president has taken few actions during his first year in office to reduce drug prices.
  • The president touted that Republicans had repealed the health law’s requirement that individuals get health insurance or pay a penalty. But that change in the law doesn’t go into effect until 2019, so his comments could be confusing to some taxpayers.
  • Idaho officials have announced that they are going to allow insurers to issue policies that don’t meet all the criteria of the federal health law. But it’s not clear that insurers are interested in participating in the experiment.
  • “Alexa, send me my Lipitor!” Can Amazon’s announcement that it and two other corporate behemoths are taking on employees’ health care create a new formula for keeping costs down and improving quality? Email Sign-Up

    Subscribe to KHN’s free Morning Briefing.

    Sign Up Please confirm your email address below: Sign Up

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

Julie Rovner: Kaiser Health News’ “No Car, No Care? Medicaid Transportation At Risk In Some States,” by JoNel Aleccia.

ALSO: JAMA’s “Are Medicaid Work Requirements Legal?” by Nicholas Bagley.

Alice Ollstein: Politico’s “Trump’s Top Health Official Traded Tobacco Stock While Leading Anti-Smoking Efforts,” by Sarah Karlin-Smith and Brianna Ehley.

Julie Appleby: The Atlantic’s “Why We Forget Most of the Books We Read,” by Julie Beck.

Sarah Jane Tribble: The New York Times’ “5-Year-Olds Work Farm Machinery, And Injuries Follow,” by Jack Healy.

To hear all our podcasts, click here.

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

Expert Advice For The Corporate Titans Taking On Health Care

Kaiser Health News:HealthReform - January 31, 2018
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An announcement Tuesday by three of the nation’s corporate titans — Amazon, Berkshire Hathaway and JPMorgan Chase & Co. — that they are joining forces to address the high costs of employee health care has stirred the health policy pot. It immediately sent shock waves through the health sector of the stock market and reinvigorated talk about health care technology, value and quality.

Though details regarding the undertaking are thin, the companies said in a release that their partnership’s intent is to improve employee satisfaction and hold down costs by bringing “their scale and complementary expertise to this long-term effort.”

They plan to create an independent company, “free from profit-making incentives and constraints,” to focus on “technology solutions.”

Berkshire Hathaway CEO Warren Buffett described health care costs as “a hungry tapeworm on the American economy,” and Amazon founder and CEO Jeff Bezos said the partnership was “open-eyed about the degree of difficulty” ahead. Jamie Dimon, chairman and CEO of JPMorgan, said the results could benefit the employees of these companies and possibly all Americans.

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But what does all of this mean and how can it be successful when so many other initiatives have fallen short? KHN asked a variety of health policy experts their thoughts on this venture, and what advice they would offer these CEOs as they go forward. Some of the advice has been edited for clarity and length.

Tom Miller, resident fellow, American Enterprise Institute (Courtesy of Tom Miller)

Tom Miller, resident fellow, American Enterprise Institute:

“It’s great that someone theoretically with resources would try to build a better mousetrap. But it’s been difficult to do, and part of it is regulatory and competitive barriers are well-constructed in the health care sphere, which tend to make it less receptive or subject to competitive pressures.

“I welcome any new capital trying to disrupt health care. … The incumbents are comfortable and could use disruption. If Amazon has an idea, and is willing to put some money behind it, that’s wonderful. What they are willing to do other than fly low-cost providers for home visits in drones — I don’t know. They’d probably have to miniaturize them, wouldn’t they?”

Stan Dorn, senior fellow, Families USA (Courtesy of Stan Dorn)

Stan Dorn, senior fellow, Families USA:

“Number one, look at prices. America doesn’t use more health care than European countries, but we pay a lot more and that’s because of prices more than anything else. Look at hospital prices and prescription drug prices. I would also say, look to eliminate middlemen operating in darkness. I’m thinking in particular of pharmacy benefit managers. Often, the supply chain is hidden and complex, and every step along the way the middlemen are taking their share, and it winds up costing a huge amount of money.”

Bob Kocher, partner, Venrock (Courtesy of Bob Kocher)

Bob Kocher, partner, Venrock:

“It has been said that health care is complicated. One thing that is not complicated is that the way to save money is to focus on the sickest patients. And that’s the only thing that has proven to work in great primary care. I hope Amazon realizes this early and does not think that [its smart digital assistant] Alexa and apps are going to make us healthier and save any money.

“It would sure be nice if they invest in a ‘post-CPT-ICD-10-and-many-bills-per-visit’ world where we know prices, can easily know what is known about quality and experience, and have same-day service.”

Tracy Watts, senior partner, Mercer (Courtesy of Tracy Watts)

Tracy Watts, senior partner, Mercer:

“Everyone thinks millennials want to do everything on their phones. But that’s not necessarily the case.

“[There was a recent] survey about this — specifically, millennials are the most interested in new health care offerings, but it wasn’t as much high-tech as it is convenience they are interested in — same-day appointments with a family doctor, guaranteed appointments with specialists, home visits, a wider array of services available at retail clinics. That was kind of an ‘aha’ — this kind of convenience and high-touch experience is what they’re looking for. And when you think of ‘health care of the future,’ that’s not what comes to mind.”

John Rother, president and CEO, National Coalition on Health Care (Courtesy of John Rother)

John Rother, president and CEO, National Coalition on Health Care:

“Health care is complex and expensive, so the aim should always be simplicity and affordability. Three keys to success: manage chronic conditions recognizing the life context of the patient, emphasize primary care-based medical homes and aggressively negotiate prescription drug costs.”

Suzanne Delbanco, executive director, Catalyst for Payment Reform (Courtesy of Suzanne Delbanco)

Suzanne Delbanco, executive director, Catalyst for Payment Reform:

“The biggest driver of health care costs is prices. Those are being driven up by health care providers who have consolidated and will continue to consolidate and amass more market power.

“It sounds like they [the companies] are limiting the use of health plans, but if they’re going to get into that business, they’re going to come up with the same challenges health plans face. What would be really innovative would be to build some provider systems from the ground up where they can truly get a handle on the actual costs and eliminate the market power that drives the prices up, and they can have control over their prices.”

Brian Marcotte, president and CEO, National Business Group on Health (Courtesy of Brian Marcotte)

Brian Marcotte, president and CEO, National Business Group on Health:

“They recognize this is [a] long-term play to get involved in this. I’d have to say, this industry is ripe for disruption.

“I think we know technology will continue to play an increasing role in how consumers access and receive health care. We’ve also learned most consumers do not touch the health care delivery system with enough frequency to ever be a sophisticated consumer. What’s intriguing about this partnership is Amazon for many consumers has become part of their day-to-day world, part of their routine. It’s intriguing to consider the possibilities of integrating health care into consumer routine.

“And I think that therein lies the opportunity. Employers offer a lot of resources to their employees to help them maximize their experience, and their No. 1 challenge is engagement.”

Joseph Antos, health economist, American Enterprise Institute (Courtesy of Joseph Antos)

Joseph Antos, health economist, American Enterprise Institute:

“My first suggestion is to look at what other employers have done (some unsuccessfully) and consider how to adapt those ideas for the three companies and more broadly. Change incentives for providers. Change incentives for consumers. Work on ways to reduce the effects of market consolidation. The bottom line: Don’t keep doing what we are doing now. I don’t see that these three companies have enough presence in health markets to pull this off anytime soon, but perhaps this should be viewed as the private-sector version of the Affordable Care Act’s Innovation Center — except, this time, there may be some new ideas to test.”

Ceci Connolly, president and CEO, Alliance of Community Health Plans (Courtesy of Ceci Connolly)

Ceci Connolly, president and CEO, Alliance of Community Health Plans:

“We know that 5 percent of any population consumes 50 percent of the health care dollar. I would encourage this group to focus on how to better serve those individuals who need help managing multiple chronic conditions.”

David Lansky, CEO, Pacific Business Group on Health (Courtesy of David Lansky)

David Lansky, CEO, Pacific Business Group on Health:

“The incumbent providers of services to our members are not doing as much as we need done for affordability and quality. So, we are pleased to see them go down this path. We don’t know what piece of the puzzle they will tackle.

“We know well-intended efforts over the years haven’t added up to material impact on cost and quality. I would suspect they are looking at doing something broader, more disruptive than initiatives we have tried before.

“I think across the board they have the opportunity to set high standards for the health system in whatever platform they use. These companies have a history of raising the bar. Potentially, it could be a help to all of us.”

Staff writers Julie Appleby, Rachel Bluth, Jenny Gold, Jay Hancock, Shefali Luthra, Jordan Rau, Julie Rovner and Chad Terhune contributed to this report.

After Polyps Are Detected, Patients May No Longer Qualify For Free Colonoscopies

Kaiser Health News:HealthReform - January 30, 2018

Insurance coverage of colonoscopies to screen for colorectal cancer is a frequent source of frustration for consumers, including a reader who asks about his situation. In addition to his query, this week I also address questions about Medicare premiums and delays in determining Medicaid eligibility.

Q: When I had a screening colonoscopy in 2015, the doctor removed a polyp and told me to come back for another colonoscopy in three years. I paid nothing for the 2015 test because it was a preventive screening. When I scheduled my appointment for this year, the provider said the procedure was diagnostic because of that earlier polyp removal. Doesn’t the law protect people in these situations from being charged for more frequent but necessary screening? 

