Home » Archive for Januari 2020

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Is anyone still having an existential crisis over the now-viral tweet about what kind of inner monologue you have? And the fact that some people’s inner voice comes in images instead of words? Did you stare off into space for a while trying valiantly not to lose your grip on this fragile thing called reality? You are not alone!

All right, enough introspection, on to what you may have missed this week.

What’s in a name? Well for block grants … quite a bit of baggage. That’s why when the Trump administration sent letters this week to states to encourage them to transform their Medicaid programs into block-grant funding, it unveiled a fancy new title for the program. Wait for it … “The Healthy Adult Opportunity” program. Not the catchiest title, but certainly on brand for CMS Administrator Seema Verma’s messaging.

Why shy away from “block grant” terminology? Because the policy’s history is rife with partisan controversy and rhetoric that the administration seems to want to distance itself from. Conservatives have been champing at this particular bit for years, but critics say block grants are illegal and will lead to coverage losses. There isn’t a question of if there will be a court challenge, but rather of how soon it will come.

The New York Times: Trump Administration Unveils a Major Shift in Medicaid

Politico: ‘Block Grants’ No More: Trump’s Medicaid Overhaul Has New Name, Same Goals

Now for the section that I think will become a mainstay for at least a few weeks, judging by the daily deluge of stories: the coronavirus roundup file! (I also wish I had a catchier name for that, so I guess I shouldn’t throw rocks at CMS’ glass houses. The coronavirus checkup, perhaps?)

Anyway here are your highlights, while emphasizing — for not the first or last time probably — that there is quite a low risk of contracting the virus for Americans at the moment.

— The U.S. has reported its first person-to-person transmission, but it was a husband getting it from his wife, who had just come back from the epicenter of the outbreaks. Officials continue to reiterate that this shouldn’t cause any panic.

The Associated Press: US Reports 1st Case of Person-to-Person Spread of New Virus

— As the number of cases worldwide surges toward the 10,000 mark, WHO has officially declared the outbreak a “public health emergency” while being extra clear that this is not a “no confidence” vote in China’s ability to contain it.

Los Angeles Times: Coronavirus Outbreak Is Now a ‘Public Health Emergency,’ WHO Says

— Do the numbers sound somewhat terrifying? Experts say it’s still too early to be doing the math on mortality rates — in pandemics, the early cases are often the most severe and skew the numbers.

Stat: Limited Data May Be Skewing Assumptions About Severity of Coronavirus Outbreak, Experts Say

— Who gets the oh-so-lucky honor of becoming the face of the crisis response in the states? That would be HHS Secretary Alex Azar (yes, the same Alex Azar who recently has been the source of some unpleasant gossip about the Trump administration).

Politico: Trump Sticks Embattled Health Chief With Coronavirus Response

— When the science is fast, but the virus is faster, a vaccine can be out of reach.

The Washington Post: Coronavirus Vaccine Research Is Moving at Record Speed

— China has invested billions into becoming a world leader in medicine. Is this outbreak a reality check?

The Wall Street Journal: China’s Vast Ambition in Medicine Gets Reality Check From Coronavirus

— Experts warn about a dangerous symptom of the coronavirus: xenophobia.

NBC News: As Coronavirus Spreads, So Does Concern Over Xenophobia

— And step away from that Amazon order for surgical masks. Not only will they not do much for you, but the surge in orders is creating a shortage for the medical professionals they actually will help.

The New York Times: Face Mask Hoarders May Raise Risk of Coronavirus Outbreak in the U.S.

The Supreme Court gave the green light to a Trump administration policy change that would allow government officials to take into consideration a green-card applicant’s use of federal safety-net programs such as Medicaid and food stamps. In the past, only substantial and sustained monetary help or long-term institutionalization counted.

The New York Times: Supreme Court Allows Trump’s Wealth Test for Green Cards

One of my favorite headlines of the week comes from this Stat story on the election and drug prices: “It’s the insulin, stupid.”

While “health care is complicated” has become a go-to one-liner for many of us wonks in recent years, Stat looks at why, when it comes to insulin, it’s just not. The drug is common, old and was previously cheap before an obesity epidemic provided an opportunity for pharma to jack up the prices. The stories that come out of that greed are devastating and plentiful.

The picture critics can paint is a fairly clear one that’s easy to understand. That may be why 2020 Democratic candidates are using it as a rallying cry.

Stat: It’s the Insulin, Stupid: How Drug Pricing’s Simplest Case Study Became a Top Issue for 2020 Democrats

“I am a danger to the public,” is not really something you want to hear from a pharmacist. But some of them are speaking out now about how chaotic workspaces and chronic understaffing are creating a breeding ground for disastrous mistakes.

The New York Times: How Chaos at Chain Pharmacies Is Putting Patients at Risk

A $145 million settlement between the government and a health technology company flew a bit under the radar this week, but it was the first of its kind. San Francisco-based Practice Fusion took kickbacks from an unnamed drugmaker (which was unmasked later as Purdue Pharma) to create an alert within its electronic health records system to encourage doctors to prescribe more opioids.

