Private not-for-profit hospitals were the facilities most likely to offer language services. Yet, in areas with the greatest need, about 36% did not have systems in place. In areas with low need, seven out of ten facilities had the capability.
This article first appeared August 8, 2016 on the Kaiser Health News website
By Carmen Heredia Rodriguez
Luis Ascanio, 61, works as a medical interpreter at La Clinica del Pueblo, a D.C.-based clinic geared toward providing health care to the surrounding Latino community.
Fluent in Spanish and French, he helps doctors talk with patients with limited English skills about health care issues that range from highly technical to deeply emotional. "You are sort of a bridge," he said. "And it is very important that you do not obscure the context of the conversation."
But according to an analysis published Monday in Health Affairs, more than a third of the nation's hospitals in 2013 did not offer patients similar language assistance. In areas with the greatest need, about 25 percent of facilities failed to provide such services.
The researchers examined survey data collected from 4,514 hospitals nationwide by the American Hospital Association. In addition, they categorized the hospitals as to whether they offered language services and by their ownership status — private not-for-profit, private for-profit or government-owned. The researchers also calculated the number of residents with low English proficiency in the facilities' service areas using census data collected from 2009 to 2013.
They concluded that about 69 percent of hospitals offered language services. Hospitals serving areas with moderate needs provided proportionately more assistance than facilities located in low- or high-need areas.
"And I think we can do better," said Melody Schiaffino, lead author and associate professor in the Graduate School of Public Health at San Diego State University.
Private not-for-profit hospitals were the facilities most likely to offer language services. Yet, in areas with the greatest need, about 36 percent did not have systems in place. In areas with low need, seven out of ten facilities had the capability.
Government-owned and private for-profit hospitals were far less likely to provide such help. Less than a fifth of private facilities offered language aid. Government hospitals had similar rates.
Researchers found no pattern to explain which facilities provided language assistance. This inconsistency suggests patients go to hospitals that may be outside their official service area based on language services, Schiaffino said, resulting in higher costs for the facility and longer waiting periods for patients.
Further research is needed, the authors wrote, because immigration patterns are leading to new areas of language-diverse communities. Models need to be developed to predict where these pockets will emerge and what the level of need for assistance might become.
"A lot of hospitals probably are not aware of the change in diversity and the scale of diversity in their community as they think," said Schiaffino.
According to the study, 60 million people claim a primary language other than English. Spanish speakers alone account for more than 10 percent of the American population in 2011, according to the Census Bureau.
Based on civil rights law, any hospital receiving federal funds must have language services available for its patients. However, many patients do not know their right to access language services, the study noted, which could become more challenging as private for-profit hospitals — the kind least likely to offer this kind of help — continue to grow in market share.
But the challenge also provides an opportunity for hospitals to empower their customers to be informed patients.
"To receive a diagnosis in the language that you prefer is not an unreasonable request," Schiaffino said.
On Monday, Dr. Tom Frieden, head of the Centers for Disease Control and Prevention, recommended Zika testing for all pregnant women who have traveled since June 15 to the one-square-mile zone near Miami where mosquitoes have likely spread the virus locally.
This article first appeared August 5, 2016 on the Kaiser Health News website
By Sammy Mack
Late last fall, Dr. Christine Curry was at a faculty meeting with her colleagues when the conversation turned to new reports linking the Zika virus to a surge in microcephaly in infants in Brazil.
"I think it's fair to say that most obstetricians had never heard of this virus a year ago," said Curry, who is an assistant professor of obstetrics and gynecology at the University of Miami Miller School of Medicine and Jackson Memorial Hospital.
Curry, an obstetrician with a background in virology, volunteered to look into it for the rest of the staff.
"I knew from the get-go that it may end up being nothing, and just an interesting story out of Brazil, or it may end up being a reproductive game-changer — which is, I think, where we're at right now," Curry said.
Since raising her hand at that meeting, Curry estimates her practice has seen about half of the 55 pregnant Floridians who have screened positive for Zika infection. For Curry and her colleagues, discussing Zika risks with patients has become a standard part of prenatal care.
So far, all of Florida's Zika cases in pregnant women have been related to travel outside the continental United States. And for months, screening guidelines have suggested testing pregnant women who have traveled to Zika-affected areas, even if they don't have symptoms of infection. But now that there are at least 15 cases of locally-acquired Zika identified in South Florida, preventing and identifying infection in pregnant women is increasingly urgent.