Not necessarily. The Affordable Care Act greatly expanded coverage of preventive services, including requiring commercial insurers to cover screenings for colorectal cancer without charging patients anything out-of-pocket if they’re between ages 50 and 75. In general, screening colonoscopies for people at average risk are recommended every 10 years by the U.S. Preventive Services Task Force. (Under the law, preventive services are covered at no cost by insurers if they meet the task force’s recommendations.) There’s no charge to the patient for the test, even if a benign growth called a polyp is found and removed.

Doctors may recommend more frequent “surveillance” testing, as they did in your case, if during screening they find any polyps, which may put you at higher risk for colon cancer. Since the task force doesn’t have a recommendation for high-risk colorectal cancer screening, insurers aren’t required to cover it without cost sharing.

“Insurers will cover the test, but whether the patient is held harmless for the copay and deductible depends on the insurer,” said Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society.

Medicare also covers screening colonoscopies without charging beneficiaries anything out-of-pocket. The program covers tests every 10 years, and every two years if someone is considered high-risk. But there’s a catch: In contrast to private coverage, if a polyp is found during the test, that procedure is then considered diagnostic and patients will be subject to a copayment.

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Q: I signed up for a plan on healthcare.gov last fall in Virginia after I lost my employer coverage and learned that my 16-year-old daughter might be eligible for Medicaid. Two months have passed, and we still don’t have an answer. I understand that her coverage will be retroactive back to the date we applied, but in the meantime, I have to pay any medical bills. The state says it has 45 days to make a decision, but we’re past that. What can I do?

Even though the federal government allows states 45 days to act on a Medicaid application, a few weeks is typical and “at this point it’s well beyond the acceptable range of time for getting an eligibility determination,” said Tricia Brooks, a senior fellow at Georgetown University’s Center for Children and Families.

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If you haven’t done so already, confirm that the Virginia Medicaid program has received your application and find out specifically what they need from you to act on it. If you’re racking up medical bills, let Medicaid officials know that your financial situation is critical and consider asking your daughter’s providers to contact them too, Brooks said.

In many states, including Virginia, local legal-aid societies, community health centers and other groups are on hand to help sort out application glitches even though the open enrollment period has ended. Check out the Get Covered Connector for links to assisters in your area.

Q: I’m a federal government retiree receiving a small Social Security payment. I’m trying to figure out why I’m paying $134 every month now for my Medicare Part B premium instead of $109. I signed up at age 65, and it’s deducted from my Social Security check. From what I’ve read, if you’re having premiums deducted from Social Security, you generally pay $109. Why am I paying more?

The standard monthly premium for Medicare Part B, which covers many outpatient services and physician visits, is $134 in 2018, unchanged from last year. In recent years, many Medicare beneficiaries have been shielded from Part B premium increases because by law they must be “held harmless” if the premium increases are larger than their Social Security benefit increases, which have generally been flat.

This year, for many people those circumstances have changed. Because of a 2 percent cost-of-living adjustment to Social Security benefits, 42 percent of Part B enrollees are now subject to the full $134 Medicare Part B premium, according to the Centers for Medicare and Medicaid Services.

From your description it sounds as if you are one of those people, said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy.

No Car, No Care? Medicaid Transportation At Risk In Some States

Kaiser Health News:Madicaid - January 30, 2018

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

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EVERETT, Wash. — Unable to walk or talk, barely able to see or hear, 5-year-old Maddie Holt waits in her wheelchair for a ride to the hospital.

The 27-pound girl is dressed in polka-dot pants and a flowered shirt for the trip, plus a red headband with a sparkly bow, two wispy blond ponytails poking out on top.

Her parents can’t drive her. They both have disabling vision problems; and, besides, they can’t afford a car. When Maddie was born in 2012 with the rare and usually fatal genetic condition called Zellweger syndrome, Meagan and Brandon Holt, then in their early 20s, were plunged into a world of overwhelming need — and profound poverty.

“We lost everything when Maddie got sick,” said Meagan Holt, now 27.

Multiple times each month, Maddie sees a team of specialists at Seattle Children’s Hospital who treat her for the condition that has left her nearly blind and deaf, with frequent seizures and life-threatening liver problems.

The only way Maddie can make the trip, more than an hour each way, is through a service provided by Medicaid, the nation’s health insurance program started more than 50 years ago as a safety net for the poor.

Called non-emergency medical transportation, or NEMT, the benefit is as old as Medicaid itself. From its inception, in 1966, Medicaid has been required to transport people to and from such medical services as mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and, in Maddie’s case, visits to specialists.

“This is so important,” said Holt. “Now that she’s older and more disabled, it’s crucial.”

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care. The numbers have grown dramatically since the program expanded in 32 states plus the District of Columbia to cover prescription drugs, health screening for children, breast and cervical cancer treatment and nursing home care.

With a Republican administration vowing to trim Medicaid, Kaiser Health News is examining how the U.S. has evolved into a Medicaid Nation, where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid’s role in transportation is a telling example. Included in the NEMT coverage are nearly 104 million trips each year at a cost of nearly $3 billion, according to a 2013 estimate, the most recent, by Texas researchers.

Citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.

Already, states have wide leeway in how to provide and pay for the transportation.

Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don’t include transportation.

They also contend that changes will help curb what government investigators in 2016 warned is “a high risk for fraud and abuse” in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) reported that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn’t have medical needs for ambulance transportation. And the mother of a Medicaid patient who was authorized to transport her child for treatment billed Medicaid for trips that didn’t take place. She was sentenced to 30 days in jail and ordered to pay $21,500.

Last March, Rep. Susan Brooks, an Indiana Republican, introduced a resolution that would have revoked the federal requirement to provide NEMT in an effort to provide states with “flexibility.” That effort stalled.

Another Republican proposal in 2017 would have reversed the Affordable Care Act’s Medicaid expansion and reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.

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Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation’s governors to consider NEMT waivers, among other actions, in a March letter to them.

“We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges,” they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration’s more expansive health policies, and has granted some states’ requests.

At least three states, Iowa, Indiana and Kentucky, have received federal waivers — and extensions —allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Critics of the cuts worry the trend will accelerate, leaving poor and sick patients with no way to get to medical appointments.

“I wouldn’t be surprised to see more of these waivers in the pipeline,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Because medical transportation isn’t typically covered by the commercial insurance plans most Americans use, it’s unfamiliar to many people and could be seen as unnecessary, said Eliot Fishman, senior director of health policy for Families USA, a nonprofit, nonpartisan consumer health advocacy group.

Formerly a Medicaid official in the federal government, Fishman called the transportation program “vital” not only for children with severe disabilities, but also for non-elderly, low-income adults.

CMS released results of a 2014 survey of Medicaid users, which found that lack of transportation was the third-greatest barrier to care for adults with disabilities, with 12.2 percent of those patients reporting they couldn’t get a ride to a doctor’s office.

“This is not something to be trifled with lightly,” Fishman said. “We’re talking about a lifesaving aspect of the Medicaid program.”

About 3.6 million Americans miss or delay non-emergency medical care each year because of transportation problems, according to a 2005 study published by the National Academy of Sciences.

That same study analyzed costs for providing NEMT to patients facing 12 common medical conditions and found that providing additional transportation is cost-effective. For four of those conditions — prenatal care, asthma, heart disease and diabetes — medical transportation saved money when the total costs for both transportation and health care were tallied.

Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation, whether that’s taxis, vans or public transit.

Most states rely on NEMT brokers or managed-care organizations to administer the transportation services. Other states run the service directly, paying providers on a per-ride basis, while some use local ride services and pay independent taxi firms to shuttle patients.

Meagan Holt wheels daughter Maddie outside for a ride to Seattle Children’s Hospital on Nov. 21, 2017. Holt doesn’t drive due to serious vision problems and can’t afford a car. (Heidi de Marco/KHN)

Dr. Molly Fuentes examines the mobility of Maddie Holt’s arms on Nov. 21, 2017. (Heidi de Marco/KHN)

Proponents of revamping NEMT note that disabled children like Maddie and other people with serious disabilities are in little danger of losing services. In Iowa and Indiana, Medicaid transportation remains available to several groups of patients, including those classified as “medically frail,” though the definition of who qualifies can vary widely.

In addition, one managed-care provider, Anthem, continues to transport Indiana Medicaid patients, despite the waiver that was first enacted in 2007.

Still, Medicaid clients like Fallon Kunz, 29, of Mishawaka, Ind., are often stuck. Kunz, who has cerebral palsy, migraine headaches and chronic pain, uses a power wheelchair. When she was a child, she qualified for door-to-door service to medical appointments, she said.

Today, she lives with her father, whose home is outside the route of a Medicaid transit van. Getting to and from medical appointments for her chronic condition is a constant struggle, she said. Taxis are too expensive: $35 each way for a wheelchair-enabled cab.

“The only way I can get rides to and from my doctor’s appointment is to ride the 2 miles in my wheelchair, despite all kinds of weather, from my home, across the bridge, to the grocery store,” she said. “Right outside the grocery store is the bus stop. I can catch the regular bus there.”

