The primary diagnosis of opioid dependency kicks off a number of medical services, including office visits, lab tests and other related treatments. The number of such services rendered to patients with a dependency diagnosis went from about 217,000 in 2007 to about 7 million in 2014.
This article first appeared August 1, 2016 on the Kaiser Health News website.
In one of the first looks at privately insured patients with opioid problems, researchers paint a grim picture: Medical services for people with opioid dependence diagnoses skyrocketed more than 3,000 percent between 2007 and 2014.
The study considers a huge cohort of people who have either job-based insurance or buy coverage on their own. Its findings illustratethat the opioid problem is "in the general mainstream," said Robin Gelburd, president of Fair Health, a nonprofit databank corporation focused on health care cost transparency and insurance information. "Is the health system preparing for this tsunami of services?" she said.
The researchers used de-identified claims data from insurers representing 150 million patients, looking for diagnosis codes related to opioid dependency and abuse, adverse effects of heroin use, and problems caused by the misuse or abuse of other types of opiates. While heroin is a street drug, other opiates are often prescription medications.
They found that much of the increase in opioid dependence occurred since 2011, a period marked by increased attention to the problem and a growing drumbeat by advocates calling on doctors to reduce the number of opioid prescriptions.
Younger patients — 19 to 35 — were most likely to be diagnosed as opioid dependent compared to other age groups. Dependence is defined by symptoms such as increased tolerance, withdrawal or unsuccessful attempts to quit.
Those younger patients were also more likely than older ones to overdose on heroin. The reverse was true, however, for overdoses related to other types of opioids. People in their mid-40s to mid-50s were more likely to suffer this consequence.
The primary diagnosis of opioid dependency kicks off a number of medical services, including office visits, lab tests and other related treatments. The report found that the number of such services rendered to patients with a dependency diagnosis went from about 217,000 in 2007 to about 7 million in 2014.
The scope of the increase found by Fair Health stunned even those already familiar with the problem.
"A 3,000 percent increase is enormous," said Andrew Kolodny, senior scientist at the Heller School for Social Policy and Management at Brandeis University. He did not work on the study.
Such a sharp rise over a short period of time is a classic definition of an epidemic, he said, and one that points out that much more effort is needed to prevent future cases and treat people who already have addiction problems.
Still, experts caution that research based solely on claims data, while common, is a good way to track the use of health services, but may not paint a complete picture. The accuracy of claims codes — which are used for billing — may be poor, for example. In this case, increased attention to the opioid problem may have also resulted in an increased use of the code. Some research studies also pair claims data with medical record information — the doctors' notes — to provide additional information. This study did not.
Other findings from the report include:
Across all age groups, men were more likely than women to be diagnosed with dependency. That gap narrowed among patients in their 40s and 50s, with women representing 45 percent of those diagnosed.
Women were more likely than men to experience an overdose.
The ratio of opioid dependence to other substance abuse problems varied by state. Rhode Island had the highest while Maine and Montana the lowest.
Kolodny is among those who say the increase in addiction is directly tied to the run-up in opioids prescribed by doctors in the past decade. Some of those who develop dependency problems are the patients who get the prescriptions. But many also obtain the drugs illicitly, from a friend, family member or dealer.
Younger people, said Kolodny, may start with prescription medications, but then turn to street drugs like heroin because they have "a harder time maintaining their opioid supply by visiting doctors."
Older patients, he said, are less likely to turn to street drugs because they have an easier time getting refills from their doctors.
Data from IMS Health, which tracks prescription drug sales, shows the number of prescriptions for opioid-based drugs have ticked down, falling 11.8 percent from 2012 to 2015. That decline, however, followed a huge increase: The number of opioid prescriptions more than doubled between 2000 and 2012, when more than 282 million prescriptions were written.
"In the past couple of years, we've seen policymakers realize that overprescribing is fueling the crisis," said Kolodny. "Before that, the focus of federal policymakers was almost exclusively on trying to stop non-medical use" of opioids.
In 2014, federal health officials reclassified certain drugs containing the opioid hydrocodone, including Vicodin, making refills harder to get.
Supporters say the legislation will help but criticized lawmakers for not including more funding.
Other efforts to combat the rise in opioid abuse have involved states.
Most have begun prescription monitoring programs, which aim to identify and track people who are "doctor shopping," in order to get multiple prescriptions for narcotics. Pharmacists or physicians can check those databases to see if a particular patient already has a prescription for narcotics before dispensing another.
In 2001, only 16 states had laws allowing such programs. By 2012, 41 states were operating one, according to a reportby the Pew Charitable Trusts.
"There's some evidence that those are helpful in reducing prescribing," said Allan Coukell, senior director for health programs at Pew.
He added that more effort is needed to provide treatment options for people seeking help.
"The reality is, even in states that have done that, demand is far in excess of what they can provide."
The new data from Fair Health, he said, shows the scope of the problem.
"What this tells you is this is not limited to a problem of the poor and unemployed," he said. "This is a problem that is cutting right across society."
The University of California regents have agreed to pay nearly $8.5 million to settle two lawsuits alleging a well-known UCLA spine surgeon failed to disclose his conflicts of interest with a leading device maker before using the company's products in harmful surgeries.
The settlements were approved last month in separate Los Angeles County Superior Court cases that focused on the financial ties among the surgeon, Dr. Jeffrey Wang, UCLA and Medtronic, the world's largest medical-device company.
