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Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model

Kaiser Health News:Insurance - October 09, 2018

Calvin Brown doesn’t have a primary care doctor — and the peripatetic 23-year-old doesn’t want one.

Since his graduation last year from the University of San Diego, Brown has held a series of jobs that have taken him to several California cities. “As a young person in a nomadic state,” Brown said, he prefers finding a walk-in clinic on the rare occasions when he’s sick.

“The whole ‘going to the doctor’ phenomenon is something that’s fading away from our generation,” said Brown, who now lives in Daly City outside San Francisco. “It means getting in a car [and] going to a waiting room.” In his view, urgent care, which costs him about $40 per visit, is more convenient — “like speed dating. Services are rendered in a quick manner.”

Brown’s views appear to be shared by many millennials, the 83 million Americans born between 1981 and 1996 who constitute the nation’s biggest generation. Their preferences — for convenience, fast service, connectivity and price transparency — are upending the time-honored model of office-based primary care.

Many young adults are turning to a fast-growing constellation of alternatives: retail clinics carved out of drugstores or big-box retail outlets, free-standing urgent care centers that tout evening and weekend hours, and online telemedicine sites that offer virtual visits without having to leave home. Unlike doctors’ offices, where charges are often opaque and disclosed only after services are rendered, many clinics and telemedicine sites post their prices.

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A national poll of 1,200 randomly selected adults conducted in July by the Kaiser Family Foundation for this story found that 26 percent said they did not have a primary care provider. There was a pronounced difference among age groups: 45 percent of 18- to 29-year-olds had no primary care provider, compared with 28 percent of those 30 to 49, 18 percent of those 50 to 64 and 12 percent age 65 and older. (Kaiser Health News is an editorially independent program of the foundation.)

A 2017 survey by the Employee Benefit Research Institute, a Washington think tank, and Greenwald and Associates yielded similar results: 33 percent of millennials did not have a regular doctor, compared with 15 percent of those age 50 to 64.

“There is a generational shift,” said Dr. Ateev Mehrotra, an internist and associate professor in the Department of Health Care Policy at Harvard Medical School. “These trends are more evident among millennials, but not unique to them. I think people’s expectations have changed. Convenience [is prized] in almost every aspect of our lives,” from shopping to online banking.

So is speed. Younger patients, Mehrotra noted, are unwilling to wait a few days to see a doctor for an acute problem, a situation that used to be routine. “Now,” Mehrotra said, “people say, ‘That’s crazy, why would I wait that long?'”

Until recently, the after-hours alternative to a doctor’s office for treatment of a strep throat or other acute problem was a hospital emergency room, which usually meant a long wait and a big bill.

Luring Millennials

For decades, primary care physicians have been the doctors with whom patients had the closest relationship, a bond that can last years. An internist, family physician, geriatrician or general practitioner traditionally served as a trusted adviser who coordinated care, ordered tests, helped sort out treatment options and made referrals to specialists.

But some experts warn that moving away from a one-on-one relationship may be driving up costs and worsening the problem of fragmented or unnecessary care, including the misuse of antibiotics.

A recent report in JAMA Internal Medicine found that nearly half of patients who sought treatment at an urgent care clinic for a cold, the flu or a similar respiratory ailment left with an unnecessary and potentially harmful prescription for antibiotics, compared with 17 percent of those seen in a doctor’s office. Antibiotics are useless against viruses and may expose patients to severe side effects with just a single dose.

“I’ve seen many people who go to five different places to be treated for a UTI [urinary tract infection] who don’t have a UTI,” said Dr. Janis Orlowski, a nephrologist who is chief health care officer at the Association of American Medical Colleges, or AAMC. “That’s where I see the problem of not having some kind of continuous care.”

“We all need care that is coordinated and longitudinal,” said Dr. Michael Munger, president of the American Academy of Family Physicians, who practices in Overland Park, Kan. “Regardless of how healthy you are, you need someone who knows you.” The best time to find that person, Munger and others say, is before a health crisis, not during one.

And that may mean waiting weeks. A 2017 survey by physician search firm Merritt Hawkins found that the average wait time for a new-patient appointment with a primary care doctor in 15 large metropolitan areas is 24 days, up from 18.5 days in 2014.

While wait times for new patients may reflect a shortage of primary care physicians — in the view of the AAMC — or a maldistribution of doctors, as other experts argue, there is no dispute that primary care alternatives have exploded. There are now more than 2,700 retail clinics in the United States, most in the South and Midwest, according to Rand Corp. researchers.

Connecting With Care

To attract and retain patients, especially young adults, primary care practices are embracing new ways of doing business.

Many are hiring additional physicians and nurse practitioners to see patients more quickly. They have rolled out patient portals and other digital tools that enable people to communicate with their doctors and make appointments via their smartphones. Some are exploring the use of video visits.

Mott Blair, a family physician in Wallace, N.C., a rural community 35 miles north of Wilmington, said he and his partners have made changes to accommodate millennials, who make up a third of their practice.

“We do far more messaging and interaction through electronic interface,” he said. “I think millennials expect that kind of connectivity.” Blair said his practice has also added same-day appointments.

Although walk-in clinics may be fine as an option for some illnesses, few are equipped to provide holistic care, offer knowledgeable referrals to specialists or help patients decide whether they really need, say, knee surgery, he noted. Primary care doctors “treat the whole patient. We’re tracking things like: Did you get your mammogram? Flu shot? Pap smear? Eye exam?”

Dr. Nitin Damle, an internist and past president of the American College of Physicians, said that young people develop diabetes, hypertension and other problems “that require more than one visit.”

“We know who the best and most appropriate specialists in the area are,” said Damle, an associate clinical professor of medicine at Brown University in Providence, R.I. “We know who to go to for asthma, allergies, inflammatory bowel disease.”

Marquenttha Purvis, 38, said her primary care doctor was instrumental in helping arrange treatment for her stage 2 breast cancer last year. “It was important because I wouldn’t have been able to get the care I needed” without him, said Purvis, who lives in Richmond, Va.

Sometimes the fragmented care that can result from not having a doctor has serious consequences.

Orlowski cites the case of a relative, a 40-year-old corporate executive with excellent medical insurance. The man had always been healthy and didn’t think he needed a primary care physician.

“Between treating himself and then going to outpatient clinics,” he spent nearly a year battling a sore throat that turned out to be advanced throat cancer, she said.

For patients without symptoms or a chronic condition such as asthma or high blood pressure, a yearly visit to a primary care doctor may not be necessary. Experts no longer recommend the once-sacrosanct annual physical for people of all ages.

“Not all access has to be with you sitting on an exam table,” Munger said. “And I may not need to see you more than every three years. But I should be that first point of contact.”

Convenience Is Paramount

Caitlin Jozefcyk, 30, a high school history teacher in Sparta, N.J., uses urgent care when she’s sick. She dumped her primary care doctor seven years ago because “getting an appointment was so difficult” and he routinely ran 45 minutes behind schedule. During her recent pregnancy, she saw her obstetrician.

Jozefcyk knows she’s not building a relationship with a physician — she sees different doctors at the center — but “really likes the convenience” and extended hours.

Digital access is also important to her. “I can make appointments directly through an app, and prescriptions are sent directly to the pharmacy,” she said.

After years of going to an urgent care center or, when necessary, an emergency room, Jessica Luoma, a 29-year-old stay-at-home mother in San Francisco, recently decided to find a primary care doctor.

“I’m very healthy, very active,” said Luoma, who has been treated for a kidney infection and a miscarriage.

Luoma said her husband pushed her to find a doctor after the insurance offered by his new employer kicked in.

“He’s a little more ‘safety first’ than me,” she said. “I figured, ‘Why not?’ — just in case.”

The Feds’ Termination Of A Tiny Contract Inflames Bitter Fight Over Fetal Tissue

Kaiser Health News:Marketplace - October 08, 2018

Federal health officials announced late last month they had terminated their contract with a company that supplies human fetal tissue for medical research and were checking that similar contracts, as well as studies conducted with that tissue, comply with federal law.

The seemingly innocuous release about a tiny government contract, which came out as Americans focused on Judge Brett Kavanaugh’s nomination to the Supreme Court, belied the big stakes and contentious issue behind it. Government officials are considering pulling federal funding for a decades-old form of research that has yielded a number of medical advances, including the polio vaccine.

The Department of Health and Human Services has faced mounting pressure from conservative lawmakers and abortion opponents, who strongly supported President Donald Trump’s candidacy, to halt the use of tissue obtained from aborted fetuses.

“The federal government must find ethical alternatives as soon as possible, and should end all association with those who participate in any trafficking or procurement of aborted baby organs,” 45 leaders from groups, including Susan B. Anthony List and the Family Research Council, wrote in a recent letter to HHS.

But a letter to congressional leaders, signed by 64 medical and scientific institutions including the American Academy of Pediatrics and Johns Hopkins University, said interfering in fetal tissue research would be “devastating.” The letter cited its impact in understanding viruses like Zika and HIV, as well as ongoing clinical trials to find treatments for spinal cord injuries.

“Fetal tissue research has been critical for scientific and medical advances that have saved the lives of millions of people,” they wrote.

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The supplier whose contract was terminated, a California-based company called Advanced Bioscience Resources, came under fire in 2015 when it was identified in videos that surreptitiously captured Planned Parenthood officials discussing how fetal tissue is provided to researchers.

The videos were part of a controversial sting operation by activists who alleged Planned Parenthood was unlawfully profiting from the sale of fetal tissue, including to Advanced Bioscience Resources. Planned Parenthood officials condemned the videos, which they said were deceptively edited. After its own investigation, a Texas grand jury declined to indict anyone from Planned Parenthood, instead indicting two of the activists responsible for the videos.

HHS vowed to look into the research “in light of the serious regulatory, moral, and ethical considerations.”

The announcement also comes weeks before Election Day, giving Republicans an opportunity to employ a potent talking point — their rigid opposition to Planned Parenthood — as they urge their supporters to vote.

Here’s what you need to know to understand the debate.

Where does fetal tissue come from, and how is it used in research?

Tissue from human fetuses is frequently used to make cell cultures, which allow researchers to examine biological processes in a laboratory setting.

The tissue comes from elective abortions, with the written consent of the woman donating the tissue. Health facilities where the abortion occurred may provide it directly to researchers or transfer it to a supplier, such as Advanced Bioscience Resources.

It is unclear how many suppliers there are. A 2015 report from the Congressional Research Service identified just a few known suppliers, citing a New York Times story that said many researchers go to just two companies: Advanced Bioscience Resources and another California-based company called StemExpress.

Researchers have used fetal tissue to study genetic diseases and development disorders like Down syndrome, as well as to test the toxicity of medications taken by pregnant women and the efficacy of vaccines. The measles vaccine, for example, was developed with the help of fetal tissue.

Fetal tissue also has been transplanted into patients in attempts to treat various disorders, injuries and illnesses, including Parkinson’s disease.

Why is HHS reviewing compliance with federal law? Isn’t this research legal?