Sometimes, she’s in too much pain or the Indiana weather — warm and humid in the summer, frigid and windy in the winter — is too much to battle and she skips the appointment.

“Today I didn’t go because it was too cold and my legs hurt too much,” she said on a December Tuesday. “I didn’t feel like getting blown off the sidewalk.”

In Maddie Holt’s case, she was shuttled to Seattle Children’s on a rainy Tuesday morning in a medical van driven by Donavan Dunn, a 47-year-old former big-rig trucker. He works for Northwest Transport, one of several regional brokers that manage NEMT services for Washington state.

Dunn said he received special training to transport patients like Maddie, who is loaded onto a motorized platform, wheelchair and all, into the van and then carefully strapped in.

“I have to drive different,” said Dunn. “I have to watch my corners, watch my starts, watch my stops. It’s always in the back of my mind that I have somebody on board that’s fragile.”

We’re talking about a lifesaving aspect of the Medicaid program. Eliot Fishman, senior director of health policy for Families USA

Dr. Molly Fuentes examines the mobility of Maddie Holt’s arms. (Heidi de Marco/KHN)

The transportation service can be used only for medical visits to the specialists who treat Maddie’s condition, which is caused by mutations in any one of at least 12 genes. If Meagan Holt needs to pick up prescriptions or get groceries, she leaves Maddie and a second daughter, Olivia, 3, at home with their dad and takes the bus or walks to her destinations.

Caring for a severely disabled child is not the life she expected, Meagan Holt said, but she cherishes time with Maddie, who has learned to communicate through tactile sign language spelled into her hand.

“She knows about 100 words. She knows the alphabet,” Meagan said. “She likes Disney princesses. She loves ‘Frozen.’”

Maddie is one of hundreds of NEMT-eligible children transported to Seattle Children’s each month. Last September, for instance, more than 1,300 clients made more than 3,600 trips at a cost of more than $203,000, according to the Washington Health Care Authority, which oversees the state’s Medicaid program called Apple Health.

The need is so great, in fact, that the hospital created a transportation will-call desk to help organize the comings and goings.

“When we realized how much transportation is a barrier to getting to your appointment, we decided to do something about it,” said Julie Povick, manager of international exchanges and guest services at Seattle Children’s.

“The majority of our patients are in survival mode,” Povick added. “You need a lot of handholding.”

But Verma, the architect of Indiana’s Medicaid overhaul plan, has suggested that too much handholding might be “counterproductive” for patients — and bad for the country.

In a 2016 Health Affairs essay, Verma noted that early analysis of the effects of curtailing NEMT in Indiana showed that more Medicaid patients with access to the program said transportation was a primary reason for missed appointments than did members without access.

“Moreover, 90 percent of [Healthy Indiana Plan] members report having their own transportation or the ability to rely on family and friends for transportation to health care appointments,” she wrote.

But Marsha Simon, a Washington, D.C., health policy consultant who has tracked NEMT for years, said Medicaid is the option of last resort. People who are able to get rides on their own already do.

“If 90 percent can and 10 percent can’t, what about the 10 percent?” Simon said.

It’s a question that haunts Kunz every day.

“I’m a college student, I have a cat,” said Kunz, who is studying psychology online at Southern New Hampshire University. “I’m just a regular human trying to do things, and the inaccessibility in this area is ridiculous.”

Idaho ‘Pushing Envelope’ With Health Insurance Plan. Can It Do That?

Kaiser Health News:HealthReform - January 30, 2018

For the past year, the Trump administration and Republicans in Congress have led a charge to roll back the Affordable Care Act, signaling an openness to state changes.

Now, Idaho has jumped in, saying it will allow insurers to ignore some ACA rules on plans not sold on the marketplace, aiming to make these state-based plans less costly. Several of the changes are viewed by the law’s supporters as hits to its core consumer protections.

Critics decried the move, saying Idaho can’t unilaterally decide not to follow federal law, including some of the ACA’s protections for preexisting conditions and its limits on how much more insurers can charge older or sick people.

Idaho’s approach has national implications because of a key underlying question: Will the administration push back to compel Idaho to follow the ACA or offer a green light that could prompt other states to take even more sweeping action?

Idaho argues its aim is to bring people back into the market, particularly the young, the healthy and those who can’t afford an ACA plan.

“That’s our goal,” said Dean Cameron, director of the state’s Department of Insurance. “Our goal is not to take away from the ACA, but to add to it or complement it.” For instance, insurers could veer from the ACA rules in creating the new plans, so long as they offer other ACA-compliant policies.

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Premiums for marketplace policies have risen sharply amid continuing GOP efforts to undermine the ACA. Middle-income Americans who don’t get subsidies are struggling to afford coverage.

“States are trying to figure out what they can do,” said Ed Haislmaier, a senior research fellow at the conservative Heritage Foundation. “How do you provide them with cheaper insurance?”

Idaho says the answer is to skip some of the ACA rules.

Here is a quick look at some of the questions the announcement raises:

1. Can Idaho do this?

Many experts say no. Nicholas Bagley, a law professor at the University of Michigan and former attorney with the civil division of the U.S. Department of Justice, tweeted early Thursday that the move was “crazypants illegal.”

In a follow-up call, he explained that the ACA created rules that — among other things — prevent insurers from discriminating against people based on their health or excluding coverage for those conditions.

“I’m completely flummoxed,” he said. “Idaho appears to be claiming they do not have to adhere to federal law.”

But Idaho officials believe there’s precedent for what they are doing, pointing to actions taken by President Barack Obama when he promised people that if they liked their health plans, they could keep them. Obama issued an executive order directing his agencies to allow the continuance of some plans purchased before the marketplaces opened— even though they fell short of ACA rules, Cameron noted.

Additionally, Cameron pointed to state laws that allow insurers to sell short-term policies that don’t meet all the ACA rules.

“We have tried to do everything we can to adhere to and follow the requirements,” said Cameron, who added that the state consulted with administration officials as it developed its plan.

“I recognize we are pushing the envelope a bit,” he said. “We think this is what is needed.”

2. What might happen?

Most experts expect that a lawsuit is likely, perhaps on behalf of someone with a preexisting condition alleging harm because the state-based plans will cost the sick more or limit coverage in other ways.

Secondly, some experts say the argument might include concerns that the state-based plans could pull healthy people out of the ACA market and drive up premiums there.

Cameron expects the effect will be the opposite, helping stabilize those premiums by bringing more healthy people into insurers’ risk pools through the state-based plans. Insurers would have to pool their claims from both ACA and state-based plans.

3. How different are these plans from ACA coverage?

Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, said they are “in the middle in terms of the consumer protections they provide, but they’re not as good as the ACA.”

They’re better than some non-ACA compliant alternatives already on the market, such as limited-benefit plans, which can be really skimpy — paying paltry amounts or nothing at all toward hospital care or drugs, for example.

By contrast, Idaho’s directive says the new plans must cover outpatient services, emergency care, hospitalization, mental health and substance abuse treatment, drugs, rehabilitation, lab services and preventive care. Insurers must include maternity coverage in at least one state-based plan.

“Setting aside the question of whether a state can do this, it would not be a radical change,” said Haislmaier at Heritage.

But, unlike ACA plans, the state plans could cap coverage at $1 million annually. They could charge older people up to five times more than younger ones (the ACA limits the ratio to 3-to-1) and sick people could be charged up to 50 percent more for premiums than standard rates. On the flip side, very healthy people could have rates of up to 50 percent below standard rates.

On preexisting conditions — which is among the ACA’s most popular provisions — the Idaho rules would require insurers to accept people with medical problems, but they could exclude coverage for those specific conditions if the person were uninsured within 63 days of the new plan taking effect.

Still, Cameron argues that the rules of the Idaho plan — in practice — would not be much different than what people face now.

Those who fail to sign up during the annual open enrollment period for the ACA then find out they have a health problem have few other options and would have to wait until the next ACA open enrollment, he noted.

Under Idaho’s plan, such consumers could buy a state-based plan and “have coverage on everything else, except for the ‘pre-ex’ [preexisting condition], until the next open enrollment period,” Cameron said.

4. What could happen legally?

At a minimum, states must follow federal law, although they generally can set more stringent standards. Some states, for example, are considering putting in place their own “individual mandate” to replace the ACA tax penalty for those who are uninsured. The tax bill Congress passed in December removes that federal penalty as of 2019.

But states cannot create rules that fall short of federal law. If the state doesn’t enforce federal rules, the ACA grants the federal government authority to step in.

Idaho may be “banking on … the Trump administration [not enforcing] the ACA,” said Bagley.

This could be one of the first tests for new Health and Human Services Secretary Alex Azar.

“If HHS does not go in and enforce the federal floor… then Idaho can do whatever it wants. Any other state can do whatever it wants,” said benefits attorney Christopher Condeluci, who formerly served as the tax and benefits counsel to the Senate Finance Committee.

He noted a parallel with the immigration debate: “If a state says, ‘hey ICE, we are going to resist you’, then the Department of Justice is allowed to come in and say these immigration officers can do what the law says they can do.”