The Associated Press: US Attorney Announces $145M Settlement in Opioid Case

In a rare bit of good news, Americans’ life expectancy rose for the first time in four years as cancer and overdose deaths dipped slightly. While public health experts said the numbers were “encouraging,” they weren’t celebrating quite yet since the increase was so small.

The Associated Press: For 1st Time in 4 Years, US Life Expectancy Rises — a Little

A prominent Harvard scientist was arrested this week over accusations that he lied about his ties to China. Charles M. Lieber was apparently making $50,000 a month through his participation in the “Thousand Talents” program in, coincidentally, Wuhan, China. The arrest is just the latest in a crackdown on U.S. research being shared with China.

The New York Times: U.S. Accuses Harvard Scientist of Concealing Chinese Funding

In the miscellaneous file for the week:

— Uh, just in case anyone was confused, Purell can’t protect someone from Ebola. And now the FDA is officially telling the company it can’t say that it does.

The Washington Post: FDA Warns Purell Over False Claims It Can Eliminate Ebola, MRSA and Flu

— A harsh spotlight shone on the Hippocratic oath this week when testimony about Guantanamo Bay touched on the role of doctors in the facilities and interrogations.

The New York Times: Guantanamo Testimony Exposes Role of Doctors in C.I.A. Interrogations

— Wilderness therapy is a hot trend to help troubled teens whose families have run out of other options. But what does the science say about it?

Undark: Does Science Support the ‘Wilderness’ in Wilderness Therapy?

— Monday marked the 75th anniversary of the liberation of the Auschwitz concentration camp. The ceremony was somber amid the global upswing in anti-Semitism and dehumanizing political rhetoric that undermines the once-unshakable promise of “never again.”

The New York Times: 75 Years After Auschwitz Liberation, Worry That ‘Never Again’ Is Not Assured

That’s it from me! Have a great weekend.

from Health Industry – Kaiser Health News

Preeminent Hospitals Penalized Over Rates Of Patients’ Injuries

Hundreds of hospitals across the nation, including a number with sterling reputations for cutting-edge care, will be paid less by Medicare after the federal government pronounced that they had higher rates of infections and patient injuries than others.

The Centers for Medicare & Medicaid Services on Wednesday identified 786 hospitals that will receive lower payments for a year under the Hospital-Acquired Conditions Reduction Program, a creation of the Affordable Care Act. The penalties are designed to encourage better care without taking the extreme step of tossing a hospital out of the Medicare and Medicaid programs, which would drive most hospitals out of business.

Now in their sixth year, the punishments, known as HAC penalties, remain awash in criticism from all sides. Hospitals say they are arbitrary and unfair, and some patient advocates believe they are too small to make a difference. Research has shown that while hospital infections are decreasing overall, it is hard to attribute that trend to the penalties.

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

“There is limited evidence that this is the kind of program that makes things better,” said Andrew Ryan, a professor of health care management at the University of Michigan School of Public Health.

Under the law, Medicare is mandated each year to punish the quarter of general care hospitals that have the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. Hospitals can be punished even if they have improved from past years.

Medicare cuts every payment by 1% for those hospitals over the course of the federal fiscal year, which started in October and runs through the end of September.

Since the program’s onset, 1,865 of the nation’s 5,276 hospitals have been penalized for at least one year, according to a Kaiser Health News analysis.

Many hospitals escaped penalties because they were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a “critical access hospital” for lack of nearby alternatives for people needing inpatient care.

This year, 145 hospitals received their first penalty, the analysis found. Conversely, 16 that had been penalized every year since the start of the program avoided punishment. Those included Novant Health Presbyterian Medical Center in Charlotte, North Carolina, and Tampa General Hospital in Florida.

Novant Health said in a statement it had lowered infection rates by being more discriminating in using urinary catheters and central lines, standardizing the steps to prevent infections in surgeries, and getting staffers to wash their hands more.

This year, Medicare penalized seven of the 21 hospitals on the U.S. News Best Hospitals Honor Roll, an annual ranking often used as a proxy for identifying the most prestigious facilities.

Those penalized “honor roll” hospitals were UPMC Shadyside in Pittsburgh; Ronald Reagan UCLA Medical Center in Los Angeles; Keck Hospital of USC; Stanford Health Care’s main hospital in Northern California; UCSF Medical Center in San Francisco; NewYork-Presbyterian/Weill Cornell Medical Center in Manhattan; and the Mayo Clinic’s hospital in Phoenix.

Only UCSF commented to KHN on the penalties, blaming its high HAC rates on its thoroughness in identifying infections and reporting them to the government.

“That commitment will naturally make our rates appear to be higher than some other hospitals,” UCSF said in a written statement.

Three other “honor rollees” have avoided punishment in all six years of the penalties: Massachusetts General Hospital, the Mayo Clinic’s flagship hospital in Rochester, Minnesota, and Penn Presbyterian Medical Center in Philadelphia.

Johns Hopkins Hospital in Baltimore has also avoided penalties every year, but Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than for the rest of the states.