It is legal to conduct research using fetal tissue, subject to laws and regulations addressing issues such as consent from the woman undergoing the abortion. Researchers in the United States have used fetal tissue since the 1930s, and the federal government has funded such research since the 1950s, according to the Congressional Research Service.

Things get thorny when it comes to acquiring the tissue. A 1993 law made it illegal “to knowingly acquire, receive, or otherwise transfer any human fetal tissue for valuable consideration if the transfer affects interstate commerce.” In other words, you can neither sell nor purchase fetal tissue in the United States.

But the ban comes with a caveat: Companies that supply researchers with fetal tissue can charge to cover their costs for things like storage, preservation and transportation.

Republican lawmakers and abortion opponents have accused Advanced Bioscience Resources, as well as StemExpress and another supplier that has since gone out of business, of inflating their costs to turn a profit.

After the release of the sting videos in 2015, House and Senate Republicans launched lengthy investigations into fetal tissue acquisition and research, culminating in a pair of reports that accused the suppliers, Planned Parenthood and a handful of its affiliates of illegal sales and purchases.

In late 2016, Republican lawmakers asked the Justice Department to investigate the matter, and several news outlets reported last December that it appeared to be doing so. (The Justice Department typically does not confirm the existence of ongoing investigations.)

So, why is HHS doing this now?

In August, the conservative news outlet reported the Food and Drug Administration had signed a one-year, nearly $16,000 contract with Advanced Bioscience Resources to acquire fetal tissue for transplantation in mice in federal research labs.

It was not the government’s first contract with the supplier. Records show the FDA contracted with Advanced Bioscience Resources in 2015 and 2016.

In September, 85 House Republicans sent a letter to Scott Gottlieb, the head of the FDA, noting that lawmakers had found evidence the supplier may have violated federal law during their investigations.

“We urge you to cancel this contract immediately and utilize alternative, modern scientific techniques that do not contribute to the trafficking in baby body parts,” the lawmakers wrote. 

Has fetal tissue research been an issue in the past?

Yes. In 1988, in fact, HHS banned funding for research on fetal tissue transplantation while an advisory panel reviewed the issue. While divided in their views on abortion, most panel members supported the conclusion that, since abortion was legal and the research could yield significant medical discoveries, this research was “acceptable public policy.”

The George H.W. Bush administration rejected the panel’s conclusion, concerned the research would create incentives for women to have abortions, and the ban stood until President Bill Clinton eliminated it in 1993, shortly after being sworn in.

Democrats in Congress seized on the safeguards recommended by the panel and soon passed the 1993 law that, among other things, banned the sale and purchase of fetal tissue.

A similar fight over stem cells erupted in 2001, when President George W. Bush severely restricted research on embryonic stem cells, which are taken from human embryos donated by couples undergoing in vitro fertilization. President Barack Obama later lifted the restrictions.

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

Medicare Advantage Plans Shift Their Financial Risk To Doctors

Kaiser Health News:Marketplace - October 08, 2018

STUART, Fla. — Dr. Christopher Rao jumped out of his office chair. He’d just learned an elderly patient at high risk of falling was resisting his advice to go to an inpatient rehabilitation facility following a hip fracture.

He strode into the exam room where Priscilla Finamore was crying about having to leave her home and husband, Freddy.

“Look, I would feel the same way if I was you and did not want to go to a nursing home, to a strange place,” Rao told her in September, holding her hand. “But the reality is, if you slip at home even a little, it could end up in a bad, bad way.”

After a few minutes of coaxing, Finamore, 89, relented and agreed to go into rehab.

Keeping patients healthy and out of the hospital is a goal for any physician. For Rao, a family doctor in this retiree-rich city 100 miles north of Miami, it’s also a wise financial strategy.

Rao works for WellMed, a physician-management company whose doctors treat more than 350,000 Medicare patients at primary care clinics in Florida and Texas. Instead of being reimbursed for each patient visit, WellMed gets a fixed monthly payment from private Medicare Advantage plans to cover virtually all of their members’ health needs, including drugs and physician, hospital, mental health and rehabilitation services.

If they can stay under budget, the physician companies profit. If not, they lose money.

Dr. Christopher Rao, a family doctor at WellMed in Stuart, Fla., comforts Priscilla Finamore about seeking inpatient rehabilitation care.(Phil Galewitz/KHN)

This model — known as “full-risk” or “global risk” — is increasingly used by Medicare plans such as Humana and UnitedHealthcare to shift their financial exposure from costly patients to WellMed and other physician-management companies. It gives the doctors’ groups more money upfront and control over patient care.

As a result, they go to extraordinary lengths to keep their members healthy and avoid expensive hospital stays.

WellMed, along with similar fast-growing companies such as Miami-based ChenMed, Boston-based Iora Health and Chicago-based Oak Street Health, say they provide patients significantly more time with their doctors, same-day or next-day appointments and health coaches. These doctors generally work on salary.

ChenMed doctors encourage their Medicare patients to visit their clinic every month — for no charge and with free door-to-door transportation — to stay on top of preventive care and better manage chronic conditions. If patients are not feeling well after-hours, ChenMed even will send a paramedic to their home.

“We can be much more creative in how we meet patient needs,” said Iora CEO Rushika Fernandopulle. “By taking risk, we never have to ask … ‘Do we get paid for this or not?’”

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A Way To ‘Provide Less Care’

Some patient advocates, pointing to similar experiments that failed in the 1990s, fear “global risk” could lead doctors to skimp on care — particularly for expensive services such as CT tests and surgical procedures.

“At the end of the day, this is a way to keep costs down and provide less care,” said Judith Stein, executive director of the Center for Medicare Advocacy.

Dr. Brant Mittler, a Texas cardiologist and trial attorney who has followed the issue, said Medicare Advantage members should be suspicious.

“Patients don’t know that decisions made on their behalf are often financially based. There may be pressure on doctors to cut corners to save money and that may not be in the best interests of a patient’s health,” he said.

The insurers and physician groups disagree. They said limiting necessary care would only exacerbate a patient’s health problems and cost the doctors’ group more money.

Noting that Medicare members stay with Humana an average of eight years, Roy Beveridge, the insurer’s chief medical officer, said the plan would be unwise to skimp on care because that would eventually leave the company with sicker patients and longer hospitalizations.

“It makes even less sense for physicians at financial risk to skimp on care because patients are typically with their physicians much longer than they are with a health plan,” he said.

A study that examined care at ChenMed, published last month in the American Journal of Managed Care, found health costs were 28 percent lower among patients who had more than double the number of typical visits with their primary physician. The study was conducted by researchers at ChenMed and the University of Miami.

To offer more personal care, ChenMed doctors typically see only about a dozen patients per day — about half as many as is usual for a doctor who gets paid for each individual service.

Medicare beneficiaries, who can choose a private health plan during the open-enrollment period that runs from Oct. 15 to Dec. 7, generally have no idea if their health plan has ceded control of their care to these large doctors’ groups.

After choosing a Medicare Advantage plan, they generally sign up for a medical group that is part of their health plan’s network, often because doctors are close to where they live or because the doctors offer extra benefits such as free transportation to appointments.

Eloy Gonzalez, 71, of Miami, said that before switching to ChenMed a couple of years ago his doctors always seemed to be in a hurry when he saw them. He’s happy with his ChenMed physicians.

On a recent visit, he spent nearly 20 minutes with Dr. Juana Sofia Recabarren-Velarde talking about keeping his blood pressure and lung condition under control. She also showed him exercises to manage back and shoulder pain.

“If she thinks she needs to see me once a month to monitor my blood pressure and see if anything else is happening, it’s OK with me,” said Gonzalez, who pays nothing for the office visits or generic drugs under his Humana Medicare Advantage plan with ChenMed.

A Growth Spurt

Nearly one-third of the 57 million Medicare beneficiaries are covered by private Medicare Advantage plans — an alternative to government-run Medicare — and federal officials have estimated that the proportion will rise to 41 percent over the next decade. The government pays these plans to provide medical services to their members.

The “global risk” system has been used in South Florida and Southern California since the late 1990s and nearly half of Medicare Advantage members in those regions get care in the model. The use has spread further in the past two years as large physician companies have become more common, and about 10 percent of Medicare Advantage plan members across the nation are in them now, health consultants say.

In addition, new information technology allows these groups to better track their patients. With mixed results, Medicare Advantage insurers for years offered doctors bonuses to meet certain quality care standards, such as getting members vaccinated against the flu or controlling diabetes and other chronic diseases.

Under the “global risk” arrangements, the health plans give the physician companies the bulk of their Medicare funding when they take on the mantle of being financially responsible for all patient care.

For the doctors’ groups, the arrangement means they get paid a large amount of money upfront for patient care and don’t have to worry about billing or having to get insurers to always preapprove treatments.

Because the “global risk” arrangements are designed to reduce plans’ costs, they potentially allow the companies to lower premiums and attract more customers, said Mark Fendrick, director of the University of Michigan’s Center for Value-Based Insurance Design.

“I see this trend continuing to grow as clinicians will be accountable for the first time for the care they provide,” he said.

Historical Lessons

But Ana Gupte, a securities analyst with Leerink Partners in New York, noted providers can also lose money if not successful.

That’s what happened in the late 1990s when some physician-management companies such as FPA Medical Management and PhyMatrix took on financial risk from insurers only to later go bankrupt, interrupting care to thousands of patients.

Health insurers say they now trust only doctors’ groups that have shown they can handle the financial risk. They also retain varying levels of control. Insurers set benefits, handle member complaints and review which doctors are allowed in its network.

Martin Graf, a partner with consulting firm Oliver Wyman, said the old financial arrangements failed because provider groups did not manage the risks facing their patients.

“Now they know physician groups must be vigilant about their patients — whether they are in the office or not,” he said. “Everyone is aware of the failure of the past.”

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

Readout of Secretary Azar’s Meetings in Buenos Aires, Argentina

HHS Gov News - October 06, 2018

Today, after the conclusion of the G20 Health Ministerial Meeting, Health and Human Services (HHS) Secretary Alex Azar traveled to Buenos Aires, Argentina for meetings. In the morning, he met with the American Chamber of Commerce in Buenos Aires to discuss the importance of innovation to improve health outcomes and the role played by intellectual property protections in incentivizing innovation.  

Following the roundtable, Secretary Azar met with U.S. Ambassador to the Argentine Republic Edward Prado to discuss the political and economic environment in Argentina and the impact of Argentina’s engagement in global health bilaterally and in the multilateral arena. They also discussed Argentina’s response to the Venezuelan regional public health crisis and how the U.S. can work with ministries of health to support a regional response.