Fallout could hit Trump, who might find himself defending a law he has adamantly opposed.

“If HHS declines to step in to enforce the law, the executive branch headed by the president is responsible for enforcing the law,” Bagley said. “His job is to make sure his agencies enforce federal law.”

5. Insurers have not said if they will offer such plans. What are their liabilities?

The ACA set fines of $100 per day, per enrollee, for violating provisions of the law. Multiplied by thousands of enrollees across several violations, that could quickly add up. The state may allow the plans, but “it’s not clear that a future administration could be prevented from looking back at past violations and imposing pretty significant penalties,” said Georgetown’s Corlette.

Death In The Family: An Uncle’s Overdose Spurs Medicaid Official To Change Course

Kaiser Health News:Madicaid - January 29, 2018

Andrey Ostrovsky’s family did not discuss what killed his uncle. He was young, not quite two weeks past his 45th birthday, when he died, and he had lost touch with loved ones in his final months. Ostrovsky speculated he had committed suicide.

Almost two years later, Ostrovsky was Medicaid’s chief medical officer, grappling with an opioid crisis that kills about 115 Americans each day, when he learned the truth: His uncle died of a drug overdose.

His family knew the uncle’s life had been turbulent for a while before his death, watching as he divorced his wife and became estranged from his 4-year-old daughter and eventually lost his job as a furniture store manager. But Ostrovsky wanted to understand what happened to his uncle, his stepfather’s younger brother. So, last fall when he found himself in southeastern Florida, where his uncle died in 2015, he contacted one of his uncle’s friends for what he thought would be a quick cup of coffee.

Instead the friend “let loose,” revealing that they had been experimenting with a variety of drugs the night his uncle died — the tragic culmination of more than a decade of substance abuse much of his family knew nothing about. An autopsy showed there were opiates and cocaine in his system, Ostrovsky later learned.

The revelation shook Ostrovsky, a pediatrician appointed to the Centers for Medicare & Medicaid Services in 2016. He had championed better drug treatment programs for the 74 million people on Medicaid — an increasingly uphill battle after Republicans signaled they would trim the program under President Donald Trump.

Within his own agency, Ostrovsky already felt that he was something of a pariah. After he’d posted a tweet against a Republican plan to repeal and replace the Affordable Care Act, he was reprimanded and removed from his major projects. A conservative group known as America Rising filed a Freedom of Information Act request for his email correspondence, a move seen as an attempt to intimidate Ostrovsky.

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But that revelation over coffee in Florida made the drug crisis deeply personal for Ostrovsky and his family, prompting him to act. He realized that solutions were not just about money, but also about combating stigma, that stain he says prevented his uncle from getting help. So, he quit his government job last month and is speaking publicly about his family’s experience, to remove the shame of drug addiction.

“It’s not what killed him,” Ostrovsky says, referring to the stigma. “But that’s what killed him.”

Last fall, the Trump administration declared the opioid crisis a public health emergency, stopping short of allocating more funding for an “epidemic” that killed more than 42,000 in 2016 — more than any year on record, according to the Centers for Disease Control and Prevention. That declaration was extended last week. Early data indicate 2017 may have outpaced 2016 in drug deaths.

In one of the latest attempts to manage the crisis, Democratic Gov. Tom Wolf of Pennsylvania recently declared the opioid epidemic a statewide disaster emergency. For the first time, Pennsylvania officials will direct emergency resources toward a public health crisis in the same way they would a natural disaster.

The uncle’s story offers an intimate look at a crisis that has vexed officials on the local, state and national level, strained public health resources — and infiltrated not just America’s streets and drug dens, but also workplaces and successful middle-class families like Ostrovsky’s. KHN agreed not to disclose the uncle’s name out of respect for his family’s privacy.

The uncle immigrated to the United States from Azerbaijan when he was 16, seeking a brighter future than the one stretched before him in the crumbling Soviet Union, Ostrovsky recalled. His family settled in Baltimore, where he married and started his own family. When he wasn’t working, he grilled lamb kebabs and danced to music from his home country. He was a warm, welcoming host, insisting guests have at least a cup of tea.

“Even when he had nothing, he would take that last piece of bread and offer it to you,” Ostrovsky says.

Andrey Ostrovsky (Courtesy of Andrey Ostrovsky)

To Ostrovsky, he was the “cool uncle,” always bringing his nephew trinkets from his travels. When Ostrovsky was in seventh grade, his uncle returned from Jamaica with a shirt that read: “See no evil, hear no evil, speak no evil, s— happens mon.” Ostrovsky wore it to school — and happily suffered the inevitable punishment. “I love him for that and was proud to get in trouble,” he wrote in an email.

Sometime around the early 2000s, the uncle and his wife divorced. He began drinking more, a vice Ostrovsky attributed in part to his cultural heritage but that he suspects grew into alcoholism.

It is unclear to the family when, exactly, drugs came into his life, though his problems seem to have escalated in his 30s. His drug of choice was cocaine, Ostrovsky learned from his uncle’s friend, who frequently took drugs with him over the years.

His inability to function at work and other financial strains eventually drove him to crack cocaine, an especially addictive, cheaper form that produces an instant, intense high when smoked. Months before his death, he lost his job and grew depressed. He began using more heavily and trying new drugs. He dabbled in benzodiazepines, a class of psychoactive drugs like Xanax and Valium, and opioids.

Opioids, which broadly include both illegal drugs like heroin and prescription painkillers like OxyContin, are particularly perilous when misused because they suppress the ability to breathe. Those who use opioids also build up a tolerance over time, encouraging them to use more to achieve a high. These facts are especially problematic considering street drugs are often cut with more powerful opioids — such as fentanyl, a fast-acting painkiller — to create a more intense high.

Eventually, Ostrovsky’s uncle began living with his drug dealer. On the night of his death, he and his friend went through the dealer’s stash when he was out, trying pills and other drugs. When the dealer returned, after the friend had left, the uncle didn’t answer the door.

They found him on the couch, looking “at peace,” his friend recounted to Ostrovsky. They tried to resuscitate him and called for help. Sitting on the curb outside, his friend watched the paramedics carry him away.

The friend says he quit using drugs and is enrolled in a methadone program, a treatment option that uses another opioid to reduce withdrawal symptoms.

Hampered by political ideology from the White House that has spurred a focus on overhauling Medicaid benefits, for instance, Ostrovsky says his former agency, CMS, is “ill-equipped” right now to handle this problem. So, for now, he’s working outside the government.

This month, Ostrovsky announced he is joining Concerted Care Group, an addiction treatment program based in Baltimore whose patients are mostly covered by Medicaid, where he will serve as CEO as the organization looks to expand.

Ostrovsky first noticed Concerted Care Group when it was part of a CMS pilot program, a standout because it eschewed the surreptitious-feeling grab-and-go approach of most outpatient addiction centers. “This can’t be a methadone clinic,” Ostrovsky thought when he first heard about it.

It offered patients private spaces to take their medicine; security guards to ensure their safety; even coffee while they wait, preserving at least a modicum of patient dignity. In the same spirit, Ostrovsky hopes that sharing his personal story about his uncle will combat the stigma that makes patients and their loved ones ashamed to reach out for help.

“I think this is really important, that people hear about his story and talk,” he says, “and get over that feeling of not wanting to have that uncomfortable conversation with my family member who needs help.”

My Grandmother Was Italian. Why Aren’t My Genes Italian?

Kaiser Health News:Marketplace - January 29, 2018

Maybe you got one of those find-your-ancestry kits over the holidays. You’ve sent off your awkwardly collected saliva sample, and you’re awaiting your results. If your experience is anything like that of me and my mom, you may find surprises — not the dramatic “switched at birth” kind, but results that are really different from what you expected.

The author got her name from her Italian grandmother, Gisella D’Appollonia, but, according to two DNA ancestry tests, not a lot of genes. (Courtesy of Carmen Grayson)

My mom, Carmen Grayson, taught history for 45 years, high school and college, retiring from Hampton University in the late 1990s. But retired history professors never really retire, so she has been researching her family’s migrations, through both paper records and now a DNA test. Her father was French Canadian, and her mother (my namesake, Gisella D’Appollonia) was born of Italian parents. They moved to Canada about a decade before my grandmother was born in 1909.

Last fall, we sent away to get our DNA tested by Helix, the company that works with National Geographic. Mom’s results: 31 percent from Italy and Southern Europe. That made sense because of her Italian mother. But my Helix results didn’t even have an “Italy and Southern European” category. How could I have 50 percent of Mom’s DNA and not have any Italian? We do look alike, and she says there is little chance I was switched at birth with someone else.

We decided to get a second opinion and sent away to another company, 23andMe. We opened our results together and were just as surprised. This time, I at least had a category for southern Europe. But Mom came back as 25 percent southern European, me only 6 percent. And the Italian? Mom had 11.3 percent to my 1.6. So maybe the first test wasn’t wrong. But how could I have an Italian grandmother and almost no Italian genes?

To answer this question, Mom and I drove up to Baltimore to visit Dr. Aravinda Chakravarti of the Johns Hopkins University School of Medicine and the Bloomberg School of Public Health, who has spent his career studying genetics and human health.

