Home » Archive for September 2019

Look Up Your Hospital: Is It Being Penalized By Medicare?

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Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.

Below are look-up tools for each type of penalty. Hospitals not penalized for 2020 are not listed if searching by year.  To see results from all hospitals, search by “Hospital penalized in any year.”

 



from Health Industry – Kaiser Health News

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Listen: Five Oklahoma Hospitals Collapsed – What Happened?

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KHN Midwest correspondent Lauren Weber joined StateImpact Oklahoma reporter Jackie Fortiér to discuss why a series of rural hospitals collapsed, leaving hundreds of residents without jobs and their communities without lifesaving emergency medical care. Weber and California Healthline senior correspondent Barbara Feder Ostrov wrote an in-depth story on the business practices of Jorge A. Perez and his management company, EmpowerHMS, that helped run that empire of rural hospitals.



from Health Industry – Kaiser Health News

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KHN Files Lawsuit To Force Feds To Disclose Medicare Advantage Audits

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Kaiser Health News is suing the U.S. Centers for Medicare & Medicaid Services to release dozens of audits that the agency says reveal hundreds of millions of dollars in overcharges by Medicare Advantage health plans.

The suit, filed late Thursday in U.S. District Court in San Francisco under the Freedom of Information Act, seeks copies of 90 government audits of Medicare Advantage health plans conducted for 2011, 2012 and 2013 but never made public. CMS officials have said they expect to collect $650 million in overpayments from the audits. Although the agency has disclosed the names of the health plans under scrutiny, it has not released any other details.

“This action is about accountability for hundreds of millions of public dollars misspent,” said Elisabeth Rosenthal, KHN’s editor-in-chief. “The public deserves details about the overpayments, since many of these private companies are presumably still providing services to patients and we need to make sure it can’t happen again.”

Medicare Advantage, mostly run by private insurance companies, has enrolled more than 22 million seniors and people with disabilities, more than 1 in 3 people on Medicare.

On July 3, KHN reporters filed a FOIA requesting copies of the CMS audits, which are known as Risk Adjustment Data Validation, or RADV, and include the audit spreadsheets, payment error calculations and other records. CMS has yet to respond to that request, according to the suit.

“By this FOIA action, KHN seeks to shine a public light on CMS’s activities on behalf of millions of Americans and their families,” the suit states. The suit asks the court to find that CMS violated the FOIA law and order the agency to “immediately disclose the requested records.”

While Medicare publicly discloses audits of other medical businesses, Medicare Advantage insurers “are being treated differently,” according to the suit. “These audits are improperly being withheld by CMS, even though CMS estimates that these audits have identified some $650 million in improper charges,” the suit alleges.

While proving popular with seniors, the Medicare Advantage industry has long faced criticism that it overcharges the government by billions of dollars every year.

Medicare pays the health plans higher rates for sicker patients and less for those in good health. However, the RADV audits have shown that health plans often cannot document whether many patients actually had the medical conditions the government paid them to treat, generating overpayments. The secretive RADV audits are the primary means for CMS to hold the industry accountable and claw back overcharges for the U.S. Treasury.

In July, KHN reported that Medicare Advantage plans have overcharged the government by nearly $30 billion in the past three years alone, money federal officials have struggled to recoup.

This month, U.S. Sen. Sherrod Brown, an Ohio Democrat, and five other senators sent a letter to CMS Administrator Seema Verma asking her to investigate Medicare Advantage overbilling. “In many cases, CMS has known for years about the tendency for some MA plans to overbill the government yet, despite this, CMS has taken little to no action to course correct. It is critical that CMS act immediately to recoup these overpayments and prevent future overbilling by MA plans,” Brown wrote.

The insurance industry is fighting a proposal by CMS to expand the impact of RADV by extrapolating error rates found in a random sample of patients to the plan’s full membership — a technique expected to trigger many multimillion-dollar penalties.

America’s Health Insurance Plans, the industry’s trade association, said in an Aug. 28 statement that the CMS proposals “violate numerous statutory requirements and are fundamentally unfair and ill-conceived.”

Stepping up RADV penalties “could lead to higher costs, reduced benefits, and fewer MA plan options for seniors,” the group argued.

The FOIA lawsuit is the second by a media organization to compel CMS to disclose RADV audit findings. In 2014, the Center for Public Integrity sued CMS and won a court order forcing the release of RADV audits for the first time. The audits showed that 35 of 37 plans had been overpaid, in some cases by as much as $10,000 per patient in a year.



from Health Industry – Kaiser Health News

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Sickened By Billing Abuses, Readers And Tweeters Stand Up For Patients’ Rights

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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Private Equity Predators?

First of all, let me thank you for writing about such an important issue (“Investors’ Deep-Pocket Push To Defend Surprise Medical Bills,” Sept. 11). I am going to tell you about my personal pain regarding surprising medical billing.

They can call themselves Doctor Patient Unity group or any other fancy name, but the reality is that they are all predators. I say this because I am the victim of these doctors groups. I work as a linguist with the U.S. Army and have top-secret clearance. I could lose my clearance if any of my bills go to a collections agency.

I had appendix surgery on Nov. 6, 2018, at the Davis Medical Center in Layton, Utah. The surgeon had told me that my surgery would take only 10 to 15 minutes. After two hours of surgery, I was released from the hospital and sent home. My insurer, CIGNA, paid all the Davis hospital bills and I paid my portion of the bills. Then in March 2019, I received two separate doctor’s bills totaling about $48,000. My insurance was not paying the doctor’s bills because they were out-of-network. The doctor’s office kept sending me letters to pay $48,000 from my pocket; if I did not pay, I was told, my bills would be sent to collections.