The federal Agency for Healthcare Research and Quality last year estimated there were about 2.5 million hospital-acquired conditions in 2017. Rates have been dropping by about 4.5% a year, the agency calculated, with the biggest decreases since 2014 in infections from Clostridioides difficile, known as C. diff.; bad reactions to medications and postoperative blood clots.

Maryellen Guinan, a senior policy analyst at America’s Essential Hospitals, the association of about 300 safety-net hospitals said, “Our folks even before the HAC program was in existence have been doing a lot to put in infection controls.”

However, a study Ryan and colleagues published in Health Affairs in November analyzed a clinical surgical data registry used by 73 Michigan hospitals and concluded that hospital complications rates were higher than what the government has estimated. The study agreed rates were dropping but said there was no proof the HAC penalties played a role.

Leah Binder, president of The Leapfrog Group, a patient safety organization, said the complex formula Medicare uses to allot penalties is too confusing and the penalty set by Congress is too small to be effective.

“Americans expect 100% of hospitals to go to the ends of the Earth to prevent needless patient suffering, and singling out some hospitals for a little 1% ding isn’t enough,” she said.

CMS did not respond to requests for comment for this story.

The Association of American Medical Colleges said 45% of its members were penalized this year — nearly double the rate of other hospitals.

Dr. Atul Grover, the association’s executive vice president, said teaching hospitals incurred penalties more often because they often treat some of the sickest people and Medicare’s calculations did not sufficiently take into account the especially weakened condition of their patients, which make them more susceptible to infections.

“There are still issues with the methodology, surveillance bias, and the inability to fully risk adjust for our institutions that have patients who are sicker” and are more likely to have multiple medical problems, Grover said in an email.

from Health Industry – Kaiser Health News

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

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

A Guide To Following The Health Debate In The 2020 Elections

Health has been a top issue in the presidential campaign during the past year: Not only do the Democratic candidates disagree with President Donald Trump, but they also disagree among themselves.

Voters have frequently complained that the debate has been confusing and hard to follow. Most of the attention so far has been focused on whether the U.S. should transition to a “Medicare for All” program that would guarantee coverage to all U.S. residents — and result in higher taxes for most people. But there is far more to the health debate than that.

The campaign is nearing some key moments — the caucuses in Iowa next week, the New Hampshire primary Feb. 11, voting in Nevada and South Carolina later in the month. By March 3, Super Tuesday, Democrats will have chosen a third of all delegates.

Here are six things to know as you tune in to the increasingly frenzied primary race.

Universal coverage, Medicare for All and single-payer are not all the same thing.

Universal coverage is any method of ensuring that all of a country’s residents have health insurance. Other countries do it in various ways: through public programs, private programs or a combination.

Single-payer is a system in which one entity, usually but not always a government, pays for needed health care services. Single-payer is NOT the same as socialized medicine. The latter generally refers to a system in which the government pays all the bills, owns the health facilities and employs the health professionals who work there. In a single-payer system, such as Medicare in the U.S., the bills are paid by the government but the delivery system remains mostly private.

Medicare for All is a proposal that was originally developed in the late 1980s. Building on the popularity of the Medicare program for senior citizens, the idea was originally to extend that program to the entire population. However, since Medicare’s benefits have fallen behind those of many private insurance plans, the later iterations of Medicare for All would create an entirely new, and very generous, program for all Americans.

Voters are more concerned about health care costs than health care coverage.

While Democrats fight over how best to cover more people with insurance, the majority of Americans already have coverage and are much more worried about the cost. A recent survey of voters in three states with early contests — Iowa, South Carolina and New Hampshire — found voters in all three ranked concerns about high out-of-pocket costs far ahead of concerns about insurance coverage itself.

It’s the prices, stupid.

There’s a good reason voters are so concerned about what they are being asked to pay for medical services. U.S. health spending is dramatically higher than that of other industrialized nations. In 2016 the U.S. spent 25% more per person than the next highest-spending country, Switzerland. Overall U.S. health spending is more than twice the average of other Western nations.

But that’s not because Americans use more health services than citizens of other developed nations do. We just pay more for the services we use. In other words, as the late health economist Uwe Reinhardt once famously quipped in the title of an academic article, “It’s the Prices, Stupid.” A later paper published last year (the original is from 2003) confirmed that is still the case.

Drug companies and insurers aren’t the only ones responsible for high prices.

To listen to many of the candidates’ messages, it may seem drug companies and health insurers are together responsible for most — if not all — of the high health spending in the U.S.

“The giant pharmaceutical and health insurance lobbies have spent billions of dollars over the past decades to ensure that their profits come before the health of the American people,” says Sen. Bernie Sanders on his presidential campaign website. “We must defeat them, together.”

Most insurance spending, though, actually goes for care delivered by doctors and hospitals. And some of their practices are far more gouging to patients than high prices charged by drugmakers or administrative costs added by insurance companies. Wall Street firms that have bought physician groups are helping block a legislative solution to “surprise bills” — the often huge charges faced by patients who inadvertently get care outside their insurance network. And hospitals around the country are being called out by the news media for suing their patients over bills almost no patient can afford.