In the afternoon, Secretary Azar attended a bilateral meeting with Dr. Adolpho Rubinstein, Secretary of Government for Health for the Argentine Republic; Claudia Perandones, Director of the National Laboratories and Health Institutes Administration; and Waldo Belloso, the Vice Director of the National Administration of Drugs, Foods and Medical Devices. Secretary Azar congratulated Secretary Rubinstein on hosting a successful G20 Health Ministerial Meeting and reflected on topics discussed at the meeting. Secretary Azar also commended Argentina for their plans to strengthen health security by conducting in 2019 a voluntary Joint External Evaluation under the International Health Regulations and for volunteering to join the Steering Committee of the Global Health Security Agenda. They discussed the U.S. and Argentina responses to the Venezuelan regional public health crisis and also areas in which our two governments collaborate on health.

Tonight, Secretary Azar will travel home to the United States. This serves as the final readout of his meetings in Brazil and Argentina for the G20 Health Ministerial Meeting.

To read the other readouts, please visit:

Patient Advocacy Or Political Ploy? Union, Industry Square Off Over Dialysis Initiative

Kaiser Health News:Marketplace - October 05, 2018

This year, California dialysis clinics — and their profits — are in a powerful union’s crosshairs.

On Nov. 6, the Service Employees International Union-United Healthcare Workers West union hopes to deliver a stinging blow with a ballot measure designed to limit clinic profits.

Proposition 8, or the “Fair Pricing for Dialysis Act,” would cap dialysis clinic profits at 115 percent of the costs of patient care, with revenue above that amount to be rebated primarily to insurers. Medicare and other government programs, which pay significantly lower prices for dialysis, would not receive rebates.

It’s been a costly campaign, suggesting high stakes for both sides. The union, which sponsored the initiative and represents over 150,000 nurses and other health care workers in California, so far has invested nearly $17 million in the effort.

Two leading national for-profit dialysis companies, DaVita and Fresenius Medical Care, dominate California’s market and are fighting back hard, contributing more than $40 million and $22 million respectively to defeat the measure. Overall, dialysis companies have raised more than $72 million to oppose the initiative.

In California, close to 70,000 patients need regular dialysis, which essentially performs the function of kidneys for patients whose own kidneys are failing. DaVita and Fresenius control 70 percent of the nation’s market. Between them, they reported more than $4 billion in operating profits last year.

Proponents say the initiative would spur clinics to reduce executive salaries, increase investment in patient care and lower the prices for patients with private insurance.

“It will allow these companies to make good profits, but not the obscene profits they make now,” said Steve Trossman, a spokesman for the union and the “Yes on 8” campaign.

Opponents argue the issue is too complicated to be decided at the polls and that it could reduce patients’ access to care, causing the vast majority of clinics to lose money and forcing many to shut down.

Fresenius and Davita referred questions on the initiative to the “No” campaign. But in an earnings call last month, DaVita CEO Kent Thiry said the passage of the initiative in California would have mostly “unsustainable” effects on dialysis centers.

A win for the union, known as SEIU-UHW, could encourage similar efforts elsewhere, said Laurel Lucia, director of the health care program at the Center for Labor Research and Education at the University of California-Berkeley.

“The initiative addresses a national problem,” she said. “If the policy is implemented successfully here, it wouldn’t be surprising if it spread to other states.”

Similar measures pushed by the union in Ohio and Arizona did not make the ballots for this November’s election.

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The initiative is part of the union’s wide-ranging campaign to force changes in the dialysis industry. In August, California legislators approved a bill promoted by the union that would have effectively capped reimbursement rates for dialysis clinics. While that was perceived as a solid victory for SEIU-UHW, Democratic Gov. Jerry Brown vetoed the measure last month.

A few years ago, SEIU-UHW began organizing among dialysis clinic workers, raising concerns about poor sanitation, high infection rates, understaffing, exorbitant prices for those covered by private insurance and other problems. The union ramped up its efforts on the ballot measure after legislative attempts to address some of the issues stalled last year.

Since 2012, the union has spent tens of millions of dollars on multiple state and local ballot initiatives in California relating to a wide range of health care issues, including access to affordable insurance, hospital and clinic funding, and training for in-home supportive services.

In 2013, for instance, SEIU-UHW launched ballot measures in California targeting hospital pricing and executive pay, and opponents accused the union of abusing the ballot process to force compliance with its demands.

According to Thad Kousser, a professor at the University of California-San Diego and an expert in the legislative process, the strategy of using ballot measures for political leverage is standard practice and not unique to SEIU-UHW. Even if the dialysis initiative is defeated, Kousser said, the effort will likely provide the union with a bargaining edge in future negotiations.

“It strengthens the union’s hand for future bargaining, even if it doesn’t win now,” Kousser said.

The union says it uses ballot measures to improve health conditions for all state residents, not just its members. “We made a decision as a union a number of years ago that in order to be successful, we couldn’t just be worried about our own members and our own narrow interests and have blinders,” Trossman said.

Nonsense, say critics.

“The spin from the SEIU-UHW is that the union is crusading for a healthier California, not trying yet again to get leverage over health-care employers,” declared an editorial last year in the San Diego Union-Tribune. “Californians with failing kidneys have enough worries. They should not be political pawns.”

The “No on 8” campaign, citing findings from the Centers for Medicare & Medicaid Services, notes that California’s clinics rate higher than those in other states on quality-of-care measures, such as avoiding unnecessary transfusions, preventing infections and maintaining proper blood levels of calcium levels.

“The ‘Yes on 8’ people talk about a crisis in dialysis and that’s not even close to being the truth,” said Kathy Fairbanks, spokeswoman for the “No” campaign.

But other research, such as a 2014 study of Medicare beneficiaries nationwide, found that patients treated at for-profit clinics had higher hospitalization rates than those in not-for-profit centers.

In June, a Colorado jury found DaVita liable for the deaths of three patients who suffered cardiac arrests following dialysis treatment, ordering the company to pay almost $400 million in damages. Witnesses had accused DaVita of failing to provide sufficient warning to doctors about the possible risks of a medication commonly used during dialysis. The company said at the time it would appeal. In 2016, Fresenius agreed to pay $250 million to resolve thousands of lawsuits involving the same medication.

In the heated battle over next month’s ballot measure, both sides have lined up many dozens of endorsements from community and statewide organizations. Proponents have strong labor and Democratic Party support. The California Medical Association, and some other medical groups, along with many veterans’ and business organizations, back the “No” campaign, arguing that the change would put dialysis patients at risk.

The “No” campaign has spent millions on television and online ads as the election nears. The “Yes” campaign has also launched an aggressive ad campaign.

Not all dialysis patients support the bill. Dialysis patient DeWayne Cox, a 55-year-old independent filmmaker and Uber driver in Sherman Oaks, said his opposition goes against his natural inclination to support labor. But he fears the mandated changes would force clinics to close and make it harder for patients like him to get dialysis.

“The thing is, I come from a union family, I believe in unions, but in this case I question their [SEIU-UHW’s] motives,” Cox said.

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

In The Battle To Control Drug Costs, Old Patent Laws Get New Life

Kaiser Health News:Marketplace - October 05, 2018

In the drug pricing battle, progressive lawmakers such as Sen. Bernie Sanders (I-Vt.) and patients’ rights activists rarely find themselves in step with the health industry’s big players.

But in a twist, these usually at-odds actors are championing similar tactics to tame prescription drug prices.

The strategies involve repurposing two obscure and rarely deployed workarounds in patent law that, in different ways, empower the federal government to take back patents and license them to other companies. The first is known as “march-in rights.” The second is generally referred to as Section 1498 because of its location in the U.S. Code.

Sanders has in recent years pointed to these steps as useful tools in the drug-pricing debate.

As an indicator of how high the stakes have become, these ideas also are finding traction among some major health industry players — most notably, two large trade groups that represent health plans and the “middlemen” companies that negotiate drug coverage.

“It used to be the case that everyone played nicely with one another, and now as prices have gone up, the knives have come out,” said Jacob Sherkow, a law professor at New York University who focuses on intellectual property and the pharmaceutical industry.

The push for march-in rights gained momentum this past summer, when activists launched a campaign challenging the patent for Truvada, the HIV treatment by Gilead Sciences that has been shown to reduce the risks of contracting HIV when taken daily as a preventive.

Initially, patient advocates focused mainly on shaming insurance companies into providing better coverage of that pill, also known as pre-exposure prophylaxis, or PrEP, because it is taken before someone is exposed to the virus. But they soon found themselves targeting a frustration that insurance happened to share: the drug’s list price.

James Krellenstein, co-founder of the PrEP4All Collaboration, an advocacy group, was part of that campaign. Health plans had put barriers in place to limit access to the drug, he said. But they, too, were worried about Truvada’s escalating price.

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“You can’t scale up to a level you need to unless we deal with the pricing problem,” he said.

Now, as insurers signal they might adopt an approach similar to that of the campaign, he voiced skepticism. On the one hand, the support could benefit their cause. At the same time, “they have their interests, and that’s not the interests of public health,” Krellenstein said.

Still, in Washington, the influence of groups like America’s Health Insurance Plans (AHIP), which is the largest trade association for health insurers, and the Pharmaceutical Care Management Association (PCMA), which represents those middlemen companies known as pharmacy benefit managers (PBMs), could add political credibility to these long-shot ideas.

President Donald Trump has said curbing prescription drug costs is a high priority. But, as congressional action seems increasingly unlikely, these two approaches offer another possible path forward.

They are “already part of a law that is intact. … An option the administration can take now,” said Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh.

AHIP says the Department of Health and Human Services should lean on a federal statute that lets the government take over drug patents and grant them to other manufacturers, as long as it adequately compensates the original patent holder.

Meanwhile, PCMA is pressing the administration to use the “march-in rights” championed by HIV activists. Provided under the 1980 Bayh-Dole Act, they empower the government to rescind a drug’s patent and let other companies develop versions of it. This applies only if government funding helped develop a drug, and it can be invoked only in specific circumstances, including a threat to public health or safety.

“Everybody is feeling the heat, and I think that is the reason you’re seeing this interest in using the tools that exist,” said Amy Kapczynski, professor at Yale Law School who has written extensively about drug patents.

But opposition is strong among drugmakers.

“Policies should spur competition and new innovations to meet patient needs, not disincentivize them such as the use of 1498 and march-in could do,” said Priscilla VanDerVeer, a spokeswoman for the Pharmaceutical Researchers and Manufacturers of America, or PhRMA, a trade and lobbying group.

Gilead, which manufactures Truvada, has a similar stance.

“We believe that there is no rationale or precedent for the government to exercise march-in or other [intellectual property] rights related to Truvada for PrEP,” said Ryan McKeel, a spokesman for Gilead. The company’s other efforts to make the drug “available for health and safety needs,” he added, “clearly satisfy” the company’s legal requirements.

And the potential for march-in authority is still theoretical. It has never been used, despite at least five petitions to the National Institutes of Health, three of which cited high drug prices.

Section 1498 was used to negotiate lower drug prices in the 1960s and ’70s, but has since faded. In 2001, during the nation’s anthrax scare, the Department of Health and Human Services threatened to invoke it to procure more of the antibiotic used to treat the deadly bacterial disease, according to contemporaneous reports. Last year, Louisiana’s health secretary unsuccessfully tried to use it to ease the toll pricey hepatitis C medications exerted on the state’s Medicaid program.