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“That’s surprising,” he told us when we showed him the results. “But it may still be in the limits of error that these methods have.”

The science for analyzing one’s genome is good, Chakravarti said. But the ways the companies analyze the genes leave lots of room for interpretation. So, he said, these tests “would be most accurate at the level of continental origins, and as you go to higher and higher resolution, they would become less and less accurate.”

As in my case — the results got me to Europe, just not Italy.

My 23andMe test also showed less than 1 percent of South Asian, Sub-Saharan African, and East Asian & Native American. This, Chakravarti said, is likely true because the genetics of people on a continental level are so different, and it’s not likely that South Asian will look like European. “Resolving a difference between, say, an African genome and an East Asian genome would be easy,” he said. “But resolving that same difference between one part of East Asia and another part of East Asia is much more difficult.”

I also learned that even though I got half of my genes from Mom, they may not mirror hers.

We do inherit our genes — 50 percent from each parent. But Elissa Levin, a genetic counselor and the director of policy and clinical affairs of Helix, says a process called recombination means that each egg and each sperm carries a different mix of a parent’s genes.

“When we talk about the 50 percent that gets inherited from Mom, there’s a chance that you have a recombination that just gave you more of the northwest European part than the Italian part of your mom’s ancestry DNA,” she said. That is also why siblings can have different ancestry results.

The companies compare customers’ DNA samples to samples they have from people around the world who have lived in a certain area for generations. The samples come from some databases to which all scientists have access, and the companies may also collect their own.

“We’re able to look at, what are the specific markers, what are the specific segments of DNA that we’re looking at that help us to identify, ‘Those people are from this part of northern Europe or southern Europe or Southeast Asia,'” Levin said.

As the companies collect more samples, their understanding of markers of people of a particular heritage should become more precise. But for now, the smaller the percentage of a population within a continent that is in the database, the less certain they are. Helix chooses not to report some of those smaller percentages, Levin said.

The 23andMe company reports results with a 50 percent confidence interval — they’re 50 percent sure their geographic placement is correct. Move the setting up to 90 percent confidence, meaning your placement in a region is 90 percent certain, and that small 1.6 percent of my ancestry that is Italian disappears.

The ancestry tests also have to take into account the fact that humans have been migrating for millennia, mixing DNA along the way. To contend with that, the companies’ analyses involve some “random chance,” as Levin put it. A computer has to make a decision.

And the ancestry companies have to make judgment calls. Robin Smith, a senior product manager with 23andMe, said their computers compare the DNA with 31 groups. “Let’s say a piece of your DNA looks most like British and Irish, but it also looks a little bit like French-German,” he said. “Based on some statistical measures, we’d decide whether to call that as British-Irish or French-German, or maybe we go up one level and call it northwestern European.”

What does he think explains my case?

“It was a bit surprising,” he said. “But in looking at the fact that you have some southern European and some French-German, the picture became a little clearer to me.”

So, for now, my Italian grandmother doesn’t show up in these tests. No matter — Chakravarti, Levin and Smith all say to let the results add to your life story. The DNA is just a piece of what makes you you.

Gisele Grayson is a senior producer on NPR’s Science Desk who runs the health reporting collaboration with member stations and Kaiser Health News.

HHS Marks 2017 Accomplishments Under President Donald J. Trump

HHS Gov News - January 26, 2018

Marking the end of the first year of the Trump Administration, the U.S. Department of Health and Human Services (HHS) released a report highlighting accomplishments from 2017.

“In 2017, HHS took bold action to advance its mission to protect and enhance the health and well-being of the American people. From a newly aggressive approach to combat the opioid crisis to round-the-clock responses to three major hurricanes, the men and women of HHS did extraordinary work this past year to foster healthier Americans, stronger communities, and a safer country,” said Caitlin Oakley, HHS press secretary.

Some of the Department’s significant accomplishments, by the numbers:


To read the document, visit https://www.hhs.gov/sites/default/files/hhs-end-of-year-accomplishments-2017.pdf.

HHS Awards Operations Blanket Purchase Agreement to ActioNet, CSRA, Leidos, NuAxis, Peraton (Harris IT), and SAIC

HHS Gov News - January 26, 2018

The Department of Health and Human Services (HHS), Office of the Chief Information Officer (OCIO) has awarded the second Next Generation Information Technology Services (NGITS) blanket purchase agreement (BPA) to ActioNet, CSRA, Leidos, NuAxis, Peraton (Harris IT), and SAIC. The BPA, with an estimated value of $139 million, provides end-to-end lifecycle support for all current and future HHS production systems regardless of manufacturer or operating system. It covers major HHS information technology operational needs such as network and security operations; data center operations; and deployment, testing, and maintenance of software and systems. SAIC won the first task order on the BPA and will provide call center, service desk, and data center support for HHS staff divisions and operating divisions.

The new operations task order promises to improve customer experience by separating call center and service desk functions, thereby directing customer service requests to those with the required expertise, providing additional technical support options to customers, and shortening response times for users. According to Steve Verber, director of operations for the Office of Information Technology Infrastructure and Operations (ITIO), “Implementing a dedicated call center will help us provide real benefit to our customers by creating a single interface for requesting any type of IT assistance. We will provide new options for customer interaction to include chat via the web and increase the availability of self-help options.” In addition, Verber states, “Functionally aligned support queues will ensure that incidents are assigned to the most experienced support staff in any subject area.”

HHS OCIO launched the NGITS program last year to provide improved support in IT service delivery, accountability, integration of new and emerging technologies, customer service, and performance measurement of information technology for the Office of the Secretary, its 22 staffing divisions, and more than 12,000 employees. In September 2017, the NGITS program awarded the first BPA in the area of application hosting. NGITS will award two more BPAs this year in engineering and program management integration.

The NGITS program offers an improved platform to leverage technology; manage standards, consistency, and activities across divisions; and allow for better services and transparency to HHS customers. “This award represents another great step forward in our efforts to provide shared services and cost-effective information technology support as a part of the HHS mission to improve the well-being of all Americans,” states George Chambers, ITIO executive director.

The Office of the Chief Information Officer advises the Office of the Secretary and the Assistant Secretary for Resources and Technology on matters pertaining to the use of information and related technologies to accomplish Departmental goals and program objectives.

Readout of Acting HHS Secretary Hargan’s Visit to Frankfort, Ky.

HHS Gov News - January 26, 2018

Acting Health and Human Services (HHS) Secretary Eric Hargan traveled to Frankfort, Kentucky on Wednesday, where he met with Governor Matt Bevin, senior members of Bevin’s administration, and citizens of the Commonwealth to discuss how HHS can better work with state partners to address America’s most pressing health challenges – all while fostering growth and innovation in the healthcare field.

Acting Secretary Hargan met with Governor Bevin and senior members of his administration to hear first-hand about the work they’ve been doing on the front lines to bring innovative solutions to their Medicaid program They then engaged in a roundtable discussion with members of the community, who shared stories regarding how Medicaid has impacted their lives, and how the addition of community engagement and work requirements to the Kentucky Medicaid program would help Kentuckians. The group also provided valuable feedback to HHS regarding how the Department can effectively partner with states, giving them the flexibility they need to best serve their citizens.

 “With Kentucky receiving the first approval for community engagement requirements for certain adults in the Medicaid program, we look forward to working with the Commonwealth on developing innovative strategies to improve the health and well-being of its Medicaid beneficiaries,” said Acting Secretary Hargan. “I enjoyed speaking with Governor Bevin, officials implementing the Kentucky waiver, and individuals who spoke about the great benefits and dignity finding work had brought to their lives.”

The Commonwealth’s Section 1115 Medicaid waiver, known as Kentucky HEALTH — “Helping to Engage and Achieve Long Term Health,” is a new initiative to improve the health of its participants. The waiver was approved by the Centers for Medicare & Medicaid Services (CMS) earlier this month.

The visits were a part of an ongoing effort by HHS to reaffirm the Trump administration’s commitment to working with local communities on efforts to address the nation’s healthcare challenges.

More information on Kentucky Health may be found here.

As Doctors Drop Opposition, Aid-In-Dying Advocates Target Next Battleground States

Kaiser Health News:States - January 26, 2018

When the end draws near, Dr. Roger Kligler, a retired physician with incurable, metastatic prostate cancer, wants the option to use a lethal prescription to die peacefully in his sleep. As he fights for the legal right to do that, an influential doctors group in Massachusetts has agreed to stop trying to block the way.

Kligler, who lives in Falmouth, Mass., serves as one of the public faces for the national movement supporting medical aid in dying, which allows terminally ill people who are expected to die within six months to request a doctor’s prescription for medication to end their lives. Efforts to expand the practice, which is legal in six states and Washington, D.C., have met with powerful resistance from religious groups, disability advocates and the medical establishment.

But in Massachusetts and other states, doctors groups are dropping their opposition — a move that advocates and opponents agree helps pave the way to legalization of physician-assisted death.

The American Medical Association, the dominant voice for doctors nationwide, opposes allowing doctors to prescribe life-ending medications at a patient’s request, calling it “fundamentally incompatible with the physician’s role as healer.”

But in December, the Massachusetts Medical Society became the 10th chapter of the AMA to drop its opposition and take a neutral stance on medical aid in dying.