The regents agreed to pay $4.2 million to Jerome Lew, a 52-year-old screenwriter in Orange County, and $4.25 million to Ralph Weiss, a 61-year-old attorney in Calabasas. The two patients said their surgeries led to complications, recurring pain and the need for additional operations.
In both cases, Wang implanted Medtronic's controversial bone-growth product in an "off-label" way not specifically approved by the Food and Drug Administration, according to the lawsuits. Doctors are legally allowed to use medications and devices in an unapproved manner, if they think it's the best way to treat patients.
But the plaintiffs argued that Wang deceived them by failing to obtain their consent for the "off-label" use and by not disclosing the tens of thousands of dollars in financial support he had received from Medtronic over the years. And Lew alleged that Medtronic promoted off-label use of its products to Wang and UCLA, which generally is not allowed under federal law.
"I chose UCLA and Dr. Wang for my spine surgery based upon their sterling reputations," Weiss said. "I was astonished and offended when I found out about the conflicts that were never disclosed to me."
The UC system and Wang, now co-director of the USC Spine Center, denied any wrongdoing in court documents. Wang, through his attorney, declined to comment.
In a statement, the UCLA Health System said the regents agreed to settle the two cases "so that UCLA Health and the David Geffen School of Medicine at UCLA could move forward with their ongoing commitment to excellence in patient care, research, education and community service."
Medtronic denied any wrongdoing and said it did not promote off-label use of its products. The company was dropped as a defendant in the Weiss case and it agreed to a separate, confidential settlement with Lew.
The device maker said there was no conflict of interest in the Lew case. "Dr. Wang was not paid for using the Medtronic products used in the surgery and as of the time of the surgery involving Mr. Lew, he was not a consultant for Medtronic," the company said in a statement.
UC and Medtronic had tried to keep emails and other information unearthed by the lawsuits under seal. But a Superior Court judge denied that request, saying they were public records involving a state institution.
The cases shine a light on the controversial role industry money continues to play in research and patient care at academic medical centers. Nationwide, doctors and universities have come under increasing scrutiny over the money they receive from drug and device makers. Although the rules for accepting money vary widely among institutions, Congress in recent years has required all drug and device companies to publicly disclose their payments.
The total amount companies paid to doctors and teaching hospitals in 2015, according to the new federal data, was $6.5 billion.
In fact, Wang played a role in spurring Congress to impose those rules in 2010. A 2009 U.S. Senate investigation into industry payments accepted by dozens of doctors across the country found that Wang failed to report nearly $460,000 he received from Medtronic and other companies on annual disclosure forms required at UCLA.
From 2004 to 2013, Medtronic paid Wang more than $275,000 for product royalties, consulting work and lectures, according to the Senate investigation and UCLA records.
During 2014 and 2015, while at USC, Wang received no money from Medtronic but did collect $1.4 million from other device companies, according to the federal data.
Wang, who joined UCLA in 1997 and was named executive director of its spine center in 2003, is considered one of the top specialists in his field. A frequent speaker at international medical conferences, he serves as a board member of the North American Spine Society and offers second opinions to injured players in the National Hockey League.
In the past, he has defended industry collaboration as a way to foster medical advances.
"If surgeons are discouraged from working with private companies to develop surgical products, the patients we are trying to protect will lose the benefit of improved treatment options," Wang wrote in a 2008 letter to UCLA officials who were responding to the Senate inquiry.
Dr. Jeffrey Wang, former UCLA spine surgeon now at USC. (North American Spine Society, courtesy of the Los Angeles Times)
However, in the two recent lawsuits, the patients alleged that Wang and Medtronic crossed the line in their effort to experiment with Infuse, a genetically engineered human protein that helps grow artificial bone.
The FDA cleared Infuse for use in the lower back in 2002, and more than 1 million patients have had it implanted. However, many Infuse patients have reported problems and hundreds of people have filed lawsuits as a result. The rate of complications prompted government investigations, and researchers began to question some of the data doctors published to support the product's widespread use.
In Lew's case, documents submitted as evidence suggested that Medtronic employees promoted spinal implants for uses that were not cleared at the time by the FDA.
One was a May 2007 email to Wang from Paul McClintock, a district sales manager at Medtronic. McClintock provided the surgeon prices and information about new, smaller doses of Infuse that had received FDA approval for use in oral and maxillofacial procedures — but not the spine.
Nearly a year later, in an April 2008 email to a UCLA official filed in court, McClintock noted that the Infuse cage known as Anatomic Peek was approved for procedures in the upper, lower and middle back but "many surgeons choose to use it in the cervical spine," or neck area.
At the time, Medtronic had a clear warning against that on the cage's label. And in July 2008, the FDA issued an alert about the dangers of implanting Infuse in the neck due to the risk of excessive bone growth.
Even so, in 2009, Wang implanted Medtronic's Anatomic Peek cage into Lew's neck along with Infuse after he was injured in a car accident, according to court documents. A Medtronic salesman joined Wang in the operating room at UCLA's Santa Monica hospital, records show.
Lew said in his lawsuit that he continued to suffer hand and neck pain and developed new symptoms, such as difficulty swallowing. It took another three years, in 2012, before Lew found out what devices Wang had implanted and discovered that his surgeon was being paid by Medtronic, according to his suit.
Robert Vaage, a San Diego attorney representing both plaintiffs, said UCLA was aware of Wang's conflict of interest with Medtronic but did nothing to address it because he "was bringing a lot of business into the university from the number of procedures to the amount of clinical studies he was doing."