On Monday, Dr. Tom Frieden, head of the Centers for Disease Control and Prevention, recommended Zika testing for all pregnant women who have traveled since June 15 to the one-square-mile zone in Wynwood and Midtown where mosquitoes have likely spread the virus locally.
Zika exposure in pregnancy has been linked to microcephaly and other abnormalities, but it's still unknown how often those problems develop in the babies of women who are exposed to Zika while pregnant.
"What we know about Zika is scary," said Frieden during a news conference Monday, adding that this is the first time a mosquito bite has been known to lead to a birth defect.
"But in some ways what we don't know about Zika is even more unsettling," he said. "We don't know the long-term impact Zika may have on children born to infected mothers who don't have obvious signs of microcephaly, and these effects may only become apparent months or years in the future."
Getting Tested
When Curry finds that a patient of hers has been to a place where there is active Zika transmission, she talks to her about getting a test — usually a blood test — that will determine whether she has the Zika antibodies or active virus in her system.
Those blood samples get sent to a state lab for testing. Curry said she's been getting results back within one to three weeks.
And while pregnant women tend to be prepared for the anxious waiting periods that come with all sorts of routine testing for birth defects during pregnancy, nothing has quite the profile of Zika right now.
"I got a mosquito bite this morning and it's probably the first time I ever cried over a mosquito bite," said Zonnia Knight, who is due with her second child in mid-October.
Knight lives in Palmetto Bay and works at a communications firm in Coral Gables, but she's spent time in Wynwood — including a dinner the night before pregnant women were told to avoid the area.
Knight called her midwife, who is giving her a prescription for a blood test that looks for antibodies that indicate whether or not she's had a Zika infection.
Knight's co-worker, Susie Gilden, is in her second trimester and is also asking for a Zika test because she's visited Wynwood since June 15. Until now, Gilden and her doctor in Hollywood haven't really talked about the virus.
"It would be nice to have some proactive communication to tell me what I should be doing," said Gilden, who said she's been "stalking" the CDC website and reading up on Zika online.
Positive For Zika
If a test in a pregnant woman does come back positive for having had Zika, her obstetrician has to add another layer of counseling and monitoring to her prenatal care.
"As with any time you deliver bad news, they're really upset and they don't hear everything you have to say initially," said Curry, who arranges to disclose the results of Zika tests with her patients in person, rather than over the phone.
There's a lot of conversation about next steps and, depending on the trimester, the mother's option to terminate the pregnancy. Curry said it's helpful to have a family member present.
"Or you may say, 'listen, I'm going to write this down for you. I'm going to see you again next week. And we're going to rehash this entire conversation when you've had a little bit of time to process things.'"
The mother may need to be retested for Zika antibodies. And her doctors will pay special attention to subsequent ultrasounds for abnormal head growth or calcifications in the baby's brain.
"You see these little calcifications in the brain that are really indicators that you're actually seeing loss of brain," said Dr. Aileen Marty, professor of Infectious Diseases in the Department of Medicine at Florida International University's Herbert Wertheim College of Medicine. She explained that the Zika virus appears to be attracted to stem cells that would otherwise become brain cells.
"And it basically tells the brain cell not to keep on maturing… It commits suicide and you lose those brain cells," Marty said.
Microcephaly is just one of the symptoms of a baby harmed by Zika. Marty and other researchers say it appears the virus is also associated with deformities of the hands and feet, trouble developing reflexes for sucking and swallowing, and vision and hearing loss.
Born With Zika Injuries
At the end of June, the Florida Department of Health announced the state's first birth of a child with Zika-related microcephaly. The baby's mother had gotten Zika outside the United States. The state said it would connect the family to Early Steps, a state- and federally-funded program that provides resources — like speech therapy and other developmental interventions — to children up to 3 years old who are at risk for developmental delays.
"Understand that this is going to be a chronic, lifelong problem," said Dr. Charles Bauer, a neonatologist and director of the Early Steps division in North Miami-Dade.
Bauer is part of a new team of doctors and therapists at UM and Jackson Health System who are coordinating to care for babies with Zika-related injuries. As soon as a baby with a known Zika exposure enters the nursery, Bauer and his colleagues will be able to start screening and developing a plan with the family.
"It's a brand new area. We don't know very much about it," Bauer said. "We could be looking at lots of other things that wouldn't show up until the baby is older and going to school — learning disabilities and things like that."
There are 15 Early Steps sites across Florida. Bauer's division sees around 3,500 infants and toddlers each year at a cost of about $7,500 per patient. The care is free to the family, though the program does bill insurance when possible.
Bauer said it's too soon to know how Zika will affect his caseload. But he said he is concerned that Washington has yet to agree on funding for Zika.
"They need to stop playing politics," he said. "It's a big problem and it's going to get bigger. As we know, it's escalating every day."
Against the backdrop of so much uncertainty, Bauer and other South Florida doctors are doing what they can to help expectant mothers and their babies.
"I picked Ob/Gyn because 95 percent of the time I am there for the happiest day of someone's life," Curry said. "But there's a small fraction of what we do that's really hard. It's the conversations about miscarriages and stillbirths and birth defects."
Curry is pragmatic. Even when she's delivering bad news, she sees opportunity to help a patient through the experience.
"It's about not losing the excitement of having a new baby, but also having a tempered expectation that we don't totally know what the infection may mean for the development of the baby," she said.
After a more than two-year moratorium on nearly all new adult patients, a California community health center has reopened its doors this month. The facility’s director discusses the experience of adjusting to the changes wrought by the Affordable Care Act.
This article first appeared August 3, 2016 on the Kaiser Health News website
A network of clinics that serves low-income patients in rural Northern California is finally finding balance after being deluged with newly insured patients under the Affordable Care Act.
After a more than two-year moratorium on nearly all new adult patients, the Redding-based Shasta Community Health Center has reopened its doors to some newcomers this month, and it will start accepting more new patients in September.
When Medi-Cal, California's version of Medicaid, was first expanded under the Affordable Care Act in early 2014, the number of people insured under the program doubled to around 40,000 people in the region served by Shasta Community Health. Not only did the clinics see new patients, but the demand for services soared from existing ones who were newly insured.
The clinic network already had a shortage of doctors and nurses. — a problem shared by many other rural health clinics in California.
"The … more new patients we brought in, the more stress on the providers, the more likely [they] were going to leave, the deeper the crisis went," said Shasta Community Health Center CEO C. Dean Germano. So he decided to close the network's five clinics to new adult Medi-Cal patients, though they continued to serve all of their existing patients and accepted new children.
During the moratorium, patients in the region had to travel long distances for primary care, or use the local emergency room, Germano said.
Shasta Community Health Center has since boosted its capacity to provide primary care. It has hired two physicians, created a family practice residency program and has a fellowship program for nurse practitioners and physician assistants. For every new primary care provider, the clinic network can add up to 1,200 new patients, Germano said. The system now serves about 60,000 people in the area.
California Healthline interviewed Germano about his health center's experience adjusting to the changes wrought by the Affordable Care Act. His comments have been edited for length and clarity.
Q: How did the ACA change the type of services you were giving or the type of care the patients needed?
Uninsured people tend to use the system much less and often at the worst possible places.
With the onset of coverage, you have all this relief to pent-up demand, people seeking more regular care and preventive [care], which often for the uninsured is not a priority. They tend to come in because they have acute issues or they have long-term chronic issues that have become complicated.
So [with] people gaining coverage, the uninsured are becoming much like our other insured populations — seeking care at the appropriate moments.
Q: Were you able to meet the demand for all these new services?
No, not at all. We quickly became overwhelmed, although there were a couple of things happening all at once. One was certainly the growth in Medicaid coverage, but at the very same time, the state of California expanded Medi-Cal managed care into 28 rural counties. We are one of them. We did not have Medi-Cal managed care prior to this.
We were assigned patients, then assigned more patients. We quickly reached a point where we could not take on more new adult patients to our practice. We had to essentially constrain and at one point close the practice to new adult Medicaid patients. We never closed the practice to uninsured patients because they don't have many options, as in the ER. We never close it to homeless or to children or to people with HIV. Interestingly enough, [it was] not a great business model because our best payers are the ones we closed to.
It was a very big hit [to] the community because adult patients had to go further afield to find services outside of the emergency room. Under managed care, it's [the health plan's] responsibility to find a medical home and some of the medical homes were 30 to 40 miles into the mountains. For patients who have transportation issues, there was no doubt that was a real imposition.
Q: Can you describe the region's shortage of providers?
We are close to 20 primary care physicians short in our community, including our insured and Medicare populations. In a rural community, that's a big number. So the deficit has always been there.
It's always been tough for rural areas to recruit [physicians], but in this environment where everyone is struggling to hire, it really made the challenge that much more difficult. Medical students don't go into primary care for lots of reasons. One of them is debt load. Most of the doctors I hire now usually have an average of $300,000 worth of student debt.
In addition, there are not enough family medicine residencies in California. We need a lot more primary care residencies, particularly in family medicine.
Q Do you think an increase in the rates Medi-Cal pays to providers is what's needed to ensure that all areas have the coverage they need?
The gap is so huge now between Medi-Cal and Medicare reimbursement. A five or ten percent adjustment would help the margins, but isn't going to create a wholesale shift of providers into Medi-Cal, because we're seeing in rural areas the provider shortage exists for patients covered by Medicare and private insurance.
Where we feel [the low reimbursements] the most is on the specialty care side. It's very difficult to get referrals in a timely way when the reimbursement is so pitifully poor. And we really lean on our specialty community.
When a specialist looks at a rural community, it's really hard for them to … say "I'm only going to take the insured patients," because typically there aren't enough insured patients to create a full practice. So they look at the full book of business. They look at what the insured population looks like, what the Medicare population looks like and then everybody else, particularly Medicaid. And in many specialties, particularly in pediatrics and the surgeries, you look at what percentage of your practice is going to be [covered by] Medicaid. In California, if that number is really high, it's often not viable for them to move into that rural community because that book of business doesn't make sense for them.
So, Medicaid being such a low payer has a huge ripple effect. And where that's important in rural communities is that if we don't have an EMT surgeon or a general surgeon or urologist because they can't put together a decent book of business, it's not just the poor people who suffer. It's the whole community.
Q: If increasing the Medi-Cal rates isn't necessarily the silver bullet, how would you remedy the overall problem of provider shortages in certain areas?
First of all, the reimbursement rate has to be better.
Secondly, we have not been good at developing training programs, particularly in the primary care specialties but across the board.
I wish there [were] money for post-graduate residency programs for [nurse practitioners and physician assistants] because if we don't have enough family doctors, general internists and pediatricians, then we're going to lean on our PAs and NPs.
Q: Would expanding the scope of what nurse practitioners can do help bring providers where they're needed?
Well, I have mixed feelings about that. If it's done in the context of a post-graduate residency program, I think that independence makes sense because they should've gotten a lot of what they needed to know. [But] just putting a new practitioner with an independent license out there and letting him hang his shingle out, I have mixed feelings about.
But I do think that if you can marry a post-graduate training program and a pathway for independence, that might work or maybe a certain number of years of practice under a physician's supervision.
The number of hospitals being penalized will be around the same as last year. But Medicare said the penalties are expected to total $528 million, about $108 million more than last year, because of changes in how readmissions are measured.
This article first appeared August 2, 2016 on the Kaiser Health News website
The federal government's penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released Tuesday show.
The government will punish more than half of the nation's hospitals — a total of 2,597 — having more patients than expected return within a month. While that is about the same number penalized last year, the average penalty will increase by a fifth, according to a Kaiser Health News analysis.
The new penalties, which take effect in October, are based on the rehospitalization rate for patients with six common conditions. Since the Hospital Readmissions Reduction Program began in October 2012, national readmission rates have dropped as many hospitals pay more attention to how patients fare after their release.
The penalties are the subject of a prolonged debate about whether the government should consider the special challenges faced by hospitals that treat large numbers of low-income people. Those patients can have more trouble recuperating, sometimes because they can't afford their medications or lack social support to follow physician instructions, such as reducing the amount of salt that heart failure patients consume. The Centers for Medicare & Medicaid Services says those hospitals should not be held to a different standard.
Medicare said the penalties are expected to total $528 million, about $108 million more than last year, because of changes in how readmissions are measured.
Medicare examined these conditions: heart attacks, heart failure, pneumonia, chronic lung disease, hip and knee replacements and — for the first time this year — coronary artery bypass graft surgery.
The fines are based on Medicare patients who left the hospital from July 2012 through June 2015. For each hospital, the government calculated how many readmissions it expected, given national rates and the health of each hospital's patients. Hospitals with more unplanned readmissions than expected will receive a reduction in each Medicare case reimbursement for the upcoming fiscal year that runs from Oct. 1 through September 2017.
The payment cuts apply to all Medicare patients, not just those with one of the six conditions Medicare measured. The maximum reduction for any hospital is 3 percent, and it does not affect special Medicare payments for hospitals that treat large numbers of low-income patients or train residents. Forty-nine hospitals received the maximum fine. The average penalty was 0.73 percent of each Medicare payment, up from 0.61 percent last year and higher than in any other year, according to the KHN analysis.