Democrats and Republicans have very different views on how to fix health care.

To the extent health has been covered in the presidential race, the story has been about disagreements between Democrats: Some want Medicare for All, while others are pushing for less sweeping change, often described as a “public option” that would allow but not require people to purchase a government health plan.

There are much bigger divides between Democrats and Republicans, however. Democrats nearly all support a larger role for government in health care; they just disagree on how much larger it should be. Meanwhile, Republicans generally want to see less government and more market forces brought to bear. The Trump administration has already either implemented or proposed a variety of ways to decrease regulation of private insurance and is weighing whether to allow states to effectively cap their Medicaid program spending.

And in the biggest difference of all for the coming campaign, the Trump administration and a group of GOP-led states are, again, challenging the entire Affordable Care Act in court, arguing that it is unconstitutional based on the 2017 tax law’s zeroing out of the tax penalty for failing to maintain insurance coverage.

The Supreme Court has opted not to decide the case in time for the 2020 election, but it is likely to continue to be a major issue in the campaign.

There are important health issues beyond insurance coverage and costs.

While Medicare for All and drug prices have dominated the political debate during the past year, other critical health issues have received far less attention.

Some candidates have talked about long-term care, which will become a growing need as baby boomers swell the ranks of the “oldest old.” Several have addressed mental health and addiction issues, a continuing public health crisis. And a few have laid out plans for the special needs of Americans in rural areas and those with disabilities.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

from Health Industry – Kaiser Health News

Trump’s Latest Health Care Challenge: Gaining Voters’ Trust

Far more Americans disapprove of President Donald Trump’s handling of several high-profile health care issues than give him positive marks, underscoring the challenge the president faces in claiming health care as a political asset in his reelection bid.

The findings, from the latest Kaiser Family Foundation Health Tracking Poll, released Thursday, found Trump’s approval ratings on various health care topics — including how he has handled the cost of prescription drugs and protecting people with preexisting conditions — lag behind those on his overall job performance. (Kaiser Health News is an editorially independent program of the foundation.)

Overall, 54% of adults disapprove of Trump’s handling of prescription drug costs, an area that he has repeatedly pledged to address and that federal officials see as crucial to his reelection pitch. In contrast, 3 in 10 said they approve.

At the same time, 35% of Americans approved of Trump’s handling of preexisting conditions and the Affordable Care Act.

The president’s overall job approval rating clocked in at 42%. He has repeatedly vowed to improve health care and lower prescription drug prices.

Trump has often misleadingly spoken about his record on preexisting conditions, one of the most popular pieces of the ACA. “I was the person who saved Pre-Existing Conditions in your healthcare,” he tweeted earlier this month, a claim that was widely debunked by fact-checkers.

Democrats’ focus on protections for preexisting conditions and other health issues helped propel the party’s successes in the 2018 midterm congressional elections. Some of the Democratic presidential contenders, especially former New York Mayor Michael Bloomberg, have hit Trump hard on his health policies.

Although certain parts of Trump’s health agenda have generated bipartisan praise — such as initiatives revamping care for Americans with kidney disease and vowing to stop the spread of HIV in the U.S. by 2030 — efforts related to the Affordable Care Act and health care entitlements have been controversial and subject to legal challenge. A narrow majority of the public — 51% — said they disapproved of the president’s handling of Medicaid, compared with 35% who approve, the KFF poll found. The Trump administration has made significant changes to the ACA’s expansion of Medicaid, most notably approving some states’ efforts to set work requirements for adults who qualify for the program.

Multiple administration proposals on drug pricing have either been scuttled or have faltered in recent months — including an effort to overhaul drug rebates and an initiative to tie certain drug payments to prices in other countries — as has competing legislation in Congress. The KFF poll found that lowering drug prices and continuing the health law’s preexisting condition protections ranked as the public’s top health care priorities for Congress to address, a finding that’s consistent with a KFF survey from a year ago.

The poll also questioned adults on the popularity of the two main proposals from Democratic presidential candidates to expand health coverage: instituting a government-run “public option” that competes with private insurers or a “Medicare for All” national health plan. Nearly 7 in 10 Americans support a public option, whereas a smaller majority — 56% — support Medicare for All.

While support was higher among Democrats, most independents also said they favor both approaches.

The poll found that nearly two-thirds of people have heard about a case brought by Republican state officials in a federal court in Texas and supported by the Trump administration that challenges the constitutionality of the ACA. Fifty-eight percent said they are “very” or “somewhat” worried that if the judge’s decision to strike down the law is upheld they or someone in their family will lose health coverage.

from Health Industry – Kaiser Health News

Appendicitis Is Painful — Add A $41,212 Surgery Bill To The Misery

Joshua Bates knew something was seriously wrong. He had a high fever, could barely move and felt a sharp pain in his stomach every time he coughed.

The 28-year-old called his roommate, who rushed home that day in July 2018. The pair drove to the nearest emergency room, the Carolinas Medical Center in Charlotte, North Carolina. After several tests, including a CT scan of his abdomen, the emergency team determined Bates had acute appendicitis.