NIH Director Francis Collins remains skeptical, repeatedly saying that a drug’s price doesn’t constitute a health or safety concern within the agency’s jurisdiction.

HHS Secretary Alex Azar, speaking at a June Senate hearing, described march-in, also known as “compulsory licensing,” as a “socialist” approach.

But health pans and other payers, increasingly squeezed by fast-climbing prices, are undeterred — touting this kind of intervention as a “market-based solution.”

“The trends of drug prices in this country suggest that we all collectively need to find new approaches — including new approaches that are available under existing law — to try to change this trend,” said Mark Hamelburg, AHIP’s senior vice president of federal programs.

Kaiser Permanente, the health system and insurance provider, called for leveraging Section 1498 in a public comment submitted to HHS about its strategy to bring down drug prices. In a similar filing, Humana, a major insurer, pointed to “existing law [that] allows for actions around patents,” singling out march-in rights.

Humana did not respond to requests for comment. Both PCMA and Kaiser Permanente declined to comment beyond their statements. (Kaiser Health News is not affiliated with Kaiser Permanente.)

Nonetheless, experts say there are serious sticking points.

Neither of these legal provisions would be a sweeping solution. And both require administration buy-in.

“They’re only as effective as the government’s willingness to pursue them,” said Robin Feldman, a law professor at the University of California-Hastings.

Simply taking a patent doesn’t bring down prices, either. There are other ways manufacturers gain favorable market positioning for specific drugs, said Rachel Sachs, an associate law professor at Washington University in St. Louis who tracks drug-pricing laws.

And creating an opening for generics is only one step. Another drugmaker would still need to create a competing product, gain approval and make it available. Then, theoretically, market competition can kick in.

Finally, there’s no guarantee such savings would benefit consumers, argued Nicholson Price, an assistant professor at the University of Michigan Law School. Insurance plans or PBMs could simply bargain greater discounts on drugs and pocket the money. (AHIP says any savings should be passed on.)

That’s the fundamental question, Krellenstein said.

“Is this going to be more armor in the fighting [between payers and drug companies]?” he said. “Or is it actually going to be a dramatic reform that actually results in real changes, that actually makes it easier for Americans to access the medications they need?”

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

Readout of Secretary Azar’s Meetings at the G20 Health Ministerial Meeting

HHS Gov News - October 05, 2018

Today, Health and Human Services (HHS) Secretary Alex Azar attended the G20 Health Ministerial Meeting in Mar del Plata, Argentina. Secretary Azar delivered the following remarks at the plenary session on antimicrobial resistance (AMR):

“Thank you Argentina and Minister Rubinstein for your leadership of this important meeting and for your hospitality. The United States is committed to engaging on the issue of antimicrobial resistance, and considers it a top priority for global health engagement and hope G20 countries will continue to advocate for high level focus on AMR at the World Health Organization and other One Health multilateral organizations.  First, we believe that it is productive to consider the role that the private sector can play in addressing this challenge.

“There is no doubt that more must be done to incentivize increased R&D for new antibiotics and diagnostics. Governments must work with companies, and not against them, to encourage innovation in this space…Our health department and the whole U.S. government strongly believe in following the best science we have in formulating policies on issues like AMR. Often the science points to very specific interventions that target certain antimicrobials, certain pathogens, and certain uses, rather than blanket rules or arbitrary thresholds…The United States has made and is making great strides in improved stewardship of the use of antimicrobials: In the agricultural sector, our government has worked collaboratively with our industries to remove any use of antibiotics for growth promotion and to provide greater oversight over the use of antibiotics for treating diseases in livestock…A One Health approach to AMR that incorporates this work is important. It helps us to gain a better understanding of where and how resistance arises and to better confront the transfer of resistance across human health, agriculture, and environment sectors….In the human health sector, we are undertaking initiatives to better educate providers and patients on the prudent uses of antibiotics and to encourage more in-depth consideration of how and when to use antibiotics in hospital settings…”

“A further challenge is substandard or falsified, SF, antibiotics, which greatly increase the risk of resistance, due to decreased effectiveness of the drugs and the uncertainty of proper dosing. At this year’s meeting, the U.S. would like to encourage a special focus on this issue, which is also a key part of health systems strengthening. When SF medicines do not work as expected when compared with genuine medicines, the health of patients suffers and they lose confidence in the healthcare system. The issue of SF medicines is also relevant to this year’s third G20 issue, pandemic preparedness and global health security, where the reliable efficacy of medical countermeasures is critical to controlling major outbreaks.”

And on the topic of strengthening health systems, Secretary Azar said:

“The United States strongly supports efforts to strengthen health security, and believes that action by the G20 is important to improve preparedness across all regions. One crucial aspect of effective pandemic preparedness is building resilient health systems.

“An important tool in this effort is transparency. External evaluations utilizing broad expertise can help identify gaps in preparedness, and published national action plans can help potential donors see opportunities for collaboration. Multi-sectoral partnerships and cross-sectoral coordination, especially engaging the private sector, are critical to fill in the identified gaps in our systems’ capacities to prevent, detect, and respond to infectious disease threats….in the United States, we are now working to advance our health system from one that pays for procedures and sickness to one that pays for outcomes and health—in other words, a value-based system.

“Health system transformation to people-centered and value based health care should be tailored to the needs of the local contexts, and allow for a basket of options to enable the broadest access to care. Nearly all healthcare delivery systems utilize a range of resources, including from non-governmental sources, to provide the most effective care for their citizens. In the United States in particular, we provide broad access to very high quality care by engaging the private sector, both private systems and community- and faith-based groups. .. We do believe that there is value in the extensive research and findings of the Organisation for Economic Co-operation and Development on healthcare systems and care delivery. As the G20, we could be leveraging their work to assist countries at different stages in the improvement of their healthcare systems.

Next, Secretary Azar delivered the following remarks at the plenary session on childhood obesity:

“We all recognize the burgeoning problem of childhood obesity around the world. These challenges demand a comprehensive and cooperative strategy. Examples of successful, voluntary collaborations with private-sector companies to address obesity and its related diseases abound in many countries around the world. In the U.S., for example, the Healthy Weight Commitment Foundation’s Trillion Calorie Pledge was a voluntary ingredient reformulation initiative launched in 2010 by 16 of the nation’s leading food and beverage companies. The aim was to reduce 1 trillion cumulative calories from U.S. diets by 2012 and 1.5 trillion calories by 2015. The initiative actually led to reducing 6.4 trillion calories—400 percent more than the pledged amount. Governments also can collaborate with companies on initiatives to better inform consumers about nutrition and healthy diets, empowering consumers to take control of tackling obesity at the individual level. Voluntary food packaging information or school- and community-based educational initiatives can go a long way towards enabling and encouraging healthy behaviors. Responding to it effectively, however, demands the kind of innovation and commitment that can only come from engaging the private sector, communities, families, and individuals themselves. When our countries do that effectively, we believe we can finally make lasting progress on this challenge.”

“A problem this significant and complex also does not have a single solution, and must be tackled by all sectors. Childhood obesity is a challenge just about everywhere, but approaches to addressing it must be tailored to national contexts and driven by national initiatives. What works for one country will not always work in another. In fact, the issue can even be differentiated across regions within a country—within the United States, different areas have different challenges. For these reasons, local, community and regional initiatives often are the most effective ways to approach the issue. Complex issues like food systems do not lend themselves to an easy, one-size-fits-all approach.  Rather, they demand a comprehensive and cooperative strategy…Responding to it effectively, however, demands the kind of innovation and commitment that can only come from engaging the private sector, communities, families, and individuals themselves. When our countries do that effectively, we believe we can finally make lasting progress on this challenge.”

In the afternoon, Secretary Azar participated in the One Health AMR Simulation Exercise. The purpose of this targeted exercise was to raise awareness and understanding of the key challenges raised by AMR across a variety of sectors.

Throughout the day, Secretary Azar attended bilateral meetings with Dr. Thomas Gebhart, the Parliamentary State Secretary to the Federal Ministry of Health of Germany; Gan Kim Yong, the Health Minister of the Republic of Singapore; Bruno Bruins, the Minister for Medical Care and Sport of the Netherlands; and Steve Brine, the Parliamentary Under Secretary of State for Public Health and Primary Care of the United Kingdom. In these conversations, Secretary Azar focused on U.S. health priorities including drug pricing, health system transformation, and global health security.

Additional information regarding the Secretary’s meetings and schedule will be forthcoming in news releases and social media posts.

Podcast: KHN’s ‘What The Health?’ Some Things Old, Some Things New

Kaiser Health News:HealthReform - October 04, 2018
Julie Rovner

Kaiser Health News


Read Julie's Stories Rebecca Adams

CQ Roll Call


Read Rebecca's Stories Kimberly Leonard

Washington Examiner


Read Kimberly's Stories Margot Sanger-Katz

The New York Times


Read Margot's Stories

Congress passed major health-related legislation in time for the fiscal year, which began Monday, including a broad bill to address the opioid epidemic and a spending bill for the Department of Health and Human Services. This marks the first time since the 1990s that Congress has agreed to HHS spending levels before the start of the fiscal year.

Meanwhile, the Food and Drug Administration is cracking down on teen use of e-cigarettes as well as brand-name drugmakers who work to delay generic competition (and keep drug prices high). And a new survey shows health insurance costs continue to rise for people with coverage provided by their employers.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Margot Sanger-Katz of The New York Times and Kimberly Leonard of the Washington Examiner.

Among the takeaways from this week’s podcast:

  • The package of bills addressing the opioid epidemic passed Congress on a rare note of bipartisanship. Many of the measures are designed to help prevent opioid addiction but are short on treatment options.
  • California Gov. Jerry Brown’s veto of a bill that would have required public university health centers to offer drugs used for medical abortions surprised many people since Democrats in the state often position themselves as defenders of abortion rights.
  • New data on insurance coverage shows that the percentage of employers offering plans is holding steady, despite concerns that the rate would fall once the Affordable Care Act was enacted and provided easy access. Still causing concern: the high deductibles required of patients in many of these work-based plans.
  • A federal raid on the offices of the e-cigarette maker Juul Labs signals a dilemma for FDA Commissioner Scott Gottlieb. While he once backed e-cigarettes as a way to help smokers cut back on their habit, it appears he is now concerned about their use by young people.

Rovner also interviews Alison Kodjak of NPR, who wrote the latest “Bill of the Month” feature for Kaiser Health News and NPR. It’s about a Texas radiologist who had an accident that resulted in a very expensive air ambulance ride.

If you have a medical bill you would like NPR and KHN to investigate, you can submit it here.

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

Julie Rovner: Bloomberg News’ “Thousands of People’s Insurance Appeals Went to a Doctor Feds Say Is a Fraud,” by John Tozzi

Margot Sanger-Katz: The New York Times’ “In Australia, Cervical Cancer Could Soon Be Eliminated,” by Livia Albeck-Ripka

Kimberly Leonard: Politico’s “Kavanaugh’s Drinking Spotlights Trump’s ‘Abnormal’ Abstinence,” by Andrew Restuccia

Rebecca Adams: The New Yorker’s “The Comforting Fictions Of Dementia Care,” by Larissa MacFarquhar

To hear all our podcasts, click here.