Finally, I received a letter from the collections agency saying that if I did not pay $26,770, it would send the information to the credit agencies. Can the Doctor Patient Unity group tell me what I should do? Should I lose my clearance and my job because I cannot afford to pay $26,770? Should I borrow money from the bank and then pay high interest to the bank for the rest of my life?

— Aziz Rehman, Kaysville, Utah

On Twitter, Dr. Amy Mecozzi Cho of Minneapolis diagnosed holes in the article. For example, she told KHN, “the contracted rates for insurance are misleading since our bad debt for patients with high-deductible insurance is greater than 60% of their deductible, but insurance companies won’t bill them because they know this. And so our effective rates for commercial insurance are actually much lower than contracted. The medical loss ratio and the CBO estimates are not capturing these costs to patients and physicians.”

Religious Malpractice

My sister, a hospital chaplain (of Roman Catholic faith), informs me that it’s considered chaplain malpractice to try to force a patient to cope with suffering in the exact way others think they should (“Firing Doctor, Christian Hospital Sets Off National Challenge To Aid-In-Dying Laws,” Aug. 30). It would follow, then, that a hospital’s requiring staff to “help” patients “appreciate the Christian understanding of redemptive suffering” is a paternalistic dismissal of patient integrity and a form of malpractice. The medical relationship is between the patient and the doctor, not the patient and the Vatican.

— Gloria Kohut, Grand Rapids, Mich.

— Amar Jesani, Mumbai, India

— Areva Martin, Los Angeles

Squeezing The Most Out Of Student Aid

I saw Jenny Gold’s excellent article in the Los Angeles Times about a disabled student’s need for assistance as she starts school at Stanford (“Spotlight: A Young Woman, A Wheelchair And The Fight To Take Her Place At Stanford,” Sept. 4). I wanted you to be aware that the Department of Rehabilitation in California pays for additional expenses for students to train them for future employment. This includes laptops, supplies, transportation expenses, necessary expenses. They might also pay for expenses for care above and beyond the approval of the state Department of Health Care Services.

All students face the issue of how to support themselves while in college. Stanford’s lovely gift of education for all who are accepted is often not used due to the high expenses of that area. Many students are unable to afford college, even with a full scholarship.

Those who have paid their way with student loans and are now employed in high service areas, such as medicine, psychiatry, social services and teaching, are strapped with lifetime payments. Our best and our brightest who serve our communities are in debt to the point where their income barely pays their lifetime of student loans. Sylvia Colt-Lacayo’s situation may have more expenses, but the debt of $2,000 a month is not unique for a full-time university student.

— Teresa L. Pardini, LMFT, Creativity in Counseling, Nipomo, Calif.

— Sonja Sharp, Los Angeles

A Heroine In The Opioid Fight

Please thank this wonderful, dedicated and tough woman (“Longtime Crusader Against OxyContin Begins To See The Fruits Of Her Struggle,” Sept. 17). That criminal company and every single member of the Sackler family had been well aware of the entire scam for decades, but they kept their mouths shut, turned their heads, denied everything and couldn’t care less since they were stuffing their individual pockets with hundreds of millions of dollars for each member of that large family. Every dollar should be clawed back from each family member. They’re laughing all the way to the Sackler Wing of 20-plus museums around this planet.

— David Padawer, Pittsburgh

— Dave Pena, Roseville, Calif.

Senior Hunger And Pangs Of Conscience

I’ve been a medic for over 20 years. I have patients that have to pick between eating or taking their medications. It’s disgraceful. We need to have articles like this written every day (“Starving Seniors: How America Fails To Feed Its Aging,” Sept. 3). Thank you.

— Eric Johnson, Marana, Ariz. 

— Dr. Tina Chee, New York City

I’m 68, a widower, disabled after two open-heart surgeries, with no family left. The last person to visit me at home was the yearly home health care nurse, back in February.

I am just like the people in your article: old, worn-out and forgotten. After a lifetime of work, I get by on a check that’s half of what a minimum-wage worker flipping burgers might make at $15 an hour. I can barely afford to eat the burgers now. No one, no insurance company, no politician is trying to help seniors out of poverty.

My biggest fear is dying and my little dogs being left alone for weeks or months to die before anyone finds me. Having moved to a rural area after my wife died, people don’t warm up fast to outsiders. It’s awful not to speak to anyone for years — yep, years — outside of cashiers. Just letting you know there are a lot of us out here.

— Rick Wrenn, Mount Carmel, Tenn.

— Maria De Jesus Chapa, Houston

Double Checking Fact-Check Facts

As the chairman of Physicians for Fair Coverage (PFC), I have joined doctors around the country in working to protect patients from surprise medical bills. I am writing now to set the record straight on the implications of various federal policies under debate in Congress. Not only did KHN’s recent article (“Doctors Argue Plans To Remedy Surprise Medical Bills Will ‘Shred’ The Safety Net,” Aug. 7) overlook research from the American Journal of Managed Care, the Centers for Disease Control and Prevention, and the Congressional Budget Office, it created a myopic interpretation of our argument in order to label it as “false,” which resulted in an inaccurate conclusion with respect to a complex issue that deserves a thorough, data-driven and factual examination.

According to the CBO, a benchmarking approach would cut payments to in-network physicians by as much as 20%. This translates into tens of billions of dollars shifted away from in-network physicians who are not sending surprise bills over the next decade. Emergency physicians treat all patients regardless of their insurance status. As a result, 70% of their patients are uninsured, seniors or poor families and children. Therefore, there is no practical difference between reducing commercial insurance payments and reducing Medicaid or Medicare rates. KHN’s own previous case study found that contributing factors to hospital closures include “high uninsured rates and a payer mix dominated by Medicare and Medicaid.” So, a benchmarking policy would create even larger disparities in quality and access to care over time for vulnerable populations.

Others agree that commercial payments play a critical role in supporting the care of America’s most vulnerable patients, including: American Academy of Orthopaedic Surgeons, American College of Emergency Physicians, American College of Radiology, America’s Essential Hospitals, American Hospital Association, American Medical Association, Association of American Medical Colleges, Catholic Health Association of the United States, Children’s Hospital Association and Federation of American Hospitals.

Instead of speaking with health care experts to better understand how reimbursement dynamics and patient access are inextricably linked in today’s economy, this article relied exclusively on the opinions of two biased research fellows who advocate for the very policy that our ad opposes and whose statements are misleading at best. The assessment also disregards a quote from the California Medical Association describing a lack of available anesthesiologists under California’s benchmarking approach.

PFC’s mission is to protect patients from surprise medical bills. That is why, this year alone, we helped drive constructive compromises that produced new laws in Texas, Colorado, Nevada and Washington. Similarly, at the federal level, we support legislation that uses a proven independent dispute resolution model to protect patients without disrupting responsible, in-network practices. To further protect patients, it’s important that Congress does not create an even larger public health issue with respect to the safety net while fixing the real issue of surprise bills.

— Dr. Sherif Zaafran, Washington, D.C.

— Gov. Laura Kelly, Topeka, Kan.

Infected With Advocacy

Your story about Medicaid expansion fails to attempt any serious description of the reasons for opposition to this expansion (“How Political Maneuvering Derailed A Red State’s Path To Medicaid Expansion,” Sept. 6). The reader is left with the clear impression that opponents are ill-informed, parsimonious, uncaring of others (especially the poor) or all of the above. There is no suggestion that such opposing might be in good faith. You really can do better than this. You insult the intelligence of your readers when you fail to deliver the whole story in a fair and evenhanded manner so they can decide for themselves. There is enough “us vs. them” in current media. Don’t drag it into health care. If you want to take positions on important health care issues, please create an editorial page; don’t infect your “news” with those positions. And no, I’m not a Republican. I’m an independent tired of constant advocacy in the media disguised as news. Thank you.

— Geoff Hargreaves-Heald, Lincoln, Mass.

— Juhyung Sun, Tucson, Ariz.

Why Prescribed Weight Loss Is Ill-Advised

What the author of the article dismissing the opinion of the dietitian who claimed stigma and yo-yo dieting cause more harm than obesity itself failed to mention is that, for many people, how weight might contribute to the development of physical illnesses is immaterial (Obesity Stigma And Yo-Yo Dieting, Not BMI, Are Behind Chronic Health Conditions, Dietitian Claims, Sept. 17). The prescription to lose weight, in and of itself, is damaging. Most dieters regain 100% or more of weight lost within five years. Additionally, people who are told to lose weight and subsequently diet are at significantly increased risk for body dissatisfaction, bingeing, disordered eating and eating disorders.

Health is not just physical health. Descartes invented mind-body dualism in a thought experiment in the 1600s. It is an idea that permeates modern culture and medicine to this day. However, we are not separate from our minds. Our mental health is not separate from our “true” health.

Obesity may or may not cause illness. If the process of losing weight creates more illness in the form of shame and eating disorders as well as health care avoidance, then continuing to blindly recommend it is irresponsible. The recommendation to diet should be made with an informed consent process. “Being overweight may put you at risk of developing X, Y and Z. I am recommending caloric restriction to remedy that. Caloric restriction is known to be ineffective in the long term, and puts you at risk of developing an eating disorder or of weighing more than you do now. The alternative to caloric restriction is to thoughtfully examine obstacles to your access of whole, nutritious foods, whether they be financial, psychological or otherwise.

“Compassionately adopting a diet that over time puts more colors on your plate and replaces processed foods with whole foods may in itself lead both to weight loss and decreased risk of chronic medical conditions. Additionally, finding a way to increase your physical activity, such that the activity is associated with joy and self-care, will also be protective against chronic conditions and may contribute to weight loss. However, if at any point weight loss becomes the goal rather than the logical outcome of sustainable changes, then we are back at the dieting step, with all its consequent risks.”

It doesn’t matter whether obesity causes illness. Deliberately losing weight is an ineffective approach to addressing what may or may not be a problem, and additionally causes harm. Let us guide patients toward what they have control over: food choices and increased activity, and let go of the number, not because it doesn’t influence health, but because focusing on it is ineffective and counterproductive.

If a formerly obese person is now skinny but miserable, hungry, obsessive, depressed and food-preoccupied because that’s what we evolved to do in the context of weight loss, why is that better? Any solution has to respect mental and physical health outcomes, or it is not truly a health-based recommendation.

— Dr. Sarah O’Neil, Boston

— Kerry Beake, Mandurah, Australia

Summer Camp Rehab — Or Torture?