“They said my appendix was minutes away from rupturing,” Bates said.

Not mentioned, he said, was that the hospital was out-of-network with the insurance plan provided through his job. Even so, he couldn’t have jumped up and gone elsewhere. His appendix was about to burst.

He had surgery that night, which went smoothly, and went home the next day.

“Everything seemed according to plan,” said Bates.

Then the bill came.

Patient: Joshua Bates, a technical recruiter for a staffing firm, who lives in Charlotte, North Carolina. The Continental Benefits insurance plan comes with a deductible of $2,000 and an annual out-of-pocket maximum of $6,350.

Total Bill: $41,212 covering the surgery, one night at the hospital and the emergency room charges. After payments by both Bates and his insurer, the hospital sent Bates a bill for the balance, just over $28,000.

Service Provider: Carolinas Medical Center, owned by Atrium Health, a for-profit health system based in Charlotte.

What Gives: Bates was “balance billed” because he went to an out-of-network hospital — and, even though it was an emergency, he fell through the limited protections in existing law.

“Terrifying,” is how Bates describes the feeling when he first saw the bill for $28,000. Don’t worry, his insurer told him, it would negotiate with the hospital.

“If you pay your complete deductible, this will all go away,” Bates recalled the insurer saying. “I pay. It doesn’t get resolved.”

More than a year later, with negotiations between the hospital and his insurer at a standstill and his credit score falling because the $28,000 debt has gone to collections, a frustrated Bates contacted “Bill of the Month.”

“From what my insurance is telling me, the hospital is just non-responsive to them trying to negotiate this price,” he said.

His situation is not unusual. A recent study found that about 18% of emergency room visits have at least one such charge for out-of-network care.

A balance bill is the difference between what insurers pay toward a bill and a provider’s “list charges,” which facilities set themselves and often bear little or no relationship to actual costs.

In Bates’ case, the insurer paid $8,944 toward the $41,212 charges, according to his explanation of benefits from his insurer. On top of that, Bates paid the hospital about $4,000, a combination of his annual deductible and his coinsurance for emergency care. That left $28,295 of the hospital’s charges unpaid.

The online site Healthcare Bluebook, which calculates costs based on health insurers’ claims data, estimates a laparoscopic appendectomy ranges from $9,678 to more than $30,000 in Bates’ ZIP code. The “fair price” it suggests for the surgery is $12,090 — completely in the ballpark of the $12,944 that Bates and his insurer already paid the hospital. Fair Health, another site that collects claims data, estimates total costs for an out-of-network appendectomy at $19,292 — about $11,000 less than the hospital says Bates still owes.

“It’s ridiculous. He’s a young kid who goes to the emergency room and he has insurance,” said Duane Sunby, the insurance broker for Bates’ employer.

Bates says it was “terrifying” to see a bill for $28,000 following his emergency appendectomy.(Logan Cyrus for KHN)

Sunby added that Continental’s payment to the hospital was nearly 2½ times more than Medicare would have paid for similar services, but the facility is going after Bates for more than seven times what the federal government would pay. A growing outcry about such balance bills has attracted attention from statehouses and Congress, but current protections for patients often fall short.

Congress last year debated several bills that would have provided federal protection nationwide, especially for emergency room patients. But bipartisan efforts stalled late in the year following intense lobbying by providers, including private equity-backed physician groups, over how to calculate what insurers should pay providers.

Bates is the kind of person who would be helped by a federal law, because his employer “self-funds” his insurance plan — all such plans are regulated by the federal government.

In the absence of federal rules, about 21 states have taken action, although a study from policy experts at Georgetown University Health Policy Institute cites only nine as having comprehensive protections.

North Carolina, where Bates lives, has partial protections for people in state-regulated plans, according to the study. It limits, for example, the amount patients owe in out-of-network emergency cases. But the state law doesn’t cover Bates’ type of job-based insurance.

“We really need a federal solution,” said Maanasa Kona, an assistant research professor at Center on Health Insurance Reforms at Georgetown.

Joshua Bates, a technical recruiter for a staffing firm, who lives in Charlotte, North Carolina, was “balance billed” by an out-of-network hospital even though he received emergency care. North Carolina law has partial protections for out-of-network emergency cases, but the law doesn’t cover Bates’ type of job-based insurance.(Logan Cyrus for KHN)

Bates’ insurer brought in third-party Advanced Medical Pricing Solutions, which examined his bill and called the nearly $28,000 “excessive charges.” It sought in September an adjustment or an explanation of the charges.

That came not long after Bates received a “final” payment notice from a collections group connected with the hospital. A credit reporting agency “told me it would continue to impact my credit score,” said Bates.

Resolution: After KHN and NPR placed inquiries about his bill with the hospital, insurer and AMPS, Bates received a call from a top executive at the Carolinas Medical Center.

“He seemed really eager to help me out,” said Bates, “which is crazy after two years of reaching out and trying to communicate with them. They call shortly after they catch wind of the story.”