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

Readout of Secretary Azar’s Last Day in Brazil and First Day in Argentina for the G20 Health Ministerial Meeting

HHS Gov News - October 04, 2018

This morning, Health and Human Services (HHS) Secretary Alex Azar attended a roundtable meeting in São Paulo, Brazil with São Paulo Mayor Bruno Covas and Secretary of Social Assistance and Development for São Paulo Filipe Tomazelli Sabará. They discussed their public-private collaboration with local and U.S.-based businesses to support Venezuelan migrants and integrate qualified workers into the local economy. The city is also working to house Venezuelan migrants and provide Portuguese language instruction to facilitate integration and work placement.

Secretary Azar heard directly from two recent migrants who discussed the situation in Venezuela, leaving their families and traveling to Brazil, and their life in São Paulo including the process to find employment. They also discussed the healthcare of Venezuelan migrants and that due to the collapse of the health system in Venezuela, migrants entering Brazil often lack routine immunizations, in particular against measles, mumps, and rubella. Secretary Azar highlighted U.S. support for proactive responses to the Venezuelan regional migration and public health crisis. He also discussed HHS’ workforce priorities and emphasized the importance of partnering with the private sector to support Venezuelan migrants.

After this roundtable, Secretary Azar departed Brazil and traveled to Mar del Plata, Argentina for the G20 Health Ministerial Meeting. Upon arrival in Mar del Plata, Secretary Azar attended a dinner with the other G20 Health Ministers and Heads of Delegation before the conclusion of the day.

At the G20 Health Ministerial meeting, Secretary Azar will advance U.S. health priorities to encourage all G20 nations to work together to increase global health security; to place a strong focus on the stewardship of the use of antibiotics to prevent antimicrobial resistance; to be more aware of and involved in controlling substandard and falsified medicines; and to work with the private sector to strengthen healthcare delivery systems and public health infrastructure.

Additional information regarding the Secretary’s meetings and schedule will be forthcoming in news releases and social media posts. 

High-Deductible Health Plans Fall From Grace In Employer-Based Coverage

Kaiser Health News:HealthReform - October 03, 2018

With workers harder to find and Obamacare’s tax on generous coverage postponed, employers are hitting pause on a feature of job-based medical insurance much hated by employees: the high-deductible health plan.

Companies have slowed enrollment in such coverage and, in some cases, reinstated more traditional plans as a strong job market gives workers bargaining power over pay and benefits, according to research from three organizations.

This year, 39 percent of large, corporate employers surveyed by the National Business Group on Health (NBGH) offer high-deductible plans, also called “consumer-directed” coverage, as workers’ only choice. For next year, that figure is set to drop to 30 percent.

“That was a surprise, that we saw that big of a retraction,” said Brian Marcotte, the group’s CEO. “We had a lot of companies add choice back in.”

Few if any employers will return to the much more generous coverage of a decade or more ago, benefits experts said. But they’re reassessing how much pain workers can take and whether high-deductible plans control costs as advertised.

“It got to the point where employers were worried about the affordability of health care for their employees, especially their lower-paid people,” said Beth Umland, director of research for health and benefits at Mercer, a benefits consultancy that also conducted a survey.

The portion of workers in high-deductible, job-based plans peaked at 29 percent two years ago and was unchanged this year, according to new data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Deductibles — what consumers pay for health care before insurance kicks in — have increased far faster than wages, even as paycheck deductions for premiums have also soared.

One in 4 covered employees now have a single-person deductible of $2,000 or more, KFF found.

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Employers and consultants once claimed patients would become smarter medical consumers if they bore greater expense at the point of care. Those arguments aren’t heard much anymore.

Because lots of medical treatment is unplanned, hospitals and doctors proved to be much less “shoppable” than experts predicted. Workers found price-comparison tools hard to use.

High-deductible plans “didn’t really do what employers hoped they would do, which is create more sophisticated consumers of health care,” Marcotte said. “The health care system is just way too complex.”

At the same time, companies have less incentive to pare coverage as Congress has repeatedly postponed the Affordable Care Act’s “Cadillac tax” on higher-value plans.

Although deductibles are treading water, total spending on job-based health plans continues to rise much faster than the overall cost of living. That eats into workers’ pay in other ways by boosting what they contribute in premiums.

Employer-sponsored group health plans, which insure 150 million Americans — nearly half the country — tend to get less attention than politically charged coverage created by the ACA.

For these employer plans, the cost of family coverage went up 5 percent this year and is expected to rise by a similar amount next year, the research shows.

Insuring one family in a job-based plan now costs on average $19,616 in total premiums, the KFF data show. The American worker pays $5,547 of that in a country where the median household income is more than $61,000.

The KFF survey was published Tuesday; the NBGH data, in August. Mercer has released preliminary results showing similar trends.

The recent cost upticks, driven by specialty drug costs and expensive treatment for diseases such as cancer and kidney failure, are an improvement over the early 2000s, when family-coverage costs were rising by an average 7 percent a year. But they’re still nearly double recent rates of inflation and increases in worker pay.

Such growth “is unsustainable for the companies I have been working with,” said Brian Ford, a benefits consultant with Lockton Companies, echoing comments made over the decades by experts as health spending has vacuumed up more and more economic resources.

For now at least, many large employers can well afford rising health costs. Earnings for corporations in the S&P 500 have increased by double-digit percentages, driven by federal tax cuts and economic growth. Profit margins are near all-time highs.

But for workers and many smaller businesses, health costs are a heavier burden.

Premiums for family plans have gone up 55 percent in the past decade, twice as fast as worker pay, according to KFF.

Employers’ latest cost-control efforts include managing expenses for the most expensive diseases; getting workers to use nurse video-chat services and other types of “telemedicine”; and paying for primary care clinics at work or nearby.

At the “top of the list” for many companies are attempts to manage the most expensive medical claims — cases of hemophilia, terrible accidents, prematurely born infants and other diseases — that increasingly cost as much as $1 million each, Umland said.

Employers point such patients to the highest-quality doctors and hospitals and furnish guides to steer them through the system. Such steps promise to improve results, reduce complications and save money, she said.

On-site clinics cut absenteeism by eliminating the need for employees to drive across town and sit in a waiting room for two hours to get a rash or a sniffle checked or get a vaccine, consultants say.

Almost all large employers offer telemedicine, but hardly any workers use it. Thirty-nine percent of the larger companies covering telemedicine now make it comparatively less expensive for workers to consult doctors and nurses virtually, the KFF survey shows.

VA Adding Opioid Antidote To Defibrillator Cabinets For Quicker Overdose Response

Kaiser Health News:States - October 03, 2018

It took more than 10 minutes for paramedics to arrive after a housekeeper found a man collapsed on the floor of a bathroom in a Boston Veteran Affairs building.

The paramedics immediately administered naloxone, often known by its brand name Narcan, to successfully reverse the man’s opioid overdose. But it takes only a few minutes without oxygen for brain damage to begin.

Pam Bellino, patient safety manager for the Boston VA, read that incident report in December 2015 with alarm. “That was the tipping point for us to say, ‘We need to get this naloxone immediately available, without locking it up,'” she said.

The easiest way to do it quickly, Bellino reasoned, would be to add the drug to the automated external defibrillator, or AED, cabinets already in place. Those metal boxes on the walls of VA cafeterias, gyms, warehouses, clinic waiting rooms and some rehab housing were installed to hold equipment for a fast response to heart attacks.

Now the VA, building on the project started in Boston, is moving to add naloxone kits to the AED cabinets in its buildings across the country, an initiative that could become a model for other health care organizations.

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Equipping police with nasal spray naloxone is becoming more common across the country, but there has been some resistance to making the drug available in public.

Bellino has heard from critics who say easy access to naloxone gives drug users a false sense of safety. She disagrees.

“Think of this as you would a seat belt or an air bag,” she said. “It by no means fixes the problem, but what it does is save a life.”

Giving naloxone to someone who hasn’t overdosed isn’t harmful, but it is a prescription drug. So, Bellino said, the VA had to persuade the accrediting agency, The Joint Commission, to approve guidelines for the AED naloxone project.

The cabinets must be sealed and alarmed so staff can tell if they’ve been opened. They must be checked daily and refilled when the naloxone kits expire.

The commission didn’t agree to let the VA put the words “naloxone” or “Narcan” on the cabinet doors to alert the public that the drug is inside, but did allow the VA to affix the letter “N.”

In December, the project will expand nationwide, as VA hospitals across the country will add naloxone to their AED cabinets.

“The overwhelming evidence is that it just saves lives,” said Dr. Ryan Vega with the VA’s Center for Innovation. “We’re hopeful that other health systems take notice and think about doing the same.”

The contents of the naloxone kit inside an AED box located in the VA West Roxbury cafeteria.(Jesse Costa/WBUR)

Vets have nearly twice the risk of overdose, compared with civilians, said Amy Bohnert, an investigator with the VA Ann Arbor Healthcare System, citing 2005 death data. She said it isn’t clear why veterans are more likely to OD, but many do have complex medical conditions.

“Some of that’s related to combat exposure,” Bohnert said. “They’ve got mental health treatment needs. They may have injuries that result in them being more likely to be prescribed opioids than your average person. And all of these things can impact their risk of overdose.”

A smattering of schools, airports, churches and employers around the country have added naloxone to their AED cabinets.

Some stock other lifesaving tools as well: tourniquets to stop bleeding after a shooting; EpiPens to keep airways open; and even injectors to treat diabetic shock.

Dr. Jeremy Cushman leads a project at the University of Rochester that has placed both tourniquets and naloxone in 80 AED cabinets across that campus as of July.

“This system is already in place,” Cushman said. “The question is, how can we leverage it to save more lives?”

Turning AED cabinets into miniature emergency medical stations presents challenges, Cushman said. Medicines can’t be left outside during extreme temperatures. They are expensive and expire.

Dr. Scott Weiner, president of the Massachusetts College of Emergency Physicians, said he has dealt with those issues while developing street-level dispensing stations for naloxone.

And then there’s the belief among some critics that naloxone enables drug use by offering an assurance of life after an overdose. Weiner said that attitude is waning and, as it does, the public may be more open to other controversial, lifesaving measures.

“Naloxone is kind of the lowest barrier for people to understand, where someone has already overdosed and we’re going to give them the antidote,” Weiner said. “The leap to giving them needles [through a needle exchange] or allowing them to inject in a safe space, that’s just another level of acceptance that people will have to get to.”

The Boston VA’s Bellino said she hopes that AED manufacturers will start selling cabinets that meet the new hospital accreditation standards. So far, the Boston VA counts 132 lives saved through all three parts of its naloxone project: training high-risk veterans, equipping police and the AED cabinets.