Most of those changes occurred in the past two years. They proved a pivotal precursor to getting laws passed in California, Colorado and Washington, D.C., said Kim Callinan, chief program officer for Compassion & Choices, an advocacy group that supports legalization efforts around the country. (The practice is also legal in Washington, Oregon, Vermont and Montana.)

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The shifts come as doctors’ views evolve: Fifty-seven percent of U.S. doctors supported medical aid in dying in a 2016 Medscape survey, up from 46 percent in 2010.

Because of the medical society’s vote, Massachusetts is the state most likely to legalize medical aid in dying this year, predicted David Stevens, CEO of the Christian Medical & Dental Associations, a national group of 19,000 health professionals that has opposed such laws in every state.

“I think a neutral stance is probably what’s going to push it over,” he said.

Doctors’ opinions are also playing a role in New York, where the New York State Academy of Family Physicians endorsed an aid-in-dying bill, and the state medical society is surveying its members on the subject.

Efforts to legalize the practice have faced pushback nationally: Last year, lawmakers in 27 states introduced aid-in-dying bills, and none passed. And in Congress, Republican lawmakers have launched several attempts to block the District of Columbia from implementing its law.

This year, Compassion & Choices’ Callinan identified New Jersey, New York and Massachusetts as its top three target states.

Peg Sandeen, executive director of Death With Dignity National Center, an aid-in-dying advocacy group based in Oregon, cited Hawaii as another top target. Advocates there are “trying to break the logjam in the legislature,” where the state Senate passed a bill in March, she said. Hawaii came close to legalizing the practice in 2000.

Massachusetts has been a fraught battleground for the right-to-die movement: In 2012, opponents narrowly defeated a referendum that would have legalized the practice. Home to a robust medical hub and Harvard Medical School, the state is a stronghold for academic medicine.

Kligler, who’s 66, has publicly described his interest in using lethal drugs to die on his own terms rather than endure what he expects to be several months of significant pain, fatigue and declining quality of life.

Kligler said he wants other dying people to have the same option: When he used to serve as a hospice physician to cancer patients, he said, patients used to “ask me to help them to die,” but he had no legal way to do so. Kligler is also suing Massachusetts, arguing that terminally ill patients have a constitutional right to medical aid in dying.

“It’s a question of justice,” Kligler said.

When the Massachusetts Medical Society surveyed members last year, 60 percent said they supported medical aid in dying, and 30 percent said they opposed it.

Dr. Barbara Rockett, a surgeon and past president of the medical society, urged fellow doctors to uphold the group’s long-standing opposition to the practice. Doctors should focus on helping dying patients through hospice and palliative medicine, she said.

“To intentionally help them commit suicide is wrong,” Rockett said. Proponents, meanwhile, say the practice is not “suicide” because the patient is already being killed by a terminal disease.

Rockett said she was disappointed that her fellow delegates in the society voted to adopt a neutral stance.

Even with the doctors group stepping out of the way, the latest aid-in-dying bill, dubbed the Massachusetts End of Life Options Act, faces formidable opposition. Catholic groups, a significant force opposing aid in dying nationally, have a robust base in Massachusetts: Over a third of residents are Catholic, second only to Rhode Island.

Catholic groups provided much of the $5.5 million that opponents spent to defeat Massachusetts’ ballot referendum in 2012, outspending proponents by nearly 5-to-1.

The Boston Archdiocese did not respond to repeated requests for comment for this story. But at the time the referendum failed, a spokesman said the church could not afford to lose on this issue in a Catholic stronghold: “If it passes in Massachusetts,” the spokesman said, “it’s a gateway to the rest of the country.”

What’s Next For ‘Safe Injection’ Sites In Philadelphia?

Kaiser Health News:States - January 26, 2018

Philadelphia is a step closer to opening what could be the nation’s first supervised site for safe drug injection. But turning the idea into reality won’t be easy.

City officials gave the proposition the green light Tuesday. They were armed with feasibility studies, harrowing overdose statistics and the backing of key leaders, including the mayor and a newly elected district attorney.

“There are many people who are hesitant to go into treatment, despite their addiction, and we don’t want them to die,” said Dr. Thomas Farley, Philadelphia’s health commissioner and co-chair of the city’s opioid task force. Supervised safe-injection sites, he said, save lives by preventing overdose deaths and connecting people with treatment.

While one big hurdle is now cleared, the details of how safe-injection sites would actually work in Philadelphia have yet to be figured out. Who will actually fund and operate a site? Where will it be located? Will users really be safe there?

“We have a long way to go,” said Brian Abernathy, first deputy managing director for the city.

Neither city council approval nor special zoning ordinances would be required to proceed, Abernathy said, but the city doesn’t plan to operate or pay for any sites. Instead, Philadelphia officials would play the roles of facilitator and connector with providers of addiction services.

In that way, Tuesday’s announcement by the city was more like an open call to potential investors and operators than it was the rollout of a specific plan.

“We took a really, really big first step,” said Jose Benitez, executive director of Prevention Point Philadelphia, a large, nonprofit needle exchange. “It’s early to talk about our involvement at this particular point. As the city officials said, there’s a lot to consider.”

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Broadly, the city envisions a place where people would be allowed to bring in drugs and inject them using clean equipment. If someone overdosed, trained staff would respond to prevent death. The sites could save lives and money otherwise lost to hospitalizations and emergency response efforts. Advocates say the sites also could reduce neighborhood problems associated with addiction, like people injecting in public and discarding needles.

A safe, supervised site wouldn’t just be about a spot to inject, Farley stressed, but also somewhere people could connect with other services and treatment.

Still, the effort to open a site will likely face additional hurdles and unknowns, from community buy-in to legal concerns.

For one, Councilwoman Maria Quiñones-Sánchez, who has voiced opposition to a safe-injection site in her district (one at the heart of the crisis), is wary of the city’s plan.

“This notion of letting a private developer or a private person come tell us how this could be done, we’re not paying for it, we’ll do wrap-around services, so much of that is just up in the air,” Quiñones-Sánchez said. “So why make an announcement with no answers?”

Another question: Could such a site be immune from federal prosecution? Realistically no, said Philadelphia official Abernathy, though some legal scholars are exploring potential safeguards.

The city’s police commissioner, Richard Ross, has gone from “adamantly against” any injection site to having an open mind. Whether police will take a hands-off approach remains to be seen. So would what the department’s role would be, what police officers would be asked to do, and how that would affect the policing of narcotics?

“I don’t have a lot of answers,” he said.

One point of clarity: Philadelphia District Attorney Larry Krasner has no plans to prosecute.

“What will we do? We will allow God’s work to go on,” Krasner said, citing state laws as justification that allow the committing of minor violations in the interest of preventing greater harms. “We will make sure that idealistic medical students don’t get busted for saving lives and that other people who are trying to stop the spread of disease don’t get busted.”

After all this, it should come as no surprise that the timeline is really unclear, too. Rollout will take months, at least, leaders have said. Though if it were up to Krasner, one would have opened years ago.

“My biggest concern moving forward with harm reduction is that government takes forever,” he said. “When we have three or four people dying every day, nobody can afford to wait.”

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

In Battleground Races, Health Care Lags As Hot-Button Issue, Poll Finds

Kaiser Health News:HealthReform - January 26, 2018
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As the midterm elections approach, health care ranks as the top issue, mentioned more frequently among voters nationwide than among those living in areas with competitive races, a new poll finds.

In areas with competitive congressional or gubernatorial races, the economy and jobs ranked as the top issue for candidates to discuss, with 34 percent of registered voters listing it as No. 1, according to the poll from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.) Following economics was the conflict with North Korea (23 percent), immigration (22 percent) and health care (21 percent). The competitive areas are 13 states with statewide races and 19 House districts judged as toss-ups by the nonpartisan Cook Political Report.

Nationwide, 29 percent of registered voters ranked health care as the most important issue for electoral discussion — though it was far more important for Democrats than Republicans. Economy and jobs were close behind with 27 percent of voters rating it most important, and then immigration, with 24 percent listing it.

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The poll found that nearly half of Americans believed there is still a federal requirement for everyone to obtain health insurance, even though Congress’ tax bill last year repealed the penalties for that requirement in the Affordable Care Act, known as the individual mandate. Only a third of the public were sure that those penalties had been repealed.

Fifty percent of the public expressed a favorable view of the health law, while 42 percent disliked it. Six in 10 people said that since President Donald Trump and the Republicans in Congress have altered the law, they are responsible for any problems. Like other opinions about the law, there was a strong partisan split: Only 38 percent of Republicans thought their party is now responsible, while 77 percent of Democrats thought so. Half of Republicans still listed repealing the health law as a top priority.

There was less of a partisan split over the importance that the president and Congress address the epidemic of prescription painkiller addiction. Among Republicans, 43 percent rated it a top priority; 54 percent of Democrats agreed.

There was no such comity over whether lawmakers should allow people brought illegally to this country by their parents — the so-called Dreamers — to stay in the country legally: 21 percent of Republicans called that a top priority, while 66 percent of Democrats did. And while 43 percent of Republicans said they wanted lawmakers to focus on passing federal funding for a border wall with Mexico, only 5 percent of Democrats and 19 percent of independents did.