However, in an email to KHN, an Atrium Health spokesperson essentially pointed to the insurer for a solution.

“We believe it is imperative that insurance companies cover the costs for patients who are unable to choose where they are treated due to a medical emergency,” wrote Dan Fogleman. “We continue to be willing to work with this patient to pursue any additional payments that may be due to them from the insurer.” Continental Benefits CEO Betsy Knorr declined to comment: “It is a legal issue at this point and we do not want to prejudice the process.”

Bates is deflated.

“The hospital is trying to put all the burden on the insurance, and the insurance is trying to put the burden on them. I’m back to square one, essentially.”

The Takeaway: Insurance plans’ yearly out-of-pocket maximums apply only if you stay in-network. So, if possible, check ahead of time to see if your hospital is in-network — and the network status of anyone who might be involved with your care.

Sometimes that isn’t possible, as in Bates’ case. What then?

If you get a balance bill after your insurer has paid the provider, check state laws and with your state’s insurance regulators to see what protections you may have, said Kona, particularly if your bill resulted from an emergency room visit.

Ask your insurer or employer to pay the bill or to negotiate a discount with the provider, said Mark Hall, a law professor at Wake Forest University who studies contract law and medical billing issues.

Check online claims data websites, such as Healthcare Bluebook and Fair Health, to research what insurers pay for similar care in your area. Use that price range in negotiations about what you may owe.

Even if your employer plan is exempt from state laws limiting patient responsibility for out-of-network emergency care, ask the provider to honor that benefit. They don’t have to agree, but it can be worth a shot.

Hall also said patients may be able to hire a lawyer and go to court challenging whether the amount being charged is reasonable, although that could be costly and success is not guaranteed.

NPR produced and edited the audio report by NPR’s Selena Simmons-Duffin.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

from Health Industry – Kaiser Health News

When Aid-In-Dying Is Legal, But The Medicine Is Out Of Reach

Last summer, Neil Mahoney was diagnosed with stage 4 cancer. Mahoney had to spend his last days fighting to find doctors willing to help him end his life.(Heidi de Marco/KHN)

GOLDEN, Colo. ― The call came the last week of September, when Neil Mahoney could still stagger from his bed to the porch of his mobile home to let out his boisterous yellow Lab, Ryder.

Rodney Diffendaffer, a clinical pharmacist in Longmont, 45 miles away, had left a message.

Your prescription is ready, it said.

Mahoney, a once-rugged outdoorsman now reduced to bones, his belly swollen with incurable cancer, sighed with relief. After months of obstacles, the frail 64-year-old finally had access to lethal drugs under Colorado’s 2016 End of Life Options Act, one of a growing number of U.S. state laws that allow terminally ill patients to obtain medications to end their lives.

Even as an increasing number of U.S. states have legalized aid-in-dying laws, exercising that option is challenging for patients in a country where most large hospital systems have deep religious ties and the religious right is powerful. One in 6 hospital patients is now cared for at a Catholic hospital, according to the Catholic Health Association. Aid-in-dying is a legal right, but desperate patients are often left feeling they are doing something terribly, morally wrong.

Centura Health Corp., the Christian-run hospital where Mahoney sought treatment for his cancer, regards the practice as “intrinsically evil,” citing the ﬁrm’s governing rules, the Ethical and Religious Directives for Catholic Health Care Services. The hospital has barred its doctors from following the state law. In August, it fired his physician, Dr. Barbara Morris, for consulting with Mahoney with the aim of carrying out his wishes.

As his condition deteriorated over the summer, Mahoney left the lawsuit, with Morris still unable to assist him. She sued the hospital for wrongful dismissal; the case is pending. In December, Centura officials filed a countersuit that says the hospital’s actions are protected by the U.S. and state constitutions’ freedom of religion guarantees.

Mahoney had access to lethal drugs under Colorado’s 2016 End of Life Options Act, a law that allows terminally ill patients to obtain medications to end their lives. He was the patient at the center of a legal battle over whether a Christian-run hospital system could bar its doctors from following the law.(Heidi de Marco/KHN)

In opposing the practice, the country’s religious institutions have received support from the Trump administration, which has consistently given providers wide latitude to refuse to participate in medical interventions they object to on religious grounds, though that previously applied primarily to abortion and contraception.

That leaves dying patients like Mahoney feeling abandoned during the most vulnerable time of their lives. When Centura fired Morris for encouraging “a morally unacceptable option,” Mahoney lost both his doctor and the confidence that he would be able to end his life when the suffering became too great.

So the brief message on his phone meant an important victory.

“This way I can say, ‘Yes, I can go,’” he said last summer. “I can call them up with a couple days’ notice and do it.”

Legal But Not Accessible

Oregon was out front in permitting aid-in-dying, approving it more than two decades ago. In recent years, eight other states and the District of Columbia have allowed the practice. It’s being considered in more than a dozen others.

Even when the practice is legal, it often isn’t accessible. Some doctors are barred from participating by their employers. Others refuse to do so. In some cases, the drugs themselves may be too expensive. A dose of Seconal, which was once the most commonly prescribed drug for the practice, can run more than $3,000. The government and some private insurers won’t cover it.