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

Readout of Secretary Azar’s Second Day in Brazil

HHS Gov News - October 03, 2018

Today, Secretary Alex Azar began his meetings in São Paulo, Brazil. First, he visited the Municipal Infant Hospital “Menino Jesus” and met with hospital leadership. They discussed the shared challenges U.S. and Brazilian hospitals face in improving quality and implementing efficient service models to integrate principles of value-based care. At the hospital, Secretary Azar visited the outpatient ward as well as the newly opened transplantation ward, which is an example of their successful public-private partnership with the Syrian-Lebanese Hospital.

Next he visited the Syrian-Lebanese Hospital with the Brazilian Minister of Health Gilberto Occhi, other government officials, and hospital leadership. Here Secretary Azar learned about efforts they are making on quality metrics and how principles of value-based care might have a positive impact on controlling costs and improving outcomes at the hospital. He saw their state-of-the-art robotic training facilities and simulation training center, which is available to all the clinicians affiliated with Syrian-Lebanese, including those at their public hospital partners. He finished his tour with a conversation with members of the board of directors, who are descendants of the women who originally founded the hospital.

In the afternoon, Secretary Azar and Minister Occhi visited the Butantan Institute with Marco Antonio Zago, the São Paulo State Secretary of Health. They were hosted by Dimas Tadeu Covas, the Director of the Butantan Institute, and Rui Curi, the Deputy Director of the Butantan Institute. The Butantan Institute is a semi-autonomous, biomedical research and production facility and is the main producer of immunobiological products in Brazil. At the Institute, Secretary Azar saw the “milking” of a snake for anti-venom and the newly expanded influenza vaccination manufacturing facility. The Butantan Institute has longstanding collaborations with HHS’ National Institutes of Health (NIH) and HHS’ Biomedical Advanced Research and Development Authority (BARDA).

While at the Butantan Institute, Secretary Azar and Minister Occhi discussed the U.S.-Brazil long-standing cooperation in health research including biotech and vaccine production. HHS’ collaborative work with Brazil has successfully resulted in a number of new treatments moving all the way to the manufacturing stage. At the Institute, Secretary Azar discussed the latest updates on the tetravalent dengue vaccine that was developed in collaboration with NIH. The candidate vaccine has completed Phase 1 and 2 trials in the United States, Brazil, Bangladesh, and Thailand. As a result of the technology transfer from NIH, the ongoing Phase 3 clinic trial in Brazil, and the completion of a state-of-the-art manufacturing plant, the Butantan Institute is now well positioned to produce the vaccine and make it available for large-scale immunization initiatives in Brazil.

Next, Secretary Azar visited the São Paulo Research Foundation (FAPESP). He participated in a meeting with senior leadership where he highlighted the extensive history of U.S. scientific cooperation with FAPESP and the larger Brazilian scientific community. Then he delivered a speech to an audience composed of members of São Paulo’s scientific and innovation community in which he discussed his priorities to spur the innovation economy in the United States, including leveraging research collaborations and utilizing public-private partnerships.

In the evening, Secretary Azar participated in a dinner and roundtable meeting with the American Chamber of Commerce in São Paulo. The meeting focused on private sector innovations in Brazil to spur value-based transformation in the health system.

Additional information regarding the Secretary’s meetings and schedule will be forthcoming in news releases and social media posts. 

To view his remarks online, please visit:

HHS Extends Deadline for DSIIS Recommendations

HHS Gov News - October 03, 2018

Today, the U.S. Department of Health and Human Services announced that it is extending the application deadline for the Deputy Secretary’s Innovation and Investment Summit (DSIIS) to October 12, 2018. As announced on September 19, 2018, the DSIIS will be a yearlong collaboration between healthcare innovation and investment professionals and HHS personnel who will meet quarterly to engage in high-level dialogues about emerging opportunities and the government’s role in facilitating more investment and accelerated innovation in the healthcare sector. Due to strong interest and requests for additional information regarding DSIIS, the Department is extending the application deadline as well as posting a list of frequently asked questions (FAQ) for further guidance.

Recommendations of DSIIS participants must include a resume/CV and a brief description of why the individual recommended would be a good candidate to help deliver on and advance the goals of the DSIIS. Recommendations should be submitted to by October 12, 2018, with the subject line “DSIIS Recommendation.” Individuals wishing to update an existing recommendation can do so by emailing the same address using the subject line “Additional Information for [NAME] Recommendation.”

FAQs are available here:

Additional information on DSIIS is available here:

Drugmakers Play The Patent Game To Lock In Prices, Block Competitors

Kaiser Health News:Marketplace - October 02, 2018

David Herzberg was alarmed when he heard that Richard Sackler, former chairman of opioid giant Purdue Pharma, was listed as an inventor on a new patent for an opioid addiction treatment.

Patent No. 9861628 is for a fast-dissolving wafer containing buprenorphine, a generic drug that has been around since the 1970s. Herzberg, a historian who focuses on the opioid epidemic and the history of prescription drugs, said he fears the patent could keep prices high and make it more difficult for poor addicts to get treatment.

“It’s hard not to have that reaction of, like … these vultures,” said Herzberg, an associate professor at the University at Buffalo.

James Doyle, vice president and general counsel of Rhodes Pharmaceuticals, the Purdue subsidiary that holds the patent, said in an email statement that the company does not have a developed or approved product and “therefore no money has been made from this technology.”

“The invention behind the buprenorphine patent in question was developed more than a dozen years ago,” he wrote. “If a product is developed under this patent, it will not be commercialized for profit.”

Yet, the patenting of a small change in how an existing drug is made or taken by patients is part of a tried-and-true pharmaceutical industry strategy of enveloping products with a series of protective patents.

Drug companies typically have less than 10 years of exclusive rights once a drug hits the marketplace. They can extend their monopolies by layering in secondary patents, using tactics critics call “evergreening” or “product-hopping.”

Lisa Larrimore Ouellette, a patent law expert at Stanford University, said the pharmaceutical industry gets a greater financial return from its patent strategy than that of any other industry.

AztraZeneca in 2001 famously fended off generic versions of its blockbuster heartburn medicine Prilosec by patenting a tweaked version of the drug and calling it Nexium. When Abbott Laboratories faced multiple generic lawsuits over its big moneymaker Tricor, a decades-old cholesterol drug, it lowered the dosage and changed it from a tablet to a capsule to win a new patent.

And Forest Laboratories stopped selling its Alzheimer’s disease drug Namenda in 2014 after reformulating and patenting Namenda XR to be taken once a day instead of twice.

Another common strategy is to create what Food and Drug Administration Commissioner Scott Gottlieb calls “patent thickets,” claiming multiple patents for a single drug to build protection from competitors. AbbVie’s rheumatoid arthritis drug Humira has gained more than 100 patents, for example.

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The U.S. Patent and Trademark Office awards patents when an innovation meets the minimum threshold of being new and non-obvious. Secondary patents are routinely granted to established drugs when an improvement is made, such as making it a once-a-day pill instead of twice a day, said Kristina Acri, an economist and international intellectual property expert at the Fraser Institute and Colorado College.

“Is there a better way? Maybe, but that’s not what we’re doing,” Acri said.

The controversial patent that Sackler and five co-inventors obtained is widely known as a “continuation patent.” (The original patent application for the wafer was filed in August 2007.)

Continuation patents do not necessarily extend the patent life of a drug, but they can have other uses. In 2016, Rhodes filed a lawsuit against Indivior alleging patent infringement.

Indivior, formerly part of Reckitt Benckiser, sells a film version of the popular addiction treatment drug Suboxone that is placed under the tongue — an oral medicine similar to what Rhodes has patented. Indivior’s comes in a lime flavor.

Indivior’s film, which federal regulators approved in 2010, dominates the market with a 54 percent average market share, according to the company’s most recent financial report. And the company has vigorously fought rivals, including filing lawsuits against firms such as Teva Pharmaceutical Industries, which sought approval to manufacture generic versions. Indivior declined to comment.

The Rhodes Pharmaceuticals version would be a wafer that melts quickly in the mouth. The inventors list potential flavors including mint, raspberry, licorice, orange and caramel, according to the patent.

For opioid historian Herzberg, the patent battles between companies like Rhodes and Indivior are “absolute madness.”

Decisions on what is available on the market to treat addicts should be based on what is the best way to treat the people who have the problem, he said.

Patent battles, Herzberg said, are “not how you want drug policy getting made.”

Attempts to change the patent system have intensified over the past decade as prices of prescription drugs continue to climb.

In 2011, President Barack Obama signed the America Invents Act, which included the creation of the Patent Trial and Appeal Board. The PTAB is an alternative to using the cumbersome U.S. court system to challenge weak patents. Generic drug manufacturers have used the board’s “inter partes review” process and overturned 43 percent of the patents they challenged, according to recent research.

Critics of the administrative process, including the pharmaceutical industry trade group PhRMA, said it creates “significant business uncertainty for biopharmaceutical companies.” Often companies have to defend their products twice — both in the courts as well as before the PTAB, said Nicole Longo, PhRMA’s director of public affairs.

Drug giant Allergan attempted to overcome the PTAB’s review process by arguing that the patent couldn’t be challenged at the review board because they sold the patent to the St. Regis Mohawk Tribe, which had sovereign immunity. A federal appeals court ruled this summer that Allergan could not shield its patents from the PTAB review this way.

This year, several members of Congress proposed bills that would unwind or limit changes made by the America Invents Act, though nothing is likely to happen before the midterm elections. The STRONGER Patents Act, introduced in both the House and Senate, would weaken the PTAB board by aligning its claims standards with what has been established by court rulings.

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

Readout of Secretary Azar’s First Day in Brazil

HHS Gov News - October 01, 2018

As previously announced, Health and Human Services (HHS) Secretary Alex Azar traveled to Brazil over the weekend to participate in bilateral meetings with government officials and others to discuss the ongoing collaboration between the United States and Brazil towards global health security, our bilateral science partnership, and health sector reform. Later in the week, Secretary Azar will travel to Argentina for the G20 Health Ministerial Meeting.

Today, Secretary Azar began his meetings in Fortaleza, Brazil. First he visited the Urgent Care Center Praia do Futuro where he learned about the structure of 24-hour urgent care units and how such centers function as a part of Brazil’s decentralized public health system. Here he also saw first-hand how Fortaleza has used its decentralized model to manage patient flows for greater efficiency and improved outcomes.

Next, Secretary Azar attended a breakfast meeting with Ceará State Governor Camilo Santana, Ceará State Health Secretary Henrique Javi, and other key health officials to discuss the unique aspects of the healthcare system in the State of Ceará and how they have implemented innovative ways to increase access and improve outcomes. They also discussed the United States-Brazil collaboration on the Zika virus and how our two nations can work together to enhance and protect our citizens against global health threats.