For his part, Weiss said in his lawsuit that he wasn't informed that Infuse would be used in an unapproved way during one of Wang's surgeries at UCLA's Santa Monica hospital in 2010. During a follow-up surgery by another doctor at UCLA, the bone-growth product was put in an infected area and without any cage, which are both potentially harmful uses.
He continued to suffer pain and faced more corrective surgery, according to his complaint.
Lawyers for the UC regents said in court filings that both Lew and Weiss signed consent forms explaining their surgeries and the risks involved. The UCLA Health system also said in a statement that it "takes seriously its duty to manage relationships with industry in a responsible manner."
The two settlements follow a $10 million payout in 2014 by the university system to one of Wang's former bosses, Dr. Robert Pedowitz, former chairman of UCLA's orthopedic surgery department.
Before that whistleblower retaliation case was settled, Pedowitz testified that he had told university administrators that Wang and some of his fellow surgeons were putting patient care at risk by accepting so much corporate money. He alleged that UCLA looked the other way because it stood to benefit financially from the doctors' activities.
UCLA denied Pedowitz's allegations, and officials said they found no wrongdoing by faculty and no evidence that patient care was jeopardized. But the UC system paid him anyway, saying it wanted to avoid the "substantial expense and inconvenience" of further litigation.
One of the key indicators of the quality of a hospital's care is how frequently its patients are readmitted within a month after being discharged. A study this month examined readmission rates for pediatric patients and found that nearly 30 percent of them may have been preventable.
The study, published online by the journal Pediatrics, reviewed the medical records and conducted interviews with clinicians and parents of 305 children who were readmitted within 30 days to Boston Children's Hospital between December 2012 and February 2013. It excluded planned readmissions such as those for chemotherapy.
Overall, 6.5 percent of patients were readmitted during the study period.
The study found that 29.5 percent of the pediatric readmissions were potentially preventable. In more than three-quarters of those cases, researchers determined that hospital-related factors played a role. A significantly smaller proportion were related to the patient (39.2 percent), often because of issues that arose after discharge, or the primary care physician (14.5 percent). (Multiple factors played a role in some patients' readmissions, so the total exceeds 100 percent.)
The most common hospital-related reasons had to do with how patients are assessed, postoperative complications or hospital-acquired conditions.
"One of the things we need to improve upon is engaging families at the time of discharge around how we're feeling and how they're feeling about the status of the child at that point in time," said Dr. Sara Toomey, the study's lead author, who is the medical director of patient experience at Boston Children's Hospital and an assistant professor at Harvard Medical School.
Sometimes clinicians and family members may be overly optimistic about a child's readiness to go home, Toomey said.
When policymakers discuss the importance of reducing hospital readmissions, they typically focus on older patients, who make up a much larger proportion of hospital patients than do pediatric patients. The Medicare program, which provides health benefits for Americans age 65 and older,imposes financial penalties on hospitals whose readmission rates are too high.
The federal Centers for Medicare & Medicaid Services doesn't penalize hospitals for pediatric readmissions, but a growing number of states are doing so, the study found.
Readmissions will never be completely avoidable, Toomey said. Still, "when you have a child coming home from the hospital, there are things you need to know, and the more active people are in creating a plan and making sure they understand it, the better that will help their children."
A U.S. lawmaker is renewing his push for Congress to toughen requirements on medical-device warnings, calling Olympus Corp.'s 2013 decision against issuing a broad alert to U.S. hospitals about scope-related superbug outbreaks "despicable."
Rep. Ted Lieu (D-Torrance) saidinternal Olympus emails about that decision, detailed for the first time in a Los Angeles Times/Kaiser Health News article on Sunday, were "incredibly disturbing" and the company officials involved should face questions at a Congressional hearing. At least 35 patients in American hospitals have died since 2013 after developing infections tied to tainted duodenoscopes.
In company emails from February 2013, a senior executive at Olympus' Tokyo headquarters told its U.S. managers not to issue a broad warning to American hospitals despite reports of scope-related infections in Dutch, French and U.S. hospitals. The executive added that they could respond to questions from a customer.
The company had issued an alert to European customers a month earlier but chose not to do so in the U.S. until last year.
"Olympus' actions in this case were despicable," Lieu said. "They knowingly failed to warn hospitals and patients of their defective scopes."
After the company opted against a U.S. alert in early 2013, Virginia Mason Medical Center in Seattle discovered an outbreak involving contaminated gastrointestinal scopes manufactured by Olympus. The hospital said 39 patients eventually became infected and at least 18 of them died. The hospital acknowledged that the patients who died had other underlying illnesses.
Hospital patients in Los Angeles, Charlotte, Denver and other cities were also sickened by antibiotic-resistant bacteria, known as superbugs, after being treated with Olympus duodenoscopes.
"We are very troubled by the now very clear facts that Olympus in Japan knew of the infection problems with their duodenoscopes long before the outbreaks we saw in America, and chose not to warn physicians," said Dr. Andrew Ross, section chief of gastroenterology at Virginia Mason Medical Center.
"If they had done so, physicians could then determine what is best in how to treat and advise their patients," Ross said.
Virginia Mason is suing Olympus for fraud and misrepresentation in Washington state court. In court documents, Olympus denies the allegations and contends that the hospital failed to follow the instructions for cleaning the scopes.