The article “At This Summer Camp, Struggling With A Disability Is The Point” (Aug. 13) portrays what you describe as “necessary” but what many of us adults with disabilities remember as rehab torture — traumatic memories of painful so-called therapy with questionable or no demonstrable results. Even if the program had results, many of us would have chosen not to experience the pain. It’s old-style rehab of pretending it isn’t torturous and “we know what’s best for you.” This sort of rehab was vehemently rejected by disability activists years ago. It’s too bad adults who experienced this kind of therapy weren’t consulted. I believe few of them would describe this in positive terms. It’s not a new concept: If you work hard, with pain, you can become independent! So if you can manage to dress yourself in four hours and get ready for bed in three hours, you’re independent and met the goals set for you, even though you’re so tired you can’t enjoy the remaining few hours of your day. Most adults with disabilities would set a goal of having a quality of life over being independent. This was a very biased story and should have been more balanced from very different perspectives, especially from those with disabilities.

— RoAnne Chaney, executive director of the Michigan Disability Rights Coalition, East Lansing, Mich.

— Tom von Alten, Boise, Idaho

Prescribing A ‘Deep-Dive’ Into Hospital Excesses

I think KHN Editor-in-Chief Elisabeth Rosenthal’s piece on hospital excesses is right on the mark (“Analysis: How Your Beloved Hospital Helps To Drive Up Health Care Costs,” Sept. 5). I was affiliated with a New York City hospital as a voluntary internist and retired four years ago. I wonder if it would be possible to do a “deep dive” analysis of a representative hospital’s charges and expenditures (several New York hospitals come to mind as candidates) by an investigative reporting group. I suspect there is a lot of money being spent that does not enhance patient quality of care (i.e., excessive numbers of administrators getting egregious salaries). I think you’ve discussed the salient reasons these contributing cost factors have not been widely discussed or debated ― but they must be.

I remember a news story about a patient who bought his artificial hip implant in the U.S. wholesale and, to save money, took it with him to Belgium to have it inserted. The hospital looked like a factory, and he was reluctant to go in — but he did, and as it turned out everything went well and he saved a lot of money!

― Dr. Lawson Moyer, New York City



from Health Industry – Kaiser Health News

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Insurers Test New Way To Cut Maternity Care Costs: Bundling

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The thrill of delivering newborns helped pull Dr. Jack Feltz into the field of obstetrics and gynecology.

More than 30 years later, he still enjoys treating patients, he said. But now, Feltz is also working to change the way doctors are paid for maternity care.

Feltz’s New Jersey-based practice, Lifeline Medical Associates, recently partnered with the insurer UnitedHealthcare to test a new payment model. The insurer sets a budget with the practice to pay doctors one lump sum for prenatal services, delivery and 60 days of care afterward. If the costs come in below that amount, the medical practice gets to keep some of the savings. (Hospitals aren’t a part of this contract; the insurer pays them separately for their services.)

“We’ve always been taught to take care of patients as if they were our mothers and our daughters,” said Feltz, who also leads a coalition of obstetricians called the U.S. Women’s Health Alliance that advocates for high-quality, affordable care. “But now we have to take care of our patients as if they were our mothers and our daughters, and as if it was our money.”

This new program, announced in May, is a first step by the insurer to bundle physician payments for maternity care into a single flat fee that covers all care and procedures. A handful of insurers and state Medicaid programs are experimenting with similar models, sometimes incorporating hospitals and other health providers as well.

By moving from paying for maternity care in a piecemeal way to relying on bundled payments, insurers and doctors say they hope to cut costs and improve the quality of care for pregnant women. The lump sums are also seen by doctors and insurers as a possible way to improve outcomes, including driving down the number of cesarean sections in the United States.

About one-third of all deliveries in the U.S. occur through C-sections, even though the World Health Organization estimates they are medically required in only 10% to 15% of births. The rate varies dramatically among individual hospitals.

These surgeries can increase the risk of infections or other medical problems for the mother and baby. And they are more expensive than a vaginal delivery.

“The way we’ve been doing things is just not justifiable,” said David Lansky, a senior adviser at the Pacific Business Group on Health, a San Francisco-based coalition of private and public organizations that collectively purchase health care for 10 million Americans. “The shift we’re talking about is to say someone is accountable for all the care that needs to be provided to support a family through this experience.”

The professional association that represents obstetricians, however, is approaching the new payment strategy with caution because it could expose doctors to financial risks.

And even fans of such a model acknowledge there are still significant obstacles to be worked out before this sort of flat-fee system could be implemented broadly.

The bundled-payment model is relatively new in maternity care, and its structure can differ by insurer. Some insurers could pay a single amount to one doctor, who uses that to cover the hospital care. Other plans can opt to negotiate a separate contract with the hospital. Insurers can choose to pay doctors before or after patients receive services. The length of care, eligibility and services included in the bundle can also vary.

Patients generally are not even aware their care is being handled under a bundled payment.

In traditional coverage, insurance payments for some women are delivered as bundled payments for portions of their prenatal care, said Suzanne Delbanco, executive director of Catalyst for Payment Reform, an organization that helps advise employers and other organizations that buy health coverage. However, the latest version is different because insurers are adding quality measures that increase accountability and additional services, such as delivery costs, to the bundle.

UnitedHealthcare began testing the option with Feltz’s practice and another in Texas. The insurer said it hopes to expand to as many as 20 practices by the end of the year. Cigna and Humana are also piloting bundled maternity care programs. A few Medicaid programs, including those in Arkansas, Ohio and Tennessee, have experimented with it.

Expanding the rarely used model to include maternity care could represent a major shift in health care finance. Births were the most common cause of hospitalizations among patients discharged in 2016, according to government data.

“Maternity care is kind of the sleeper of health care services,” said Dr. Neel Shah, an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School.