Later in the morning, Secretary Azar met with Dr. Islane Verçosa of CAVIVER and her medical team. CAVIVER is a non-governmental organization (NGO) in Brazil that engages with the public health system and international partners. Secretary Azar and Dr. Verçosa discussed the partnership between the Centers for Disease Control and Prevention (CDC) and the Brazilian Ministry of Health on the CDC’s Zika Outcomes and Development in Infants and Children (ZODIAC) investigation and how the results of this study have informed the care of children impacted by Zika. This follow-up assessment of children aged 12-24 months conceived during the 2015-2016 Zika virus outbreak in Brazil provided a first-ever description of the longer-term health and developmental effects of congenital Zika virus infection in children with microcephaly. At CAVIVER, Secretary Azar met and spoke with children and families affected by congenital Zika syndrome.

In the afternoon, Secretary Azar met with additional children and families affected by congenital Zika syndrome at the Albert Sabin Infant Hospital. This hospital serves as a specialty care center in the Brazilian public health system and as a reference center for care of infants and children in the northeastern region of Brazil. Here Secretary Azar learned about the hospital’s partnership with CDC on Zika and about the services they provide to care for children affected by the range of problems caused by microcephaly, including hearing and vision problems and other neurological conditions.

Secretary Azar reaffirmed HHS’ and the CDC’s continued support for Zika activities and reiterated that the Zika story is not over for affected families who face  managing lifelong disabilities for affected children.  CDC continues to monitor the health outcomes and care of affected babies to learn how to best protect mothers and babies from Zika virus infection and other emerging threats. Zika remains a threat in over 100 countries and territories, and pregnant women should still avoid travel to areas with risk of Zika. For a full list of areas with risk of Zika, please visit

Later in the afternoon, Secretary Azar traveled to São Paulo, Brazil where he will participate in meetings on Tuesday, October 2. Additional information regarding the Secretary’s meetings and schedule will be forthcoming in news releases and social media posts.

HHS, Genentech join forces on medicines to combat influenza, other health security threats

HHS Gov News - October 01, 2018

To develop innovative medicines that combat diverse national health security threats, the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR) today announced a strategic partnership with Genentech, a member of the Roche Group, of South San Francisco.

The company and ASPR’s Biomedical Advanced Research and Development Authority (BARDA) will jointly manage and share the cost to develop a portfolio of medicines that meet national health security requirements and have commercial uses. The partners will focus first on developing a first-in-class therapeutic for hospitalized influenza patients and a treatment for lung injuries caused by inhaling sulfur mustard gas.

“The United States faces a host of national health security threats requiring innovative solutions,” said BARDA Director Rick Bright, Ph.D. “Partnership agreements like this one allow flexibility to detect, prevent, or treat diverse illness and injury caused by these threats and at the same time decrease costs and maximize efficiency.”

BARDA will contribute $43 million over five years to support a study of the investigational oral medicine baloxavir marboxil in treating severely ill patients hospitalized with seasonal or pandemic influenza viruses. Influenza, or flu, is one of the most common, yet serious, infectious diseases, representing a significant threat to public health. CDC estimates that influenza has resulted in between 140,000 and 900,000 hospitalizations and between 12,000 and 80,000 deaths in the United States annually since 2010.

BARDA also will provide $19 million over 18 months to advance the development of alteplase (tPA) for a new indication to treat acute lung injuries called cast formation caused by inhaling sulfur mustard gas. The medicine, known under the brand name Activase is approved and marketed to treat heart attacks, stroke, and pulmonary embolism.

There are currently no FDA-approved therapeutics for use by severely ill patients hospitalized with influenza or for treatment of inhalational injury due to sulfur mustard.

In addition to sharing development costs, BARDA will have joint oversight, help determine which medicines to develop, and collaborate on decisions about which products enter or leave the partnership’s portfolio.

The agreement also gives BARDA access to Genentech’s extensive portfolio of potential medical countermeasures, including diagnostics, therapeutics for influenza, and medicines to reduce the transmission of influenza, and other products to combat health security threats.

Rather than standard contracts, HHS entered into the agreement using other transaction authority that was granted to HHS under the Pandemic and All Hazards Preparedness Act of 2006. Although not a contract, grant or cooperative agreement, other transaction authority provides a funding and collaboration vehicle to promote innovation in technology for advanced research and development. The new partnership agreement is BARDA’s eighth under other transaction authority.

Feds Settle Huge Whistleblower Suit Over Medicare Advantage Fraud

Kaiser Health News:Marketplace - October 01, 2018

One of the nation’s largest dialysis providers will pay $270 million to settle a whistleblower’s allegation that it helped Medicare Advantage insurance plans cheat the government for several years.

The settlement by HealthCare Partners Holdings LLC, part of giant dialysis company DaVita Inc., is believed to be the largest to date involving allegations that some Medicare Advantage plans exaggerate how sick their patients are to inflate government payments. DaVita, which is headquartered in El Segundo, Calif., did not admit fault.

“This settlement demonstrates our tireless commitment to rooting out fraud that drains too many taxpayer dollars from public health programs like Medicare,” said U.S. Attorney Nick Hanna in announcing the settlement Monday.

Medicare Advantage plans, which now enroll more than 1 in 3 seniors nationwide, have faced growing government scrutiny in recent years over their billing practices. At least a half-dozen whistleblowers have filed lawsuits accusing the insurers of boosting payments by overstating how sick patients are. In May 2017, two Florida Medicare Advantage insurers agreed to pay nearly $32 million to settle a similar lawsuit.

The DaVita settlement cites improper medical coding by HealthCare Partners from early 2007 through the end of 2014. The company, according to the settlement agreement, submitted “unsupported” diagnostic codes that allowed the health plans to receive higher payments than they were due. Officials did not identify the health plans that overcharged as a result.

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One such “unsupported” code was for a spinal condition known as spinal enthesopathy that was improperly diagnosed in patients in Florida, Nevada and California from Nov. 1, 2011, to Dec. 31, 2014, according to the settlement. The agreement did not say how much health plans took in from the unsupported codes.

The company also contracted with a Nevada firm from 2010 through January 2016 that sent health care providers to visit patients in their homes, a controversial practice that critics have long held is done largely to inflate Medicare payments. These house calls also generated “unsupported or undocumented” diagnostic codes, according to the settlement.

Officials said that DaVita disclosed the practices to the government. It acquired HealthCare Partners, a large California-based doctors’ group, in 2012. They said the government agreed to a “favorable resolution” of the allegations payment because of the self-disclosure.

In a statement, DaVita said the settlement “reflects close cooperation with the government to address practices largely originating with HealthCare Partners.” DaVita said the settlement will be paid with escrow funds set aside by the former owners.

“This case involved illegal conduct in which patients’ medical conditions were improperly reported and were not corrected after further review — all for the purpose of boosting the bottom line,” reads the government’s statement.

The settlement also resolves allegations made by whistleblower James Swoben that HealthCare Partners knew that many of the diagnostic codes were unsupported, but failed to report them. The company reported only cases in which it deserved higher reimbursement, while ignoring codes that would slash payments, a practice known as “one-way” chart reviews.

Swoben, a former employee of a company that did business with DaVita, will receive just over $10 million for the settlement of the “one-way” allegations, under the federal False Claims Act, which rewards whistleblowers who expose fraud.

Immigrants’ Health Premiums Far Exceed What Plans Pay For Their Care

Kaiser Health News:Insurance - October 01, 2018

President Donald Trump has repeatedly condemned U.S. immigration policy, arguing that many immigrants pose a threat to the nation and drain U.S. resources. But a study released Monday about health insurance challenges the president’s portrayal.

The study in the journal Health Affairs found that immigrants covered by private health insurance and their employers contributed nearly $25 billion more in premiums in 2014 than was spent on their care. Those in the country without legal status contributed nearly $8 billion toward the surplus.

In contrast, U.S.-born enrollees spent nearly $25 billion more than they paid for in premiums.

These findings surface as the Trump administration’s immigration policies — including a plan to tie migrants’ efforts to get permission for permanent residency to their use of federal benefit programs — have come under scrutiny.

Earlier studies also found that immigrants contribute more to Medicare than they receive in benefits, but the authors of this study say it is the first to look at the effect in private insurance plans.

Leah Zallman, assistant professor of medicine at Harvard Medical School and lead author of the study, said her findings allude to the potentially negative consequences that tighter immigration policies could have on the health care industry.

“I think in today’s era … there’s so much concern about immigrants and immigration really sort of draining our resources in the U.S.,” Zallman said. “This really points to the critical role that immigrants have in actually subsidizing and maintaining our current systems.”

Researchers calculated the financial contributions and expenses of enrollees and their employers using two surveys created by the federal government. Plans sold on the federal health law’s insurance exchanges were not included because they “differ from other private insurance in important ways and are unavailable to undocumented people,” the study authors noted.

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Anyone born outside of the United States was categorized as an immigrant. However, the surveys did not ask non-citizens with private coverage about their legal status. Researchers used national data on undocumented immigrants to estimate how many people in the study group illegally resided in the country.

In 2014, immigrants and their employers contributed $88.7 billion in private insurance premiums, but spent only $64 billion for care, according to the study’s findings. Of that group, undocumented immigrants alone paid more than $17 billion to private insurers but used only $9.4 billion.

Native-born consumers paid $616 billion in premiums and received nearly $641 billion in insurers’ payments for care. They also consistently outspent immigrants across all age groups. Among enrollees 65 and older, the U.S.-born made a net contribution of nearly $10,000 more toward their care than those born overseas, according to the study.

The researchers reported that, on average, individual immigrants paid $1,123 more for premiums in 2014 than they received in insurance-covered care. U.S. natives instead cost insurers $163 on average.

Leighton Ku, director of the Center for Health Policy Research at George Washington University who was not involved in the study, said several factors contribute to immigrants’ low health care expenses. The group tends to be healthier and younger when they arrive in the United States. Cultural and language differences also hinder them from accessing care.

The study noted that immigrants’ health care expenditures increased the longer they remained in the country. But it added that since their premiums also increased at the same time, they continued to make a net contribution to their private health plans.

The findings come about a week after the Department of Homeland Security proposed redefining how it would determine “public charge,” a term used to describe a person likely to become dependent on the government for assistance. The proposal would make it harder for immigrants to live and work permanently in the U.S. if they receive certain types of federal assistance, such as Medicaid, food stamps and housing subsidies.

Trump has vowed to be tough on immigration standards. During his campaign, he berated U.S. health expenditures on immigrants, arguing that the U.S. spent $11 billion for care to people who were in the country without authorization, the study’s authors note.

But they point out that earlier research shows that immigrants have low rates of health care use and spending, compared with native residents. Their payments to private plans and Medicare in essence prop up care for patients who are U.S.-born, the authors say.

A study Zallman published earlier showed unauthorized immigrants contributed $35.1 billion more to Medicare from 2000 to 2011 than they used in services.

Benedic Ippolito, an economist at the American Enterprise Institute, cautioned using the study’s findings to draw conclusions on a large scale about immigrants and their role in health insurance. An estimated 20 percent of immigrants — including nearly half of the undocumented population — are uninsured, according to the study. Ippolito said the cost of their uncompensated care affects whether immigrants’ financial contributions actually lead to surpluses for health care overall.