Lieu filed a bill in April, known as the Device Act, which would make it mandatory for device makers to share safety alerts more widely, including those issued abroad.
Under the proposed legislation, companies would have to notify the Food and Drug Administration when they issue safety warnings in other countries related to the design and cleaning of their devices. The legislation also would require manufacturers to notify the FDA when they change the design or cleaning instructions of their devices, regardless of whether those changes warrant new government approval.
Lieu said he will press lawmakers to take up the bill in September when Congress reconvenes.
"This is why Congress needs to act and pass legislation to make sure this doesn't happen again as well as hold a hearing," Lieu said. "I believe it is now time for the decision-makers at Olympus to be held accountable and for Congress to hear what they have to say."
Olympus didn't have an immediate comment when reached Tuesday. The company has said previously that patient safety is a top priority and it is "working with the proper authorities and our stakeholders to understand and address the potential root causes" of contamination and infection tied to duodenoscopes.
Federal prosecutors are investigating Olympus and two other smaller scope manufacturers over their role in the superbug outbreaks at U.S. hospitals. In California, UCLA's Ronald Reagan Medical Center, Cedars-Sinai Medical Center and Pasadena's Huntington Hospital all have reported infections linked to Olympus scopes.
At those three hospitals, 28 infections have been reported and 14 of the patients later died. Some of the patients who died were seriously ill and the role of the infection in their deaths is unclear.
Lieu has introduced an additional bill, a companion to legislation that Sen. Patty Murray (D-Wash.) has filed, requiring that the cleaning instructions for medical devices be scientifically validated to ensure they work.
The duodenoscopes are long, flexible devices that are put down a patient's throat during a procedure known as ERCP, or endoscopic retrograde cholangiopancreatography. Nearly 700,000 such procedures are performed annually in the U.S.
Olympus holds an 85 percent share of the U.S. market for these devices and other specialty endoscopes. Pentax and Fujifilm are two other manufacturers.
Overall, as many as 350 patients at 41 medical centers worldwide were infected or exposed to contaminated scopes made by the three manufacturers from January 2010 to October 2015, according to the FDA.
In a preemptive effort to rebut criticisms, CMS noted its analysis shows "hospitals of all types are capable of performing well on star ratings and also have opportunities for improvement." The ratings will be released "shortly."
Despite objections from Congress and the hospital industry, the Obama administration said it will soon publish star ratings summing up the quality of 3,662 hospitals. Nearly half will be rated as average, and hospitals that serve the poor will not score as well overall as will other hospitals, according to government figures released Thursday.
The government says the ratings, which will award between one and five stars to each hospital, will be more useful to consumers than its current mishmash of more than 100 individual metrics, many of which deal with technical matters. The hospital industry, however, fears the ratings will be misleading and oversimplify the many types of care at the institutions.
The Centers for Medicare & Medicaid Services said it would release the ratings "shortly." In a preemptive effort to rebut criticisms, it noted its analysis showed "hospitals of all types are capable of performing well on star ratings and also have opportunities for improvement."
The stars are based on 64 individual measures of hospitals that are already public on the government's Hospital Compare website. Those include mortality rates, the number of readmissions, patient opinions, infection rates and frequency of medical scans like MRIs.
Medicare said that based on its current data, 102 hospitals would receive the best rating of five stars, 934 would get four stars, 1,770 would receive three stars, 723 would be awarded two-stars and 133 would get the lowest rating of one star. Another 937 hospitals would not be rated because the government did not have enough data to properly evaluate them.
"The star ratings provide people a broader picture," Medicare officials said in a statement. "CMS used a similar approach to simplify complex quality information on other healthcare quality reporting websites, such as Nursing Home Compare, Home Health Compare, Dialysis Facility Compare and Medicare Plan Finder."
The ratings factor in the mix of patients at a hospital, so those with a high proportion of sicker patients are not supposed to rate lower than those that handle more run-of-the-mill cases. The analysis showed hospitals of different sizes also did about the same, and critical access hospitals — small, mostly rural facilities — performed slightly better overall.
Medicare did not consider the relative wealth of patients. Its analysis showed hospitals serving large swaths of low-income people tended to receive lower star ratings. An analysis by Kaiser Health News of the hospitals that CMS rates shows 22 percent of safety-net hospitals were rated above average — four or five stars — compared with 30 percent of hospitals overall. Twenty-nine percent of safety-net hospitals were rated as below average, with just one or two stars, while 22 percent of other hospitals received those lower ratings.
Teaching hospitals also received lower scores on average. A third were rated with only one or two stars, while only a fifth of other hospitals received fewer than three stars, according to the KHN analysis. The teaching hospitals include large academic medical centers that often top the lists of best hospitals put together by groups likeHealthgrades and U.S. News & World Report.
Dr. Janis Orlowski, an executive at the Association of American Medical Colleges, said the fact that so many prestigious hospitals fare poorly in the star ratings is a signal that Medicare's methods are flawed.
"These are hospitals that everyone in the know tries to get into, so we need to be careful about the consequences, that this star rating can be misleading," Orlowski said. "Putting the information out at this time is not in the patient's interest."
The American Hospital Association also expressed continued concerns.
The government originally planned to release the star ratings in April but postponed it after a majority of members of Congress echoed the industry's concerns. Debra Ness, the president of the National Partnership for Women & Families, a nonprofit in Washington, urged Medicare to post the ratings before the end of the month.
"We believe great thought and care went into development of the Hospital Star Ratings Program," she wrote on the group's website. "If needed, the program can be adjusted over time. But now is the time to move forward and give consumers a tool that will allow them to assess which hospitals do the best job of providing the care they need."
Visits to private dental offices fell by 9% from 2006 to 2012, but adults have been seeking more care at health centers and emergency departments, where dental appointments have increased 74% and 20% respectively.
This article first appeared July 20, 2016 on the Kaiser Health News website.
Shane Peebles has a ticking time bomb in his mouth.
He has multiple cavities, including one that has been infected and formed a pocket of painful pus. He also has a disease that causes swollen, bleeding gums, making it painful to chew.
He finally visited a health clinic two months ago when the pain became unbearable — and learned that it would cost $300 for surgery to treat the infection.
But Peebles is homeless and he cannot afford that. He got a free checkup, cleanings and antibiotics to reduce the swelling in his face and jaw from the Venice Family Clinic, a health center in Los Angeles that serves more than 22,000 low-income, uninsured and homeless individuals. Last year, the clinic had more than 5,000 dental visits, overseen by two full-time dentists and one volunteer. They offer procedures like tooth examinations, cleanings, fillings, extractions and basic gum treatment — but not the surgery that Peebles needs.
Last month, the Department of Health & Human Services awarded $156 million to 420 health centers around the country — including the Venice Family Clinic — to help address an overwhelming demand for affordable dental coverage. According to the department, 108 million Americans have no dental insurance and access to care can be difficult even for those who are covered.
"It's the first time the grants are targeting oral health services," said Martin Kramer, head of the communications office at the Health Resources and Services Administration, a part of HHS.
Dental care has become a luxury item for many middle- and low-income families, especially for adults. Cost is the primary barrier. Twenty percent of low-income adults say their mouth and teeth are in poor condition, according to the American Dental Association.
While dental benefits are guaranteed for lower income children under Medicaid and CHIP, dental coverage for adults in Medicaid is not compulsory and varies from state to state.
But even if Medicaid offers coverage, many patients have trouble getting appointments because often dentists say reimbursement rates are too low.
For these people, health centers are the go-to for dental care. Yet health centers, which generally rely heavily on federal funding, say they have trouble supporting the level of dental services needed by patients.
The Lingering Toothache For Adults
Marko Vujicic, chief economist of the Health Policy Institute in the American Dental Association, found that as the number of children getting dental carehas been rising, adults have been increasingly staying away from their dentists.
Dr. Nicole Thompson-Marvel, the dental director at Venice Family Clinic, sees a patient. (Courtesy of Venice Family Clinic)
Visits to private dental offices fell by 9 percent from 2006 to 2012 – but adults have been seeking more care at health centers and emergency departments, where dental appointments have increased 74 percent and 20 respectively.
"What's driving that? Coverage is a huge issue," he said. "We see adults increasingly reporting financial barriers to dental care because we haven't had any sort of coverage expansion."
A study by the Kaiser Family Foundation found that in 2013, 49 percent of adults with private coverage had a dental visit in the last year, while only 20 percent of adults insured by Medicaid or CHIP and 17 percent of uninsured adults saw a dentist. (Kaiser Health News is an editorially independent project of the Kaiser Family Foundation.)
Even for those with dental insurance, Vujicic said coverage and cost is still a problem.
"Dental insurance is not really health insurance. Health insurance is to help you smooth out the risk, it protects people from catastrophic costs," he said, referring to the maximum out-of-pocket cost health insurance plans offer. "Dental insurance is structured completely the opposite. There is a cap on how much the plan will pay and beyond that, it's fully out of pocket."
In California, A "Broken" Dental Care System
Peebles has dental coverage under California's state dental insurance, Denti-Cal. But Denti-Cal has a history of funding problems, and it has limits on care.
In 2009 the state legislature removed adult dental services from Denti-Cal coverage because of budget constraints. The health department was sued over the cuts, and the coverage was reinstated in 2010.
A state auditor reportin 2014 condemned Denti-Cal for limiting access, and last April the independent Little Hoover Commission found that fewer than half of those eligible for dental benefits use the services because of the paucity of dentists who will accept Denti-Cal patients. At least five counties have no Denti-Cal providers, and many counties have no dental providers who would accept new Denti-Cal patients.
The reason, according to the commission, was that California has one of the country's lowest reimbursement rates for dentists.
In 2013, only 29 percent of California dentists participated in Denti-Cal compared to the national average of 42 percent. Nonprofit dental providers testified at the commission's hearings that they are overwhelmed with Denti-Cal patients, putting some on three-month waitlists.
"It's getting harder to find dental care," said Maria Chandler, a pediatrician and the chief medical officer at the Children's Clinic: "Serving Children and Their Families" in Long Beach, Calif. "Patients line out every day to get care, it's so highly overwhelmed that most of our adults cannot get care."
Her clinic is one of the health centers awarded dental funding last month in the federal grant. The clinic plans to hire dentists and assistants with the $349,999 it received.
The clinic never had in-house dentists in the past and relied on pediatricians or medical assistants. Patients receive basic dental services, such as screening and cleaning, while more complex procedures are referred to dentists elsewhere.
"It's hard to provide dental care without some sort of grant support because the revenue from the care will not cover the cost," she said. "And I think this grant and the services that we are going to provide is still only a fraction of what is needed."
Peebles might agree to that. He just found a new job as a bouncer at a local bar, and he is somewhat resigned to the fact that part of his paycheck will be spent on the oral surgery.