The poll was conducted Jan. 16-21 among 1,215 adults. The margin of error was +/-3 percentage points. The poll included 298 people who said they were registered to vote in one of the areas the Cook Report identified as a battleground in the fall elections. The margin of error for results for this group was +/-7 percentage points.

Podcast: ‘What The Health?’ CHIP (Finally) Gets Funded

Kaiser Health News:HealthReform - January 25, 2018

Three and a half months after funding expired for the Children’s Health Insurance Program, CHIP is finally refinanced, this time for six years. That was one of several health policies attached to the short-term spending bill Congress passed Monday, which reopened the federal government after a weekend shutdown.

The spending bill also delayed — again — several unpopular health care taxes that are intended to help fund the Affordable Care Act, including the “Cadillac tax” on very generous health plans.

This week’s “What The Health?” panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Alice Ollstein of Talking Points Memo and Paige Winfield Cunningham of The Washington Post.

In addition to those topics, they discuss new leadership at the Department of Health and Human Services, after the Senate confirmed Alex Azar to lead the agency, and efforts by religious conservatives at HHS to make it easier for health workers to decline to participate in abortions, physician-assisted death or other controversial health procedures.

Among the takeaways from this week’s podcast:

  • Now that Congress has funded the Children’s Health Insurance Program, health care advocates are lining up to push for funding for community health centers, which serve about 1 in 12 Americans and ran out of federal funding on Oct. 1.
  • At the same time, the bipartisan effort in the Senate to pass legislation to stabilize the ACA’s marketplaces seems to be losing steam.
  • The new HHS rule that protects workers who have conscientious objections to services — such as providing birth control, treating transgender patients or performing abortions — addresses protections already contained in similar state and federal laws. Email Sign-Up

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

Julie Rovner: Politico’s “The religious activists on the rise inside Trump’s health department,” by Dan Diamond.

Joanne Kenen: Dallas News’ “Bishop Lynch High School having online school Thursday and Friday due to flu outbreak,” by Dana Branham.

Alice Ollstein: The Washington Post’s “Trump’s 24-year-old drug policy appointee to step down by month’s end,” by Robert O’Harrow Jr.

Paige Winfield Cunningham: The Texas Tribune, “Dangerous Deliveries: Is Texas doing enough to stop moms from dying?” by Marissa Evans and Chris Essig.

To hear all our podcasts, click here.

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

After Months In Limbo For Children’s Health Insurance, Huge Relief Over Deal

Kaiser Health News:Insurance - January 25, 2018

When parts of the federal government ground to a halt this past weekend, Linda Nablo, who oversees the Children’s Health Insurance Program in Virginia, had two letters drafted and ready to go out to the families of 68,000 children insured through the program, depending on what happened.

One said the federal government had failed to extend CHIP after funding expired in September and the stopgap funding had run out. The program would be shutting down and families would lose their insurance.

The other letter said they could stop worrying because federal funding had finally come through and the program’s future was assured.

Since Monday’s deal to end the shutdown included a six-year reauthorization of CHIP, enrolled families in Virginia will get that second letter. The program will go on and no children will lose their health insurance.

Taking Stock Of Costs

After months of uncertainty, Nablo said she’s relieved. “Hugely relieved. It’s over and the program is safe, and we can all go back to our normal jobs,” she said.

Preparations to shut down the program in Virginia began over the summer, even before funding expired. Staff spent untold hours gearing up to end the program, retooling enrollment systems, changing contracts and more.

“Those aren’t huge dollar amounts,” Nablo said. “I think the cost more is in the worry from parents.”

CHIP covers children in low-income families — most can’t afford private insurance and their children might have had to go uninsured. Nationally, about 9 million children get health coverage through CHIP.

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An Unprecedented Situation

In its 20-year history, CHIP had always been uncontroversial, even popular in both parties. Its funding needs to be periodically renewed, and it always had been taken care of well in advance of the money running out.

CHIP is a match program — states and the federal government split the cost. When states made their budgets for this year, they assumed federal funding for CHIP would be there, so they were blindsided by the funding gap.

Every state’s calculus for how long they could run on leftover money was different. In Texas, Hurricane Harvey threw off that state’s projections. Because of the disaster, it waived fees for CHIP and enrollment spiked, so it had less money coming in and more going out.

A handful of states — including Virginia — sent out letters warning families their coverage was in jeopardy because of the uncertainty in Congress.

“One state — Connecticut — did freeze enrollment between the week of Christmas and New Year’s,” said Joan Alker of the Georgetown University Center for Children and Families, which monitored CHIP funding closely the past few months.

Virginia’s Nablo said there might be other, more subtle, costs from all the uncertainty.

“I can’t quantify it, but I am sure there are states that held off on things like mounting an outreach program to encourage people to enroll because they didn’t know if the program was going to be there for them,” she said. “There may have been states that were thinking of implementing some efficiencies or innovations, but didn’t because — again — is the program going to be there?”

Six Years Of Certainty

Alker said she is happy with the CHIP deal Congress passed. It’s the same one they agreed on in September, she noted, so she’s not sure why it took a shutdown to finally get it through.

The deal keeps the federal investment in the program at its current level for two fiscal years. After that, the amount that states have to pay for the program will increase.

“At least states now have time to plan for that,” Alker said. “Overall, it really was a fair and reasonable compromise.”

What puzzles her is why it was extended only for six years when the Congressional Budget Office estimated extending CHIP for 10 years would save the federal government $6 billion, she said.

“The six-year [extension] is a small saver — it saves just under a billion dollars,” Alker said. “Now there’s nothing preventing Congress from coming back as they move ahead with the bigger budget deal — they could come back and extend CHIP for four more years and grab those savings.”

Impact On Children’s Uninsured Rate

Alker does worry that the months of uncertainty around CHIP may have already caused children to drop out of the program, increasing the uninsured rate among children, she said. That should become clear in the fall, when the Georgetown Center For Children and Families does its annual assessment of the children’s uninsured rate.

If that trend develops nationally, it hasn’t been the case in Virginia, where CHIP enrollment went up this past fall.

“We actually saw a boost in enrollment,” Nablo said. “I can’t really quite explain it.”

Maybe, she said, it was all the attention the unprecedented funding crisis brought to CHIP. A silver lining, perhaps, to many months of anxiety.

This story is part of a partnership that includes WAMU, NPR and Kaiser Health News. Selena Simmons-Duffin is a producer at NPR’s “All Things Considered,” currently on an exchange with Washington, D.C., member station WAMU.

Big Pharma Greets Hundreds Of Ex-Federal Workers At The ‘Revolving Door’

Kaiser Health News:Marketplace - January 25, 2018

Alex Azar’s job hop from drugmaker Eli Lilly to the Trump administration reflects ever-deepening ties between the pharmaceutical industry and the federal government.

A Kaiser Health News analysis shows that hundreds of people have glided through the “revolving door” that connects the drug industry to Capitol Hill and to the Department of Health and Human Services.

Azar was confirmed Wednesday as  HHS secretary, joining other former drug industry alumni in top positions.

Nearly 340 former congressional staffers now work for pharmaceutical companies or their lobbying firms, according to data analyzed by KHN and provided by Legistorm, a nonpartisan congressional research company. On the flip side, the analysis showed, more than a dozen former drug industry employees now have jobs on Capitol Hill — often on committees that handle health care policy.

“Who do they really work for?” said Jock Friedly, Legistorm’s president and founder, who called that quantity “substantial.” “Are they working for the person who is paying their bills at that moment or are they essentially working on behalf of the interests who have funded them in the past and may fund them in the future?”

In many cases, former congressional staffers who now work for drug companies return to the Hill to lobby former co-workers or employees. The deep ties raise concerns that pharmaceutical companies could wield undue influence over drug-related legislation or government policy.

“You’ll take the call because you’ve got a friendly relationship,” said Diana Zuckerman, president of the nonprofit National Center for Health Research and a former congressional staffer. “You’ll take the call because these people are going to help you in your future career [and] get you a job making three times as much.”

A 2012 Sunlight Foundation investigation found that, on average, a chief of staff on the Hill could increase his or her salary 40 percent by moving to the private sector.

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Experts say the cozy relationships don’t necessarily mean congressional staffers do favors for lobbyists they know, but the access doesn’t hurt.

When John Stone left the House Energy and Commerce Committee last fall to join lobbying firm BGR, he told Politico that he had consulted with two lobbyists at BGR “for advice on basically everything that came across my desk.”

KHN’s review of Legistorm data indicates that one of the lobbyists, BGR’s Ryan Long, overlapped with Stone on the House panel. Brent Del Monte preceded them both on the committee and then spent 10 years at the Biotechnology Innovation Organization (BIO), a trade group for the biologic drug industry, before joining BGR in 2015. BGR’s clients include PhRMA, Celgene and other pharmaceutical firms.

Like Stone, Long and Del Monte, many ex-Hill staffers working in some way for the pharmaceutical industry came from key committees, including the Senate Committee on Health, Education, Labor and Pensions (HELP) and the House Energy and Commerce Committee, which in 2016 shepherded the 21st Century Cures Act into law. The law faced criticism from watchdogs who feared it would make drug approval cheaper and easier but could lead to unsafe approvals.

Tim LaPira, a James Madison University associate professor who co-authored a book about the revolving door published in June, said the practice of leaving government service to lobby for industry isn’t as corrupt as it seems. Rather, as congressional staffs have shrunk over time, they’ve been forced to essentially outsource expertise to lobbyists, he said.

“Don’t tell the private sector to stop doing it. Tell Congress to stop relying on the private sector so much,” LaPira said, adding that Congress spends just 0.5 percent of the discretionary budget on itself.

The number of congressional employees declined by more than 7,000 people — about 27 percent — from 1979 to 2015, according to data compiled by the Brookings Institution, a nonprofit research group.

While there’s a fear that lobbyists are slipping industry-friendly language into legislation, LaPira explained, more often they’re monitoring what’s happening inside government.

The reverse-revolving door, in which former pharmaceutical employees enter public service, is not as clearly understood. Neither is the flow of serial revolvers, who go from industry to government and back.

Some of those Hill staffers, according to financial disclosures, maintain drug industry pensions and stock, Kaiser Health News found. They are not required to divest and are required to disclose those connections only if they hold key positions.

Reverse revolvers may not realize they’re doing Big Pharma’s bidding, Friedly said, but they’ve been so exposed to the industry’s point of view that their implicit biases may seep into their legislative work.

The revolving door operates beyond the Hill, however, LaPira said

In addition to Azar, several former drug industry officials have landed key jobs in Trump’s Cabinet and administration, including Food and Drug Administration Commissioner Scott Gottlieb, a former venture capitalist with deep ties to the pharmaceutical industry.

Gottlieb disclosed serving on boards of several pharmaceutical companies, including GlaxoSmithKline and Daiichi Sankyo, prior to returning to government for his third trip through the revolving door.

KHN also reviewed the résumés of more than 100 HHS appointees, obtained via a Freedom of Information Act request by American Oversight, a nonprofit founded to hold government officials accountable. Although only a handful of recent appointees were employed directly by drug companies, more than a dozen had worked as lobbyists, consultants and lawyers on behalf of pharmaceutical firms.

The high-level HHS appointees include: Keagan Lenihan, a former lobbyist for drug distributor McKesson who now serves as senior counselor to the secretary at HHS; former PhRMA lobbyist John O’Brien, now deputy assistant secretary of health policy for the agency’s Planning and Evaluation arm; and former Bristol-Myers Squibb lobbyist Mary-Sumpter Lapinski, an attorney in the HHS secretary’s office.

Sen. Elizabeth Warren expressed concerns about the revolving door during Azar’s confirmation hearing before the HELP committee in November. Not long after telling Azar that his “résumé reads like a how-to manual for profiting from government service,” she asked him whether drug industry CEOs should be held accountable when the companies they run break the law. He did not answer yes or no.

His reply: “I’m satisfied with our discussion.”

METHODOLOGY

Kaiser Health News obtained revolving-door and lobbying disclosure data from Legistorm, a for-profit, nonpartisan congressional research firm based in Washington, D.C.

The revolving-door data include congressional staffers’ jobs on and off Capitol Hill. It is current through August 2017 and dates to 2001. For lobbyists who did not directly work for pharmaceutical firms but worked for lobbying firms on behalf of pharmaceutical companies and their trade groups, Kaiser Health News used lobbying disclosure data to identify individuals registered to lobby on behalf of these clients. Reporters then tracked down these lobbyists in Legistorm’s revolving door data and checked them by hand.

The HHS appointee résumés obtained by American Oversight covered individuals appointed from Jan. 20 to July 12, 2017.

Hospitals’ Best-Laid Plans Upended By Disaster

Kaiser Health News:Marketplace - January 24, 2018

It was 3:35 a.m. and flames from a massive Northern California wildfire licked at the back of a Santa Rosa hospital.

Within three hours, staffers evacuated 122 patients to other facilities — something they’d never come close to doing before. Ambulances sped off with some of the sickest patients; city buses picked up many of the rest.

With phone lines charred and communication restricted, doctors and nurses struggled to figure out who was sent where — forced to keep their wits even as some of their own homes burned and their families fled.

This was not exactly covered in their meticulously executed drills and disaster-preparedness videos.

“You never know how you’ll react until it comes your way … until fate taps you on the shoulder,” said Dr. Josh Weil, an emergency medicine physician at Kaiser Permanente in Santa Rosa who led the hospital evacuation operation on Oct. 9.

America’s hospitals were beset by an unusual number of calamities in 2017: The fires that raged in Northern and Southern California; hurricanes that displaced thousands in Houston, Florida and Puerto Rico; the deadliest mass shooting in modern history that killed 58 people and wounded more than 500 others in Las Vegas; and the attack at a Bronx hospital in which a doctor turned a gun on his former colleagues, killing one and injuring six.

Across the country, natural disasters have become more frequent and more deadly; the carnage from mass shootings resembles that on a battlefield. In some cases, these crises are more severe and elaborate than most hospitals — particularly smaller ones — are prepared for, and experts say it is time to bring facilities up to speed.

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“The probability that any individual hospital will be involved in an unusual event is increasing,” said Dr. Carl Schultz, professor emeritus of emergency medicine and public health at the University of California-Irvine. “All hospitals are potentially vulnerable,” he said, and “there is more pressure for hospitals to be prepared.”

That’s the case, he added, even though hospitals often lack the resources and funding to upgrade their disaster plans.

In the new year, hospitals that responded to outsized tragedies in 2017 are reassessing their plans in light of their painful experiences. Below are some instructive examples:

Keeping Track Of Patients

In Northern California, staffers from the Kaiser hospital in Santa Rosa rushed to clear out their wards as the ferocious Tubbs Fire approached. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

The original plan was to jot down details from each displaced patient’s identification bracelet so that the hospital could later confirm that patients arrived at other hospitals safely. But with the fire coming fast upon them, it became clear this would take too long, Weil said.

On the fly, one staffer suggested taking photos of patient wristbands with smartphones, he said.

“That was a brilliant idea that really saved us,” Weil said.

The hospital is now considering whether smartphones might be of greater use in future emergencies, or if there’s a more efficient way to track patients who must be rapidly whisked away.

Incredible video of patients being evacuated from Kaiser Hospital in #SantaRosa #NapaFire pic.twitter.com/cxF686RSnP

— Jason Martinez (@10NewsJason) October 9, 2017

Eight days earlier, another tracking issue surfaced at Sunrise Hospital & Medical Center in Las Vegas — this one concerning incoming patients. The facility was suddenly inundated by people shot or otherwise injured during the tragedy at the outdoor country music festival; 212 patients were admitted in a two-hour window, 124 of them with gunshot wounds.

Of those, 92 had no official photo identification on them.

Families dashed desperately from one hospital to another searching for their loved ones, said Alan Keesee, the hospital’s chief operations officer. Without IDs for patients, it was a challenge to confirm whether they were at the hospital, let alone whether they would be OK.

Enterprising staffers listed their unidentified patients’ physical traits and unique features, such as tattoos, to help match people with the descriptions family members provided. In turn, many relatives pulled up social media profile photos of their loved ones to give the hospital something to go by.

The chaotic process of patient identification exposed a desperate need for a centralized data hub where descriptions of unidentified patients in a massive emergency could be uploaded and accessed by all area hospitals, Keesee said.

And indeed, he said, his hospital is working with the Nevada Hospital Association and other local health agencies to determine whether the hub can be created.

Communication And Coordination

Last June, a former doctor stormed Bronx-Lebanon Hospital armed with a semiautomatic rifle.

Staff members had trained for just this kind of incident. But they had not anticipated how restricted their movements would be once police took over, said Dr. Sridhar Chilimuri, the physician-in-chief that day.

“Shooting victims need blood transfusions, so you need to get from the blood bank to the operating rooms quickly,” Chilimuri said.

But the hospital lockdown blocked access to elevators. Doctors and nurses also had to fetch surgical instruments and move patients, he added, but they couldn’t do so without approval from police.

Because it was an internal shooting, police had to clear staffers of suspicion before they could return to work — even the doctors needed for lifesaving operations.

The hospital has since updated its drills to include an accelerated process of police screening — targeting the medical staff most urgently needed — and its training videos now show an attacker armed with an assault weapon rather than a small handgun.

“Hopefully that will help us cut down on the time we are crippled,” Chilimuri said.

Running Low On Supplies

When Hurricane Irma barreled into South Florida in September, the 10 Tenet Health hospitals in the region felt ready.

They had beefed up their disaster plans after Hurricane Matthew landed a year earlier, said Cathy Philpott, a director of nursing practice and clinical operation for the hospital system. They also brought in staff from other states and rolled in backup generators, she said.

Even so, they faced an unexpected challenge: a shortage of platelets, cells that help the body form clots to stop bleeding.

Until sister hospitals in Boston could airlift platelets in, the hospitals had to work with local blood banks to conserve the supply and prioritize their use for trauma patients. When hurricanes are forecast in the future, the hospitals will reach out to local blood banks and host platelet drives as the storms approach, Philpott said.

“That’s the lesson learned,” she said.

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