One of nine siblings in a close Catholic family, Mahoney seemed an unlikely candidate to test the Colorado law.

Left: Neil Mahoney (wearing a tie in the front row) in a 1962 family portrait in Denver; Right: Mahoney in Boulder, Colorado, in April 2013(Photos courtesy of Patrick Mahoney)

Weathered and rangy, with a reddish crew cut and broad hands, he’d never had a major illness or injury despite years of physical labor. For the past five years, he managed planting crews at Welby Gardens, a wholesale nursery near Denver.

“The dahlias have always been one of my favorites,” Mahoney said. “Just because of the flowers, the way those millions of petals can open up. That just still baffles me.”

He lived with Ryder, his 6-year-old golden Lab, and Lakewood, a sleek calico cat.

Mahoney was never comfortable around doctors, said his youngest brother, Patrick Mahoney, 60, who supported his older brother’s efforts to obtain help in planning his death.

“Neil had a long belief that health systems, including physicians, capitalize on those that are ill,” Patrick Mahoney said.

Mahoney, who worked at a local landscape company, said he’d never had a major illness or injury despite decades of physical labor.(Heidi de Marco/KHN)

Mahoney lived alone with his dog, Ryder, and cat, Lakewood. (Heidi de Marco/KHN)

Neil Mahoney started feeling sick last January, then worse in April and May. By mid-June, he couldn’t ignore a bout of stomach cramps, nausea and vomiting that sent him to urgent care.

Doctors ordered a CT scan, which showed multiple masses on his liver and likely in his lymph nodes, plus tumors at the junction of his stomach and esophagus. In July, tests at a local cancer center confirmed the bad news: stage 4 adenocarcinoma, a cancer that forms in the body’s glands.

There’s no cure, the doctor said. Without treatment, Mahoney could expect to live four more months. With chemotherapy, he might make it a little more than a year.

Neil Mahoney immediately asked about medical aid-in-dying. He was among 65% of Colorado voters who supported the law in 2016, and now he expected to use it. The medical oncologist turned him down flat.

Neil Mahoney recalled: “I feel like I got slapped in the face.”

Mahoney struggled to move around despite the use of his cane. Mahoney eventually lost more than 50 pounds from his 185-pound frame.(Heidi de Marco/KHN)

‘The Healing Ministry’

Mahoney’s primary care doctor had no qualms about participating. At 65, with 40 years of experience, Morris said that, in her view, medical aid-in-dying should be part of a continuum of care for dying patients.

“We cannot know when a person has reached their limit of suffering,” she said. “Only that person knows.”

Dr. Barbara Morris was fired by Centura Health Corp. in August 2019 for wanting to help her patient, Neil Mahoney, under the guidelines of Colorado’s End of Life Options Act.(Heidi de Marco/KHN)

But Centura, jointly run by Catholic and Seventh-day Adventist churches, describes its work as “the healing ministry of Christ.” When it became aware of the plans in the works, Centura fired Morris, contending that Morris had violated an employment contract requiring her to abide by its faith-based rules.

Morris immediately lost her malpractice insurance and access to a medical office, leaving her unable to prescribe drugs or provide care for Mahoney ― and 400 geriatric patients.

The lawsuit she and Mahoney filed in August alleged that Centura’s faith-based policy violates both the End of Life Options Act and Colorado laws barring health systems from interfering with medical judgment. It sought to clarify whether Centura could prevent Morris from helping Mahoney as long as he wasn’t on the health system premises.

“We believe it is a morally unacceptable act, regardless of how you couch it, and we are not going to participate in it,” Centura chief executive Peter Banko told Kaiser Health News.

In December, Centura officials hired Nussbaum Speir Gleason, a Colorado law firm that specializes in religious freedom cases. In its counterclaim, Centura officials are asking a judge to declare that a health care organization cannot be forced to allow its employees to support or carry out provisions of Colorado’s End of Life Options Act.

Mahoney didn’t have the time to let the legal battle play out in the courts. By July, he’d lost 30 pounds from his 185-pound frame. He grew weaker, wrenched with pain from tumors at the junction of his stomach and esophagus.

The Mahoney children had watched their mother, Charlotte Mahoney, endure a slow decline two weeks before her death in 2007 at age 85.

“I did not want to face an agonizing death without any means to help control when and where I will die,” Neil Mahoney told lawyers.

With his own doctor’s hands tied, a desperate Mahoney resorted to a backdoor route to exercise his legal right.

Mahoney was never comfortable around doctors and typically handled health issues on his own. In the weeks preceding his death, he had to take multiple medications to ease nearly constant pain.(Heidi de Marco/KHN)

Rodney Diffendaffer, a pharmacist who runs a network that quietly connects terminally ill patients in Colorado with doctors willing to follow the law, reached out after reading about Mahoney’s dilemma.

“It’s his choice to have that drug,” said Diffendaffer, 51, who works at the independently owned Flatirons Family Pharmacy in Longmont. “No one else should even have a say.”