“I would be careful about how much I extrapolate these results to a) other parts of the health insurance market and b) even further to what this means for immigration policy,” Ippolito said. “This paper alone does not tell us everything we need to know.”

Ku echoed the uncertainty. He said he is not certain how the Trump administration’s latest actions will affect immigrants enrolled in private insurance. Having a private plan may suggest they are employed with a certain income stability. However, if enough immigrants leave the insurance market, he added, it may have the unintended consequence of making health plans more expensive for everyone else.

“That does have the following implication that to the extent that we do things to suppress immigrants or make it harder for them to purchase insurance then in that case we may do harm to the citizens,” he said.

White Coats As Superhero Capes: Med Students Swoop In To Save Health Care

Kaiser Health News:Marketplace - October 01, 2018

NEW YORK — Each wall of the library reading room at the New York Academy of Medicine is lined with tall wooden bookshelves holding leather-bound medical tomes. Atop the shelves perch busts — seemingly all white, all male — lit by two large brass chandeliers. Floor-to-ceiling windows overlook New York City’s Central Park and Fifth Avenue.

This setting, which speaks to medicine’s staid past, recently became the backdrop for plotting medicine’s future.

On a gray Sunday in September, 150 medical and nursing students dragged themselves in before 9 a.m. to learn how to meld their chosen professional careers with societal and political activism.

“As doctors, we will have this tremendous opportunity to talk to people every day,” said Miriam Callahan, a second-year student at Columbia University medical school. “We’ll have the ability to organize with them, to bring people together.”

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While doctors have traditionally been branded a mostly conservative group, there is growing evidence that young doctors-to-be are leaning leftward. This year, the American Medical Association student caucus persuaded the organization to drop its decades-long opposition to single-payer health care and instead study the concept, for example.

The conference at the academy, which was organized by medical students and sponsored by the New York City Department of Health’s Center for Health Equity along with four New York medical schools, sought to help students navigate that path. It featured a panel discussion and speeches by public health workers and doctors, including Dr. Abdul El-Sayed, a physician who mounted an unsuccessful progressive campaign this year for governor of Michigan.

The Advocacy in Medicine Conference, held Sept. 23 in New York City, trained medical students to push progressive issues. On the agenda: combating gun violence, promoting single-payer and treating refugees.(Rachel Bluth/KHN)

Dressed in blazers and dress shirts reflecting their professional identity, some also donned Planned Parenthood Buttons or Democratic Socialists of America pins. The agenda had a clear progressive bent, with workshops on LGBTQ+ health, gun violence, abortion access and criminal justice reform.

Attendees gave each other advice about how to advocate for single-payer, for example. Don’t talk about socialism, focus on the inefficiency and inequality you see, some said. Forget the “decrepit old physicians only worried about money,” their minds will never change, advised others.

Some participants were motivated by a humanitarian streak. Others were galvanized by the conditions they saw at free clinics, where they work as part of their medical education, or by a goal to increase national student engagement on issues like gun violence.

All were struggling with what they perceived as the responsibility that comes with a white coat and grappling with their place in a health care system they saw as broken.

Keven Cabrera, a fourth-year medical student at the Zucker School of Medicine at Hofstra University/Northwell, said this notion became real to him when he and some of his classmates participated this year in the March for Our Lives, a rally against gun violence.

Accustomed to the student position at the bottom of the medical hierarchy, he was taken aback by how much the white coat, even a short one that marks a student instead of a full-fledged attending doctor, afforded him respect in the community.

“We were all surprised by how much our voices counted,” Cabrera said.

About 150 medical students from eight schools gather at the New York Academy of Medicine to discuss how to advocate for their patients as they enter the medical field.(Rachel Bluth/KHN)

Everyone came to the table with the general agreement that health care for all was a moral necessity and abortion access was a fundamental right.

So they discussed how best to move these ideas forward. How do you get better reproductive education into a conservative medical school syllabus? How can you organize other students to protest, call legislators and show up for marches?

In one noisy room after lunch, students crowded around tables where doctors with experience lobbying on behalf of Physicians for a National Health Program led role-playing conversations to demonstrate how best to communicate with congressional staff or state assembly members. They also learned how to use the stories of patients they saw on a daily basis to work within the system to advocate for single-payer health care.

The students fretted — at least a bit — about how activism could help or hinder their professional success. A group sat in a semicircle listening to a doctor tell his story of being arrested at a protest.

Students asked about how civil disobedience could affect their residency placements, or get them marked as agitators within their departments. Then another chimed in: “Would you even want to be in a residency program where they would disqualify you for a protest arrest?”

Judges In California Losing Sway Over Court-Ordered Drug Treatment

Kaiser Health News:Madicaid - October 01, 2018

SANTA CRUZ, Calif. — Dressed in jailhouse orange, with hands and feet shackled, Jimi Ray Haynes stood up in a Santa Cruz County courtroom and pleaded guilty to a felony weapons charge.

Haynes, then 32, had spent the previous two weeks in jail detoxing from methamphetamine and heroin. The judge told Haynes he could serve part of his yearlong jail sentence in a drug treatment program rather than locked in county jail.

Eileen Jao, an assistant district attorney, quickly interjected: “It has to be residential, not outpatient,” she said. “It’s residential or jail.”

Jao wanted the terms to be crystal-clear. Because of a new county policy that took effect at the beginning of the year, treatment for low-income residents like Haynes, with drug-related criminal charges, must be decided by clinicians and providers — not the court. Judges can order whatever they want in terms of treatment, and prosecutors can block designated treatment they deem too risky, but essentially the type and length of treatment deemed appropriate is out of their hands.

The official record online showing that Jimi Ray Haynes can only do a residential program.

When conflicts arise between what the court orders and the providers decide, felons can languish in jail with no treatment at all.

Court-ordered rehab is increasingly falling out of fashion in California as Santa Cruz and 18 other counties begin to treat addiction like any other health condition — with the Medicaid program relying on evidence-based practices and trained personnel to make decisions on care. That has upended the status quo for judges, attorneys and defendants who often had agreed to residential treatment in lieu of jail — or at least to reduced sentences so inmates could get that treatment.

The California program appears to be unique in many respects, but other states — including Utah, Indiana, Kentucky, West Virginia, Virginia, Maryland, New Jersey and Massachusetts — also have sought federal permission to experiment with innovations in Medicaid-funded drug treatment.

In California, “these changes are a tough pill to swallow for the criminal justice system,” said Gavin O’Neill, drug court manager for the Alameda County Superior Court, which implemented the policy in July. “In the past, some judges and attorneys have been able to use residential treatment as a sanction and long-term monitoring mechanism, as well as a chance to address the underlying drug problem,” said O’Neill. “That option has been shut down.”

Proponents say that evidence-based treatment will lead to better outcomes and that residential care should be reserved for those with the most severe addictions. Under Medi-Cal, it is limited to 90 days.

“From the provider’s perspective, the judge ordering services has always been a problem,” said Katie Mayeda, a Santa Cruz County Superior Court clinician. “Judges have good intentions to put someone in treatment rather than in jail, but they don’t know the whole story. They don’t work in that realm — they’re not a clinical professional.”

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Advocates of the new approach — a Medicaid-funded pilot program that eventually is expected to be implemented in 40 California counties — say residential treatment is the most expensive and invasive option, and in many cases, outpatient treatment works as well, if not better.

If clinicians don’t approve residential treatment and prosecutors or judges won’t allow a release to outpatient treatment, the case can stall and felons become doomed to spend more time in jail.

Nearly three months into his jail stay, Haynes still was waiting for someone from a drug treatment program even to evaluate him, let alone determine his care plan. In the meantime, Haynes said, he received no drug treatment.

Because of the policy change, some prosecutors say they are less likely to accept anything but jail time.

The sign for the Santa Cruz County main jail as seen from Water Street.

“We are more inclined to just say, ‘Hey, put him in the custody of the sheriff,’ and not worry trying to treat the substance abuse problem,” said Santa Cruz County assistant district attorney Archie Webber. “If you want to do a program, you can do it on your own time.”

Webber’s rationale: He doesn’t trust the care providers, drug treatment organizations that contract with the county, to act in the interest of the state.

“We don’t want someone else to come in after us — a care provider, who hasn’t been in the process — and make those decisions for us,” Webber said.

The new policy, operating now in a third of the state’s 58 counties, stems from the expansion of Medicaid under the Affordable Care Act. That increased access to health care, including drug treatment, to the more than 13 million low-income adults in California who qualify for Medicaid.

In the past, counties had to use general funds or “block grants” to pay for court-ordered drug treatment for those who couldn’t afford it. Now, counties can pay for a range of drug treatment services — outpatient, medication-assisted, detox and residential — through Medicaid, or Medi-Cal, as it is known in California. But the new policy requires everyone seeking residential treatment to have a clinical assessment to determine whether that setting suits their diagnosis.

The counties that have begun providing drug treatment services under the so-called Drug Medi-Cal Organized Delivery System represent nearly 75 percent of the state’s more than 13 million Medi-Cal enrollees, according to the California Health Care Foundation. (California Healthline is an editorially independent publication of the California Health Care Foundation.) The rules on clinical decisions apply to everyone, not just inmates.

Santa Cruz County Superior Court on May 18.

Proponents hope all 58 California counties will come on board eventually, although the pilot Medi-Cal program is approved only through 2020, after which the federal government would have to reapprove the experiment.

Los Angeles County implemented the new Medi-Cal program just over a year ago and indicates it is running relatively smoothly.

“L.A. County got in front of it early on,” said Albert Senella, president and CEO of Tarzana Treatment Centers. “Treatment is now driven by medical necessity.”

But educating the courts on the new procedures can be a time-consuming process, and experts say it may take months or longer in some counties before the new rules sink in.

Because of a new county policy that took effect at the beginning of the year, treatment for low-income residents like Jimi Ray Haynes, with drug-related criminal charges, must be decided by clinicians and providers. (Courtesy of Santa Cruz County Sheriff’s Office)

In addition, counties and drug treatment providers say they have been weighed down by an administrative and staffing burden unlike anything they’ve seen before.

“It has been a tremendous amount of work,” said Senella. “A huge sea change in the way things are done.”

Some offenders say delays in receiving care are tough.

Haynes said he just wanted treatment, ideally in a residential setting.

“I’ve tried the whole white-knuckling sobriety thing,” said Haynes, who has a 10-year history with methamphetamine and heroin addiction. “The only measure of success I’ve had being clean and sober was in a residential drug treatment program.”

He would like to be able to visit with his wife and three children in a setting more pleasant than jail. Haynes wasn’t much older than his school-age kids are now when he visited his own father, then behind bars. He shook his head as if to erase the image.

“I don’t want my kids to see me in jail,” he said.

Haynes was released from jail this summer. Court records say his probation was revoked on July 17 after he was discharged from a drug treatment program for defiance and non-compliance.

He was re-arrested and, as of late last month, jailed in Fresno County.

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