The pivot in payments is being made as the quality of maternity care in the United States comes under renewed scrutiny. An estimated 700 women in the U.S. die each year because of pregnancy-related complications, the federal Centers for Disease Control and Prevention reported. The rate of deaths in the U.S. is worse than that of many other affluent countries, NPR and ProPublica reported in 2017.

And C-sections cost more. In the Denver area, for instance, the average vaginal delivery costs $7,716 while the average C-section costs $14,274, according to 2019 data from the Health Care Cost Institute. On average, commercial and Medicaid insurers pay 50% more for C-sections than for vaginal deliveries, according to a 2013 report by Truven Health Analytics, a health industry consulting group.

Lansky’s group tested bundled payments for births in 2014 in Southern California. According to their report, the rate of C-sections in first-time, low-risk pregnancies dropped by nearly 20% in less than one year among the first three participating hospitals.

However, some of the bundled-payment models fall short of aspirations. Tennessee saved money in 2017 after adopting the payment model for Medicaid beneficiaries. But the rate of C-sections remained unchanged, according to a report by the Medicaid and CHIP Payment and Access Commission (MACPAC), a nonpartisan advisory group for Congress.

In Ohio, where the Medicaid program covered complicated pregnancies as well as those that were low-risk, bundling payments into a lump sum for OB-GYNs cost the state more than expected, the advisory group found.

Bundling raises other concerns, too. Because some bundled-payment programs assign the total cost of care to a single physician, the financial burden falls on that physician. Dr. Lisa Hollier, the immediate past president of the American College of Obstetricians and Gynecologists, is concerned that these models may discourage team-based care.

If the physician providing prenatal care overlooks a problem that a different doctor must treat during delivery, for example, it wouldn’t be fair for the OB-GYN delivering the baby to bear the financial burden, Hollier said.

How payers define a low-risk pregnancy is also unclear, she said. If the target price for the suite of services in the model is not risk-adjusted for the cost of treating conditions like gestational diabetes, she said, doctors could be penalized for treating these patients.

Gestational diabetes occurs in up to 10% of pregnancies in the U.S. annually, according to the CDC, and patients with the condition need additional tests, checkups and insulin.

Julianne Pantaleone, national director of bundled payments and strategy at UnitedHealthcare, said the insurer, as it works through its pilot program, will not penalize physicians for providing care beyond the initial budget.

The lack of robust data systems built for bundled payments also poses a potential barrier to successfully adopting the model, said Blair Barrett Dudley, a senior manager at the Pacific Business Group on Health.

Insurers and doctors need real-time data to ensure they are meeting the model’s quality measures. However, these information banks are expensive to build, Dudley said, and many of the existing ones aren’t structured for this payment structure.

Feltz agreed that getting such data will be imperative to a successful bundled payment program. Without the information, he said, “it’s like launching a ship and not knowing where it’s going to go.”



from Health Industry – Kaiser Health News

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Uber And Lyft Ride-Sharing Services Hitch Onto Medicaid

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Arizona Medicaid Director Jami Snyder heard many complaints about enrollees missing medical appointments because the transportation provided by the state didn’t show or came too late.

So this summer she hatched a solution familiar to millions of Americans looking for an efficient ride: She turned to Uber and Lyft.

Arizona became the first state to revamp its Medicaid regulations to make it easier for ride-sharing companies to participate in its nonemergency transportation benefit. Under the changes, Arizona eliminated several safety rules such as requiring all drivers to undergo drug testing and first aid training.

The strategy has added thousands of vehicles to the fleet serving Arizonans on Medicaid, nearly 24% of the state’s 7 million residents.

“It seemed like an obvious solution,” Snyder said. “So far, our anecdotal reports have been very positive.”

As they seek to lower costs and improve care, Medicaid and other insurers have begun to examine the transportation needs of patients — along with other so-called social determinants of health such as adequate food and housing. Whether states save money remains to be seen.

In 2017, more than 2 million Medicaid enrollees under age 65 ― about 4% of the program’s members — delayed care because they lacked transportation, according to a federal survey.

Lyft is working with about 35 state Medicaid programs, according to LogistiCare, one of the nation’s largest Medicaid transportation brokers. Uber works with Medicaid only in Arizona.

Lawmakers in Florida and Texas this year also relaxed state regulations to make it easier for Uber and Lyft to provide services for appropriate Medicaid patients. That service is expected to begin early next year.

Uber and Lyft can’t handle all Medicaid transportation demands because they generally don’t have enough drivers with cars fit to ferry people with serious disabilities, such as those who use a wheelchair. But Arizona’s Snyder said many Medicaid enrollees are healthy enough to use a typical ride-sharing service.

Van Means, executive director of a company that Arizona pays to arrange transportation for Medicaid enrollees, said the expanded options help even some patients who can’t use them.

“It gives us way more supply, it’s faster and frees up space [in specialized transportation] for people who need more substantial help such as those in wheelchairs,” he said.

In most traditional Medicaid transportation programs, patients need to reserve rides days ahead and then often must share a van. In contrast, the ride-sharing companies need little advance notice and can easily take solo passengers.

To ease the use of Uber and Lyft, states generally waive safety requirements that are standard for more traditional transportation. Those include mandates that drivers undergo drug testing and learn first aid and CPR. State officials said such mandates are not necessary since Uber and Lyft serve ambulatory enrollees who likely are in better health than those needing specialized transportation.

The ride-sharing companies already work with hospitals and health systems across the country, but participating in Medicaid could bring them millions of more riders.