Under the Affordable Care Act, which created the penalties, a variety of hospitals are excluded, including those serving veterans, children and psychiatric patients. Maryland hospitals are exempted as well because Congress has given that state extra leeway in how it distributes Medicare money. Critical access hospitals, which Medicare also pays differently because they are the only hospitals in their areas, are also exempt.
As a result, more than 1,400 hospitals were automatically exempt from the penalties. Other hospitals did not have enough cases for Medicare to evaluate accurately and were not penalized. Of the hospitals that Medicare did evaluate, four out of five were penalized.
The KHN analysis found that 1,621 hospitals have been penalized in each of the five years of the program.
Researchers analyzed the effect of a web-based tool that uses patient medical records to enhance communication during the patient handoff. The number of medical mistakes was cut in half the year after the hospital introduced the software tool and taught employees how to use it.
This article first appeared August 1, 2016 on the Kaiser Health News website
It's 4 p.m., and if you're a hospital patient, that could be one of the most critical times of the day. Your doctor's shift just ended, and someone new will take over your care. How these professionals communicate could have major repercussions for your recovery.
Those shift changes, also known as handoffs, are prime opportunities for key information about a patient's condition to get lost in the shuffle. It's essential that these relevant points are not only captured, but also effectively conveyed between hospital staff.
All too often, that doesn't happen. But a research letter published Monday in JAMA Internal Medicine suggests hospitals can avoid such missteps by using technology to improve communication among the doctors, nurses and other health care providers at that vital point in care.
"This shows that [an electronic patient record] can help mitigate medical error," said Dr. Stephanie Mueller, the study's main author and an associate physician in primary care and general internal medicine at Brigham and Women's Hospital.
Researchers analyzed the effect of a web-based tool that uses patient medical records to enhance communication during the patient handoff. It scans a patient's electronic medical record for the information that doctors and other health workers need to know most. Then it automatically pulls that information into a separate page that's been designed to highlight those essential details.
To evaluate the tool, the researchers surveyed residents at the end of their shifts who worked "nightfloat" — midnight to 7 a.m. — and "twilight" — 4 p.m. to 12 a.m. They checked for possible medical errors, and then rated those errors in terms of how avoidable they were. The survey started in November 2012 in advance of the tool's February 2013 introduction, and then compared the level of error that took place before the tool was being used with those that occurred in the year that followed. Overall, the survey examined more than 5,000 patient cases.
The result: The number of medical mistakes was cut in half the year after the hospital introduced the software tool and taught employees how to use it. There were 77 errors identified between November 2012 and February 2013, compared with 45 in the following year.
As hospitals become more shift-driven because of increased attention to regulating physician work hours, these figures take on added importance. In the past, residents often worked 24-hour shifts. But safety advocates worried such a system could mean sleep-deprived doctors, who in turn would make more errors while treating patients. In fact, reducing hours has increased the number of patient handoffs, meaning there are more opportunities for information to get lost and for mistakes to be made.
The researchers argued their findings offer a path forward.
Brigham and Women's built its tool in-house and has integrated it into the hospital's commercially produced electronic health record.
This tool is unique to Brigham and Women's, but it offers a strategy that other hospitals and health facilities could adopt, said Robert Wachter, interim chair at the University of California San Francisco's Department of Medicine, and an expert in patient safety. Wachter co-authored a commentary published alongside the study.
"As hospital care is increasingly shift based, a clear and efficient handoff process is vital," according to the commentary. "[This] study … shows how web-based handoff tools may improve hospital workflow and patient safety, but only if they are carefully built and integrated into existing systems."
And that requires efforts by both the hospital and the vendors who develop and sell medical records systems to health facilities.
"This can be used as a model for what other health care institutions can do. … It gives a really good argument for what can be done," said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health's National Center for Human Factors in Healthcare in Washington, D.C. He was not involved in the study.
That said, any reduction in medical errors that resulted after the web-based handoff tool was put to use should not be viewed in isolation. Brigham and Women's also introduced an educational component that accompanied the technology's introduction. It emphasized how health professionals should talk to each other, to make sure the computer-based information is actually conveyed, and it focused on how to navigate the computer system. Plus, Mueller noted, health care is moving culturally toward emphasizing better communication, especially at shift changes. Those all could have had an impact, too.
But those threads are more entwined than they may appear, she said. Any hospital that turns to technology needs to properly teach staff how to use it and highlight why it's important.
"They're all merged," she said. "You're not going to throw a tool in someone's lap and say, 'Here. Use this, and good luck.'"