His caseworker from the clinic is trying to help him find an affordable option for treatment.
"The toothache is probably my biggest issue right now," he says. "I'm going to have to get it done as soon as possible. I'm tired of going through the pain."
Unlike freestanding EDs, microhospitals are fully licensed hospitals with inpatient beds. So far, they are being developed primarily in a few states: Texas, Colorado, Nevada, and Arizona.
This article first appeared July 18, 2016 on the Kaiser Health News website.
Eyeing fast-growing urban and suburban markets where demand for health care services is outstripping supply, some health care systems are opening tiny, full-service hospitals with comprehensive emergency services but often fewer than a dozen inpatient beds.
These "microhospitals" provide residents quicker access to emergency care, and they may also offer outpatient surgery, primary care and other services. They are generally affiliated with larger health care systems, which can use the smaller facility to expand in an area without incurring the cost of a full-scale hospital. So far, they are being developed primarily in a few states — Texas, Colorado, Nevada and Arizona.
"The big opportunity for these is for health systems that want to establish a strong foothold in a really attractive market," said Fred Bentley, a vice president at the Center for Payment & Delivery Innovation at Avalere Health. "If you're an affluent consumer and you need services, they can fill a need."
SCL Healthhas two microhospitals operating in the Denver metropolitan area and another two in the works. Microhospitals "are helping us deliver hospital services closer to home, and in a way that is more appropriately sized for the population compared to larger, more complex facilities," said spokesman Brian Newsome.
The concept is appealing, and some people suggest they should be developed in rural or medically underserved areas where the need for services is great.
Small hospitals, even tiny ones, with robust outpatient services could be a real boon for people who live far from major metro areas.
"Right now they seem to be popping up in large urban and suburban metro areas," said Priya Bathija, senior associate director for policy development at the American Hospital Association. However, "we really think they have the potential to help in vulnerable communities that have a lack of access."
Analysts liken microhospitals to standalone emergency departments, which have been cropping up in recent years in fast-growing metropolitan areas where people are often well-insured and waits at regular hospital emergency departments may be long. Both can handle many emergencies and are equipped with lab, imaging and some diagnostic capabilities.
However, patients facing serious emergencies, such as severe chest pain or major medical trauma, should call 911 and let trained medical personnel decide where best to seek treatment, said Dr. Bret Nicks, an associate professor of emergency medicine at Wake Forest Baptist Health.
The SCL Health Community Hospital-Southwest facility opened in Denver in May. The microhospital offers two operating rooms. (Courtesy of Emerus and SCL Health)
Unlike standalone EDs, microhospitals are fully licensed hospitals with inpatient beds to accommodate people admitted from the emergency room. They may have other capabilities as well, including surgical suites, a labor and delivery room, and primary care or specialist services on site or nearby.
Dignity Health, a health care system with facilities in Nevada, Arizona and California, opened its first microhospital in the Phoenix area more than a year ago and will open another one there this year, said Peggy Sanborn, vice president of strategic growth, mergers and acquisitions. It also plans to open four microhospitals in the Las Vegas area and is exploring the model for California.
One of the advantages of a microhospital is that it can help connect patients with specialty and primary care physician networks, said Sanborn. In Las Vegas, for example, the microhospital design includes a second floor with separate specialty and primary care physician offices to which patients could be referred.
The growing interest in microhospitals can be linked to the shift toward providing more care in outpatient settings, said Bathija. In addition to the emergency department, the facilities can include medical home services and other outpatient services.
Between 2010 and 2014, the annual number of inpatient hospital admissions declined by more than 2 million to 33.1 million, according to figures from the American Hospital Association. Meanwhile, the total number of outpatient hospital visits increased to 693.1 million in 2014 from 651.4 million four years earlier.
Microhospitals offer an opportunity to "really ramp up outpatient services," Bathija said.
A spending jump, along with a sharp increase in the number of patients getting the compounded drugs “may indicate an emerging fraud trend,” says a researcher involved with a report by the OIG.
This article first appeared July 17, 2016 on the Kaiser Health News website.
Government spending on "compounded" drugs that are handmade by retail pharmacists has skyrocketed, drawing the attention of federal investigators who are raising fraud and overbilling concerns.
Spending on these medications in Medicare's Part D program, for example, rose 56 percent last year, with some of the costliest products, including topical pain creams, priced at hundreds or thousands of dollars per tube. The federal workers' compensation program has also seen a recent spike in spending.
The spending jump, along with a sharp increase in the number of patients getting the compounded drugs "may indicate an emerging fraud trend," said Miriam Anderson, who helped oversee aJune report on the Medicare spending by the inspector general's office at the Department of Health and Human Services.
Some of the prescriptions may not have been medically necessary — or even dispensed at all, notes the report, which also details recent fraud cases brought by U.S. attorneys in several states.
The practice of compounding drugs, which is done by mixing drugs in pharmacies or special compounding centers by licensed pharmacists, is as old as the pharmacy profession itself. By creating specifically tailored medications, compounding is aimed at patients who can't take commercially available, FDA-approved medications.
But use among Medicare beneficiaries and federal employees in workers' compensation insurance plans has recently soared, according to Anderson's report and a separate Postal Service inspector general's study of the workers' comp program released last spring.
Similar run-ups in spending for compounded drugs were also noted by private-sector benefit managers in recent years.
In Medicare's drug program, known as Part D, the number of Medicare beneficiaries getting compounded drugs has grown 281 percent since 2006 to nearly 280,000 in 2015. Spending on such drugs in Medicare's Part D grew 625 percent between 2006 and 2015, to $509 million, according to the OIG report. That is still a tiny fraction of the program's total spending on drugs.
The fastest-growing category of compounded drugs are topical creams and gels, often used for pain. Spending on those increased 3,466 percent in the Medicare program since 2006, the report said, while the average cost per prescription hit $331, up from $40 in 2006.
A large spike in spending for compounded drugs led the U.S. Postal Service to try to hold back payments for its share of federal workers' compensation costs last year, saying the agency overseeing the program had failed to more strictly police the use of such drugs. It eventually paid.
Overall, the federal government's worker's compensation program, which includes the Postal Service, saw spending on compounded medications grow from $2.35 million in fiscal 2011 to $214 million in fiscal 2015, according to the Department of Labor, which oversees the program.
New rules from the DOL went into effect July 1, aimed at slowing the spending. Among other changes, the agency will now limit initial prescriptions to 90 days.
While legitimately prescribed compounded drugs "can dramatically improve a patients' quality of life," it is also important to have "proper controls around billing," said John Voliva, executive vice president of the International Academy of Compounding Pharmacists, last week in a written statement. The HHS inspector general's report demonstrated that such controls "are not in place," he said.
Benefits Vs. Drawbacks
The studies come amid ongoing scrutiny of the drug compounding industry, particularly following a meningitis outbreak that killed 64 Americans in 2012. Those deaths were linked to a Massachusetts pharmacy that sold tainted injectable medications.
Following that outbreak, some states tightened their oversight of such pharmacies, particularly those producing products that must be sterile.
Compounding pharmacies are generally overseen by state boards of pharmacy, and the drugs they produce are not considered FDA approved. The agency does get involved, however, when it is concerned that pharmacies might not be making medications properly or have started to mass produce treatments, rather than preparing them for individual patients.
When prescribed appropriately, compounded drugs allow patients who can't take or tolerate commercially prepared products to have special formulations mixed just for them. Patients who can't swallow pills, for example, can get liquid formulations or those allergic to certain dyes can get products made without them.
And sometimes such drugs can be more cost-effective.
When Turing Pharmaceuticals raised the price of a drug used for patients with compromised immune systems from $13.50 a pill to $750 last year, for example, one of the nation's largest pharmacy benefit managers partnered with a compounding pharmacy to produce its own version for $1 a pill, said Glen Stettin, senior vice president for clinical research of Express Scripts.
"Some compounding we should be happy for," said Stettin.
But his organization nonetheless has sharply toughened its rules about what pharmacy-made products it will cover after seeing a sharp increase in spending that started in 2012.
Nationally, since 2012, pharmacies have been required to report all the ingredients they used to make a compounded drug. The idea was to provide insurers with more information about what they were being billed for and to make sure there were no hidden ingredients.
The effect that had on drug prices is up for debate. Stettin and others say a few unscrupulous pharmacies began adding more ingredients so they could charge more.
"They are [creating] combinations of things that have never been tested together," said Stettin. "We saw a diaper cream that was billed at $1,000, where a patient could get one over the counter for $2.50."
In California, federal investigators say a marketer for one pharmacy paid doctors to write prescriptions for compounded pain creams formulated to include a "five-pack" of the most expensive ingredients. Then the pharmacy could bill California's worker's compensation program $3,000 per tube for creams it cost about $20 to make, according to afederal indictment filed in June.
In Florida, federal prosecutors also in June unsealed an indictment against a doctor who allegedly was given kickbacks — including a $72,000 BMW — for sending prescriptions to a particular pharmacy, which then billed Tricare, Medicare and other government health programs for compounded creams. Prices ranged from about $900 to $21,000 for a one-month supply, according tocourt documents.
To combat rising spending, Express Scripts in 2014 drew up a list of about 1,000 ingredients used by compounders for which it would no longer pay, saying they were high priced and weren't any safer or more effective than other treatments. Many of its clients, including the military health program Tricare, have incorporated that list into their health plans.
Since the limit, Express Scripts says it has seen its clients' spending on pharmacy-made drugs fall sharply. The list has also prompted two antitrust lawsuits filed against Express Scripts in federal court by compounding pharmacies.
Awaiting Action
What actions Medicare will take — and the effectiveness of a July 1 change in how such medications are paid for in the federal compensation program — remain unclear. The Medicare report does not make any recommendations, although investigators expect to issue a follow up report that will.
In its March report, the inspector general criticized a lack of action by the Labor Department to address the growing spending, saying that it estimated the Postal Service "has incurred over $81.8 million in excessive compound drug costs and nearly $4.1 million in excessive administrative fees" for the past two fiscal years.
Following that, Labor issued new rules it says will "contain the cost of compound drugs … but still allow for appropriate medical treatment," according to Leonard J. Howie III, director of the Office of Workers' Compensation Programs.
At Edgewood Summit retirement community in Charleston, W.Va., 93-year-old Mary Mullens is waxing eloquent about her geriatrician, Dr. Todd Goldberg.
"He's sure got a lot to do," she said, "and does it so well."
West Virginia has the third oldest population in the nation, right behind Maine and Florida. But Goldberg is one of only 36 geriatricians in the state.
"With the growing elderly population across America and West Virginia, obviously we need healthcare providers," Goldberg said.
That includes geriatricians — physicians who specialize in the treatment of adults age 65 and older — as well as nurses, physical therapists and psychologists who know how to care for this population.
"The current workforce is inadequately trained and inadequately prepared to deal with what's been called the silver tsunami — a tidal wave of elderly people — increasing in the population in West Virginia, across America and across the world really," Goldberg said.
The deficit of properly trained physicians is expected to get worse.By 2030, one in five Americans will be eligible for Medicare, the government health insurance for those 65 and older.
Goldberg also teaches at the Charleston division of West Virginia University and runs one of the state's four geriatric fellowship programs for medical residents. Geriatric fellowships are required for any physician wanting to enter the field.
For the past three years, no physicians have entered the fellowship program at WVU-Charleston. In fact, no students have enrolled in any of the four geriatric fellowship programs in West Virginia in the past three years.
"This is not just our local program, or in West Virginia," said Goldberg. "This is a national problem."
The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled. With that kind of competition, Goldberg laments, why would a resident apply to a West Virginia School, when they could get into a program like Yale or Harvard?
Adding to the problem, the average medical student graduates with $183,000 in debt, and every year of added education pushes that debt higher.
Dr. Shirley Neitch, head of the geriatrics department at Marshall University Medical School in Huntington, W.Va., says students express interest in geriatrics almost every year. But, "they fear their debt," she said, "and they think that they need to get into something without the fellowship year where they can start getting paid for their work."
This trend troubles many people, including Todd Plumley, whose mother, Gladys, has dementia and lives in West Virginia.
"It's kind of scary that [older patients] don't have the care that they really need to help them through these times, and help them prolong their life and give them a better life," Plumley said.
There are no geriatricians in the family's hometown of Hamlin, so Plumley drives his mother almost 45 minutes to another town, Huntington, to see one. He says seeing this specialist has helped stabilize his mother's symptoms.
"Right now, if we didn't have the knowledge and resource," he said, "I believe my mother would have progressed a lot further along, quicker."
Plumley is in his 50s. He worries that if he needs the care of a geriatrician as he gets older, driving even 45 minutes may not be an option.
President Barack Obama Monday called on Congress to revisit the controversial idea of providing a government-run insurance plan as part of the offerings under the Affordable Care Act.
This article first appeared July 12, 2016 on the Kaiser Health News website.
President Barack Obama Monday called on Congress to revisit the controversial idea of providing a government-run insurance plan as part of the offerings under the Affordable Care Act.
The so-called "public option"was jettisoned from the health law by a handful of conservative Democrats in the Senate in 2009. Every Democrat's vote was needed to pass the bill in the face of unanimous Republican opposition.
But in a "special communication" article published on the website of the Journal of the American Medical Association, the president said a lack of insurance plan competition in some areas may warrant a new look.
"Now, based on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited," Obama wrote.
The president also called on Congress to take more steps to rein in the cost of prescription drugs and make government assistance more generous for those who still cannot afford health coverage, while urging the 19 states that have not yet expanded the Medicaid program under the health law to do it.
The public option has been a point of controversy from the start. It was included in the version of the health law passed by the House, and had support from most Democrats in the Senate, before it was dropped. Many liberals hoped — and conservatives feared — that having the government provide insurance alongside private companies would be a step toward a full government-run system.
Presumptive Democratic presidential nominee Hillary Clinton — under pressure from Sen. Bernie Sanders' call for a single-payer government system — in February endorsed the idea of including a public optionto allow people age 55 and older to purchase Medicare coverage. On Saturday, as part of a deal with Sanders,Clinton announcedshe will also "pursue efforts to give Americans in every state in the country the choice of a public-option insurance plan," which is broader than what Obama is endorsing.
But even if Clinton wins and the Democrats take back control of Congress in November, a true public option remains a political longshot.
The article, titled "United States Health Care Reform: Progress to Date and Next Steps," is apparently the first by a sitting president published by the prestigious medical journal.
It includes a justification for the health law, statistics on how its implementation has improved both insurance coverage and health care quality, as well as recommendations for further action.
Kristie Canegallo, the White House deputy chief of staff for implementation, told a group of health reporters that the article grew out of a comprehensive review of the law ordered by the president late last year.
The review was to look at "what's working, what's not, and what we should do about it," she said. Upon receiving the review, she added, Obama "thought it was important to share some of this publicly."
Among those parts of the law the administration says are working are the coverage provisions. "The number of uninsured individuals in the United States has declined from 49 million in 2010 to 29 million in 2015," the president wrote.
The article also claims that the health law has played a substantial role in slowing the rate of health spending.
"While the Great Recession and other factors played a role in recent trends, the [president's] Council of Economic Advisers has found evidence that the reforms introduced by the ACA helped both slow health care costs growth and drive improvements in the quality of care," says the article.
Jason Furman, chairman of the council, told reporters at the briefing that the continuing slow growth in health spending so many years out from the recession makes the argument that the economy is mostly responsible for the slowdown "absurd at this point."
While most of the piece is a chart-driven, footnoted recitation of the impact of the health law, Obama did use his perch to suggest the current state of politics in Washington threatens progress going forward.
"Any change is difficult, but it is especially difficult in the face of hyperpartisanship," he wrote. "Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported."
Republicans, however, are continuing their assault on the health law. Just last week, two House Committees released ajoint investigative report and held two hearings asserting that the administration is illegally providing funds to help lower-income individuals pay for their health coverage.