Unlike typical Uber or Lyft riders, Medicaid enrollees don’t order rides on their smartphones. Instead, these patients will continue to request transportation services by phone or computer through their health plan or a Medicaid transportation broker.

The Medical Transportation Brokerage of Arizona said about 15% of rides taken by Medicaid recipients this summer relied on Uber and Lyft.

So far, though, Means said the brokerage hasn’t found the service substantially cheaper in most areas of the state.

Arizona officials did not have an estimate of cost savings.

Officials at Atlanta-based LogistiCare said working with Lyft in dozens of cities has added vehicles and helped speed service.

“The ride-sharing companies are cost-effective and for curb-to-curb, urban or suburban short-distance trips,” said Effie Carlson, a LogistiCare executive vice president.

But she cautioned that the companies are not the ideal option for enrollees who need extra time getting in and out of their house because drivers typically leave within five minutes of arriving.

Uber and Lyft are often cheaper than using taxis or other private transportation companies, but not always. She noted that when companies raise prices during peak-traffic hours, alternatives may be less expensive.

Carlson said her company decides whether ride-sharing services or more traditional transportation is most appropriate based on the health information provided about each Medicaid enrollee.

The Medicaid transportation benefit varies by state but typically includes rides by taxi services, wheelchair vans, private vehicles and public transportation. Enrollees are eligible for the services if they do not have another means of transport.

Despite states’ growing interest in expanding transportation options, a University of Pennsylvania study, published last year in JAMA Internal Medicine, found providing ride-sharing services did not improve the no-show rate for primary care appointments among Medicaid patients in West Philadelphia. The no-show rate among patients offered free rides was 36.5%, compared with 36.7% for those who weren’t offered free rides.

Krisda Chaiyachati, co-author of the study and a University of Pennsylvania associate professor of medicine, said reliability of transportation is not the only factor determining whether Medicaid enrollees show for medical appointments. “People on Medicaid tend to live more chaotic lives, so they may be more OK with missing primary care appointments,” he said, referring to how low-income people often fear missing work, or have difficulties arranging child care and other necessities.

Still, Chaiyachati envisions Uber and Lyft playing larger roles for Medicaid.

“Their cars can be everywhere, and having a dispatcher draw upon that network is a no-brainer,” he said. “It may not solve the transportation needs for everybody, but it’s certainly an answer for many.”

Megan Callahan, vice president of health care at Lyft, said she expects more states to adopt ride-sharing.

“I think what we are seeing is the beginning of a domino effect,” she said. “Our overall driver availability and speed are the big advantages that will have an impact on Medicaid members’ satisfaction.”

Uber officials said in about dozen cities they are developing a fleet of drivers trained to work with patients who must travel with fold-up wheelchairs, walkers and scooters.

“From a cost standpoint, we can save states significant dollars,” said Dan Trigub, head of Uber Health.



from Health Industry – Kaiser Health News

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In Tiny Doses, An Addiction Medication Moonlights As Treatment For Chronic Pain

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Lori Pinkley, a 50-year-old from Kansas City, Mo., has struggled with puzzling chronic pain since she was 15.

She has had countless disappointing visits with doctors. Some said they couldn’t help her. Others diagnosed her with everything from fibromyalgia to lipedema to the rare Ehlers-Danlos syndrome.

Pinkley has taken opioids a few times after surgeries, but they never helped her underlying pain, she said.

“I hate opioids with a passion,” Pinkley said. “An absolute passion.”

Recently she joined a growing group of patients using an outside-the-box remedy: naltrexone. It is typically used to treat addiction to opioids or alcohol, in pill form or as a monthly shot.

As the medical establishment attempts a huge U-turn after two disastrous decades of pushing long-term opioid use for chronic pain, scientists have been struggling to develop safe, effective alternatives.

When naltrexone is used to treat addiction in pill form, it’s prescribed at 50 milligrams. But chronic pain patients say it helps their pain at doses of less than a tenth of that.

Low-dose naltrexone has lurked for years on the fringes of medicine, and its zealous advocates worry it may be stuck there. Naltrexone, which can be produced generically, is not even manufactured at the low doses that seem best for pain patients.

Instead, patients go to compounding pharmacies or resort to DIY methods — YouTube videos and online support groups show people how to turn 50 mg pills into a low-dose liquid.

Some doctors prescribe it off label even though it’s not FDA-approved for pain.

University of Kansas pain specialist Dr. Andrea Nicol recently started prescribing it to her patients, including Pinkley. Nicol explained that for addiction patients it works by blocking opioid receptors — some of the brain’s most important feel-good regions. So it prevents patients from feeling high and can help patients resist cravings.

At low doses of about 4.5 mg, however, naltrexone seems to work differently.

“What it’s felt to do is not shut down the system, but restore some balance to the opioid system,” Nicol said.

Some of the hype over low-dose naltrexone has included some pretty extreme claims with limited research to back them, like using it to treat multiple sclerosis and neuropathic pain or even using it as a weight-loss drug.

In the past two years, however, there’s been a significant increase in new studies published on low-dose naltrexone, many strengthening claims of its effectiveness as a treatment for chronic pain, though most of these were small pilot studies.

Dr. Bruce Vrooman, an associate professor at Dartmouth’s Geisel School of Medicine, authored a recent review of low-dose naltrexone research.

Vrooman said that, when it comes to treating some patients with complex chronic pain, low-dose naltrexone appears to be more effective and well-tolerated than the big-name opioids that dominated pain management for decades.

“Those patients may report that this is indeed a game changer,” Vrooman said. “It may truly help them with their activities, help them feel better.”

So how does it work? Scientists think that for many chronic pain patients the central nervous system gets overworked and agitated. Pain signals fire in an out-of-control feedback loop that drowns out the body’s natural pain-relieving systems.

They suspect that low doses of naltrexone dampen that inflammation and kick-start the body’s production of pain-killing endorphins — all with relatively minor side effects.

Despite the promise of low-dose naltrexone, its advocates say, few doctors know about it.

The low-dose version is generally not covered by insurance, so patients typically have to pay out-of-pocket to have it specially made at compounding pharmacies.

Advocates worry that the treatment is doomed to be stuck on the periphery of medicine because, as a 50-year-old drug, naltrexone can be made generically.

Patricia Danzon, a professor of health care management at the Wharton School at the University of Pennsylvania, explains that drug companies don’t have much interest in producing a new drug unless they can be the only maker of it.

“Bringing a new drug to market requires getting FDA approval, and that requires doing clinical trials,” Danzon said. “That’s a significant investment, and companies — unsurprisingly — are not willing to do that unless they can get a patent and be the sole supplier of that drug for at least some period of time.”

And without a drug company’s backing, a treatment like low-dose naltrexone is unlikely to get the promotional push out to doctors and TV advertisements that has made household names of drugs like Humira and Chantix.

“It’s absolutely true that once a product becomes generic, you don’t see promotion happening, because it never pays a generic company to promote something if there are multiple versions of it available, and they can’t be sure that they’ll capture the reward on that promotion,” Danzon said.

The drugmaker Alkermes has had huge success with its exclusive rights to the extended-release version of naltrexone, called Vivitrol. In a statement for this story, the company said it hasn’t seen enough evidence to support the use of low-dose naltrexone to treat chronic pain and therefore is remaining focused on opioid addiction treatment.

Lori Pinkley said it’s frustrating that there are so many missing pieces in the puzzle of understanding and treating chronic pain, but she, too, has become a believer in naltrexone.

She’s been taking it for about a year now, at first paying $50 a month out-of-pocket to have the prescription filled at a compounding pharmacy. In July, her insurance started covering it.

“I can go from having days that I really don’t want to get out of bed because I hurt so bad,” she said, “to within a half-hour of taking it, I’m up and running, moving around, on the computer, able to do stuff.”

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



from Health Industry – Kaiser Health News

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Meet The Health Officials Who Alerted The World To The Alarming Vaping Illness

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MILWAUKEE — Dr. Lynn D’Andrea knew something was amiss when three teenagers with similar mysterious, dangerous lung injuries came into the Children’s Hospital of Wisconsin one after another, gasping for air.

As the only pulmonologist on duty that Fourth of July holiday week, D’Andrea noticed those alarming cases followed on the heels of another teen who had a non-infectious condition with matching symptoms.

“‘We need to be thinking about something else,’” she told Dr. Michael Meyer, medical director of the Pediatric Intensive Care Unit, as he later recounted.

That “thinking about something else” led to the discovery of at least 530 probable vaping-related injury cases in 38 states, a U.S. territory and Canada. At least nine people have died. While the exact cause of the illness remains unclear, President Donald Trump is considering a ban on flavored e-cigarettes, and Walmart has taken them off its shelves altogether.

The epidemic has prompted outrage about federal oversight of vaping, but there is also a local public health success story to be told. Doctors and regional officials in Wisconsin, Illinois and elsewhere pieced together that this mysterious illness was much larger than it appeared. It’s a tale of teamwork, communication and long-serving public health officials tapping into their networks in an era of limited public health funding, diminished public health infrastructure and high turnover.

It’s surprising in some ways that Wisconsin became ground zero for uncovering the link. The state has ranked near the bottom nationwide for per-person spending on public health until a huge boost of $588 million more was greenlighted for the next two years. Wisconsin is also home to Juul vaping pod manufacturing sites, and one of its U.S. senators, Republican Ron Johnson, credits his win to vaping advocates.

And yet the state’s officials discovered the outbreak, which shows no signs of stopping.

“I don’t think anyone could have anticipated how wide-reaching this problem has become,” D’Andrea said in an email.

Discovering The Vaping Link 

Although isolated cases of vaping-related respiratory problems were spotted elsewhere, including as early as 2015 in West Virginia, a new wave of cases began popping up across the country starting in mid-April.

Otherwise healthy patients, many of them teenagers, complained of shortness of breath. unexplained weight loss, fatigue and gastrointestinal issues. They were often diagnosed with acute respiratory distress syndrome — essentially a lung injury from an unknown cause. The cases baffled health providers nationwide.

In North Carolina, clinicians puzzled over how healthy teenagers could suddenly be so ill that they needed ventilators for something that wasn’t infectious, said Zack Moore, the state’s epidemiology chief.

But in Wisconsin, doctors from Children’s Hospital used extensive patient histories to piece together the missing link among that cluster of four cases: vaping.

This is no easy feat when dealing with teenagers who may not want to admit to vaping in front of their parents — especially when it comes to vaping THC oil, the psychoactive chemical in marijuana. But for D’Andrea, a 25-year veteran who specializes in breathing issues among children and leads the hospital’s pulmonary team, the patients’ openness is part of what made the discovery possible.

“They were part of the ‘team’ who was trying to help us figure this out,” she said.

After discussing the cases with Meyer and other colleagues, D’Andrea called Dr. Michael Gutzeit, the hospital’s chief medical officer, on July 8. That phone call raised the warning from within Children’s Hospital to the local health department, then to the state health department and eventually to the Centers for Disease Control and Prevention in Atlanta — effectively putting this health crisis on the nation’s radar.

“It’s incredible that they saw this,” said Dr. Jeffrey Gotts, a pulmonologist at the University of California-San Francisco. “As front-line clinicians, there are very few things that we would report to public health authorities in the ICU. It’s not that unusual to have people show up with respiratory failure.”

From Local To State

Because the four patients with these symptoms at Children’s Hospital of Wisconsin were from Waukesha County just outside Milwaukee, infection specialists from the hospital gave the local health department a call.

Shortly thereafter, Waukesha’s public health officer, Ben Jones, reached out to the state’s respiratory disease epidemiologist, Thomas Haupt, whom he’d known for 15 years.

“They didn’t know how vaping would be involved” with these mysterious cases, said Haupt, a 34-year veteran of the Department of Health Services. “They called me right away.”

Haupt was immediately alarmed. He put down the phone and marched to the office of his boss, Chief Medical Officer Jonathan Meiman, on July 10, interrupting a meeting.

“We need to talk about this,” he recalled saying.

At that point, both the hospital and Haupt knew only that this was a local problem — and one that was getting worse. “It went from four cases to eight,” Haupt said. The team retroactively realized they had treated a patient admitted June 11 with similar symptoms, and had three more come in by July 19.

Haupt went to work notifying fellow public health officials across state lines in case this mysterious illness reached beyond Wisconsin, emailing two groups. Twelve years ago, he had set up a Midwest Influenza Coordinators Group, composed of officials from 11 states in the region to better manage flu season. He also helped lead the Council of State and Territorial Epidemiologists.

“Communication is always the biggest asset you’ve got as far as any disease investigation,” Haupt said.

It didn’t hurt that most of the people on these emails had run in the same public health circles for years. Several wrote back that they’d check things out with their poison control centers and public health departments.

In the meantime, the state health department and Children’s Hospital coordinated a press announcement and clinicians’ alert on July 25. Communication and trust was easy — Meiman and Gutzeit had worked together previously on Ebola preparedness efforts a few years earlier.

The news conference was livestreamed on Facebook. Following the briefing that day, another set of Wisconsin parents took a teenager with similar symptoms to the hospital.

The Case In Illinois

Within days, a clinician in Illinois who had seen the coverage called the Wisconsin state health department worried that a patient in Illinois might have the same condition. That’s when Meiman called his Illinois counterpart, Dr. Jennifer Layden, to let her know her state might have the mysterious illness, too.

“We started calling health departments and hospitals to see if others had this very vague description,” Layden said. “In a couple of days, just by those calls, we had two other patients.”

In San Francisco, Dr. Elizabeth Gibb saw a patient whose mom had seen the news out of Wisconsin and asked if it might be connected to her hospitalized teenager.

By Aug. 2, Illinois had put out a clinicians’ alert looking for more cases. Wisconsin was up to 11 cases.

As more cases appeared across the country, Wisconsin drafted a questionnaire for states to send out to clinicians, so they could all have a similar case definition and work off of similar data, Haupt said. At least 20 people in the Wisconsin state health department hustled on the response — on top of their regular workload.

The Epi-X Tipping Point

Following the news of a case across the border in Illinois — and one month since that first phone call from D’Andrea to Gutzeit — the Wisconsin health department decided to send out an Epi-X alert on Aug. 8. That’s an alert to all state health departments on the Epidemic Information Exchange network run by the CDC.

After the bulletin announcing Wisconsin had up to 25 suspected cases linked to vaping, calls poured in from New Jersey to North Carolina.

From there, it started to snowball.

The CDC announced on Aug. 17 that 94 possible cases existed, kicking off a media frenzy that culminated in national awareness of the dangers of vaping and cries for the head of the Food and Drug Administration to resign.

Within days, the CDC dispatched a team — two people to Illinois, two to Wisconsin — that helped comb through cases. Meiman and Layden continued to work together to further define the condition and coordinate information from other states.

As the caseload has quintupled, much still remains unknown about the illness. Many experts don’t believe this outbreak will end anytime soon. Still, Haupt said he’s incredibly proud of the work the officials in Wisconsin — from Children’s Hospital to the state health department — did spotting it. He believes their notification may have helped save lives.

“That’s the way public health is supposed to work,” he said. “And trust me, it doesn’t always work that way.”

California Healthline senior correspondent Anna Maria Barry-Jester contributed to this report.



from Health Industry – Kaiser Health News

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Congress Rakes In Millions From Drugmakers

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Members of Congress raked in almost $4 million from pharmaceutical manufacturers and their trade groups in the first six months of 2019. Two members — Sen. Chris Coons (D-Del.) and Sen. Thom Tillis (R-N.C.) — each received over $100,000. Rep. Greg Walden (R-Ore.) is $5,000 shy of qualifying for the “million-dollar club,” a group of current members who’ve received $1 million or more since 2007.

The pharmaceutical industry has a long history of seeking to influence legislation by donating to the committees controlled by powerful members of Congress. As they return from recess and drug-pricing legislation comes into focus, find out how much your state’s representatives and senators took from the industry by examining KHN’s exclusive “Pharma Cash to Congress” feature.



from Health Industry – Kaiser Health News

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Listen: India Gives Opioid Makers A Huge And Growing New Market

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KHN senior correspondent Sarah Varney discussed the changing attitudes toward opioid painkillers in India with NPR’s Rachel Martin on “Morning Edition” Thursday.

Varney traveled to India to report a two-part series on the issue in partnership with The Guardian.



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