When it comes to hospitals, which benefit most from high health care prices? It may sound counter-intuitive, but a group of not-for-profit hospitals appear to be among those doing the best business.
At least, that’s the idea in a study published Monday in Health Affairs. It analyzes how hospitals make money and ranks the nation’s 10 most profitable ones — those making hundreds of millions of dollars through their inpatient and outpatient care. Seven were nonprofits, including the top four.
The findings are based on Medicare cost reports from fiscal year 2013, analyzing almost 3,000 acute-care hospitals. About 60 percent were nonprofit, while one in four were for-profit. The rest were public, or government-owned.
The top three were nonprofits. Gundersen Lutheran Medical Center, part of the large Wisconsin-based health system, made the most money: $302.5 million just on its patients. California-based Sutter Medical Center, also part of a large system, came in second. Stanford Hospital, also in California, was third.
Those hospitals share a key attribute, the authors argued. Whether because of their size, their prestige or their influence in the community, they have more power to negotiate prices, meaning they can charge insurers more for the care they give.
“They are the only provider — or they are clearly the dominant provider — and the insurers in that community are relatively weaker, and there are a lot of them,” said Gerard Anderson, director of the Johns Hopkins University Center for Hospital Finance and Management, and one of the study’s authors. “[The hospitals] can take advantage of their market position. And they do.”
The researchers looked only at profits made from actual medical care, meaning they didn’t factor in the often substantial amount of money hospitals make from sources like investments, grants, donations, parking fees and property rentals. The idea was to focus on what hospitals make from patients alone, said Ge Bai, the study’s primary author. Bai is currently an assistant professor of accounting at Washington and Lee University, though she’s joining the faculty at Johns Hopkins’ Carey Business School in the fall.
Most hospitals — particularly nonprofits — don’t actually earn money from patient care. Rather, a large market share or inclusion in a big health system — like Gundersen — better predicted how well hospitals would do.
“Many of the hospitals best-positioned to earn profits are non-profits — they’re the ones often that have the most prestige, they’re the largest hospitals,” said Paul Ginsburg, the director of the Center for Health Policy at the Brookings Institution and director of public policy at the University of Southern California’s Schaeffer Center for Health Policy and Economics.
Ginsburg, an expert in health economics, wasn’t affiliated with the study.
Market muscle matters in bargaining with insurers. That may be driving the hospital industry trend toward consolidation.
In recent years, many hospitals have merged to form larger health networks. They argue that doing so leads to better service to patients — for instance, care can be coordinated across more locations. In addition, they say they can then better negotiate with insurance companies. The study notes that in markets dominated by insurance companies, hospitals were less likely to profit from patient services.
But mergers have also been shown to increase the cost of health care. That’s because they often give hospitals leverage to set higher prices or charge insurance companies more. Likewise, brand-name hospitals, such as those affiliated with prestigious universities, can exert a similar pressure, Bai said. For instance, she explained, if she were shopping for health insurance in Baltimore she wouldn’t buy a plan that didn’t include Johns Hopkins Hospital.
Increased health care costs, the study authors said, are felt by consumers — either in the form of higher health plan premiums, or, in higher hospital bills for patients who don’t have insurance or who receive care out of network. The latter situation happens more often than people expect, Bai said, especially in emergencies, when people don’t have time to pick who’ll treat them.
The study also adds to the debate about whether the tax status of nonprofit hospitals needs more thorough scrutiny, Ginsburg said. They typically don’t have to pay taxes because, the idea goes, they provide a public service. But the paper’s findings “very clearly raise the issue about … whether these hospitals need or deserve the tax exemption.”
That’s an issue federal policy has tried to address, too. The 2010 health law, for instance, included a provision intended to make nonprofit hospitals prove they deserve their tax-exemption — increasing the standards for the “community benefit” those hospitals are supposed to provide.
Often, the local hospital is the largest economic engine in a community, and not taxing it means the local governments forgo a significant amount of revenue. The benefit a not-for-profit hospital provides hardly differs from that provided by one that’s for-profit, especially when both types of hospitals have rosy financial outlooks, based on the patient care, Ginsburg said.
Meanwhile, Bai said, the findings also support the notion that hospital mergers need to be better regulated. Setting federal limits on what hospitals can charge for a particular service might also help, she added. Maryland and West Virginia have experimented with that idea. Despite outcry from some executives, the study notes, hospitals in those states are still profiting.
Without that kind of oversight, Bai said, consumers will get shortchanged.
“We’re absolutely paying a higher price,” she said.
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.