In the past two years, Diffendaffer and his fledgling group, Dying With Dignity of the Rockies, have helped more than 50 terminally ill Coloradans obtain medications to end their lives.

“I have seen the pure torture that people went through,” said Diffendaffer, who grew up on a farm and says dying animals are treated more humanely.

Instead of planning for retirement, I’m planning for death.

Neil Mahoney

Although nearly 4,000 people in the United States have used a medical aid-in-dying law, under-the-radar groups like Diffendaffer’s have emerged to match patients with doctors willing to help — but not willing to be included on a public list.

“They don’t want to be labeled ‘Dr. Death,’” said Lynne Calkins, a board member for End of Life Choices California, a volunteer group formed in that state last spring.

The problem grows not just from powerful religious medical centers, but also the loud voice of the religious right in national politics as well as a genuine discomfort among some physicians who are loath to use their skills to end lives rather than save them.

Dr. Ira Byock, founder and chief medical officer at the Institute for Human Caring at Providence St. Joseph Health in Gardena, Calif., has long opposed the practice he calls “hastened death.” He said his objections are based on his understanding of his profession, not on faith.

“I can only say that from my perspective, and that of many non-Catholic practitioners, it is outside the scope of medical practice,” he said. “Ending somebody’s life intentionally is not part of medical practice. It is something else.”

In Vermont, where the practice has been legal since 2013, few doctors outside larger cities such as Burlington are trained to administer the law and few pharmacies are equipped to supply the drugs, said Betsy Walkerman, president of the group Patient Choices Vermont.

“The rest of the state is very thin on medical presence,” Walkerman said. “It’s much more difficult.”

In New Jersey, which enacted a law in August, the family of Zeporah “Zebbie” Geller contacted 40 doctors before they found two willing to help. Geller, 80, a retired teacher, had been diagnosed with terminal lung cancer and died on Sept. 30 after ingesting the prescribed medication.

Mahoney made arrangements for his beloved companion to live with his close friend after his passing. “I feel like he knows what’s happening,” said Mahoney. After his death, his cat went to live with Mahoney’s sister.(Heidi de Marco/KHN)

Neil Mahoney’s Choice

Dr. Glenda Weeman, 60, a family physician who operates an independent practice in Longmont, agreed to prescribe aid-in-dying drugs for Mahoney after two exams, which confirmed he met the law’s requirements.

Weeman had prescribed the drugs for only one patient before Mahoney under Colorado’s relatively young law.

“My role is to relieve pain and suffering. That is my job,” Weeman said. “I have to help people understand that there are choices. If you don’t know the choices of how to die, I’m going to help you figure that out.”

By late September, Mahoney had his prescription, which included two anti-nausea drugs and a cocktail of four medications that would induce death. He paid about $575 for it all, out-of-pocket.

Still, he wasn’t sure when — or if — he’d use them. About a third of people who get the drugs don’t wind up taking them, data from Oregon and Washington show.

“It’s a little spooky,” Mahoney said on Sept. 30, sitting in his small, cluttered mobile home. A green T-shirt hung from his bony shoulders; he’d lost another 20 pounds. Around his neck was a pendant that said DNR: Do not resuscitate.

Mahoney still had a list of things to do. A friend had promised to care for Ryder, the dog. The cat might do OK on her own, though his sister later offered to take her. He wanted to write a will.

“It’s quite a turnaround,” he said quietly. “Instead of planning for retirement, I’m planning for death.”

Mahoney and Ryder in late August. On Nov. 5, surrounded by family, Mahoney took his prescribed end-of-life medication. He died within an hour. The once-rugged outdoorsman, now reduced to gaunt bones and a swollen belly, was determined that he ― not the disease ― would decide when he died.(Heidi de Marco/KHN)

Over the next few weeks, Neil grew frailer day by day. Patrick Mahoney, who quit his job to help, said that he and another brother, John, took turns sleeping on their brother’s couch.

Neil Mahoney knew he had a window of time where he could take the medicine. If he waited too long, he wouldn’t be able to swallow it. Then he’d lose his chance to make the choice.

On Tuesday, Nov. 5, he decided it was time.

At 9:45 p.m., in bed, surrounded by family, Neil Mahoney took the drugs to halt anxiety and nausea. Minutes later, using a straw, he quickly drank the rest of the medications, dry powders mixed with raspberry-flavored liquid. Then they waited.

“It was perhaps the hardest hour of our lives,” Patrick Mahoney said.

About 10:45, Patrick “felt for his pulse. I put my hand on his chest to check his respiration rate, and then I said, ‘He’s gone.’”

Reached by email, Barbara Morris was somber about the death of a patient whom the religious teachings of her former employer had prevented her from helping. She has found another place to practice, starting in the new year.

“It was great honor to know Neil both as his doctor and his friend,” she wrote. “Out of respect for his memory, we will continue to advocate for care focused on patient values and wishes.”

from Health Industry – Kaiser Health News

Related Posts:

Related Posts:

Related Posts:

Related Posts:

Related Posts:

Related Posts:

Related Posts: