'Not all of this is about mental health,' said top VA official.
This article was first published on Wednesday, May 1, 2019 in MedPage Today.
By Shannon Firth, Washington Correspondent, MedPage Today.
WASHINGTON -- Members of the House Committee on Veterans' Affairs wrestled with the challenge of veteran suicide during a hearing earlier this week.
Suicides in younger veterans have spiked over the last 2 years, and in the past 6 weeks alone, six veterans took their lives on VA campuses, said Richard Stone, MD, executive in charge of the Veterans Health Administration for the Department of Veterans Affairs.
Each day about 20 veterans die by suicide -- roughly 7,300 deaths per year.
As both the Committee's chair and ranking member noted, those figures have changed little since the 1990s, despite new legislation and increased funding.
Ranking member Phil Roe, MD (R-Tenn.), explained that funding for VA mental healthcare rose 258% since 2005 -- now up to $9.4 billion in the most recent budget request -- yet "too little progress has been made."
Stone stressed that "not all of this is about mental health," and agreed that funding is not the issue. Veterans are coping with financial and "relational" issues as well as the challenge of homelessness.
"This is a problem with the society that we live in," he said, highlighting issues of isolation and loneliness.
"I can hire another 24,000 mental health providers, " he said. "I can hire additional people for at-risk [programs], but this is about ... whole health and identifying what connects us as humans to other humans."
Stone pointed out that when his own family moved to a military base, other families visited for weeks, bringing over food and introducing themselves. Now as a civilian, his family knows only the neighbors on either side of their house.
Committee members tried to attack the problem of suicide by zeroing in on specific risk factors, from veterans' access to guns, to homelessness and loneliness.
Rep. Kathleen Rice (D-N.Y.) noted that 69% of veterans complete suicide with a firearm and that female veterans are more likely to use guns than women without a military background.
Richard McKeon, PhD, MPH, chief suicide prevention branch at the Substance Abuse and Mental Health Services Administration (SAMHSA) and Keita Franklin, PhD, national director of suicide prevention for the VA, emphasized the importance of lethal means counseling.
Franklin said teaching clinicians to talk to veterans in a "firearm-friendly way" is a critical part of the safety plan for any at-risk individual.
Rep. Anthony Brindisi (D-N.Y.) pointed to an unusual approach being scaled in upstate New York known as "freeze the keys," where veterans are encouraged to literally place the keys to their gun cabinet in a cup, perhaps one with a photo of a loved one pasted to it, fill it with water, and then freeze it.
Stone said research among survivors has shown that the time between the decision to commit an act of self-harm and actually executing that act can be less than 60 minutes.
In that sense, anything that puts distance between veterans and executing their plan for suicide has value, he said.
Rep. Mike Levin (D- Calif.) highlighted "extreme risk" laws that have been passed in 15 states. Such laws allow a family member or law enforcement to ask a judge to enact temporary restrictions on access to firearms of an individual who shows warning signs of being at risk to themselves or others.
After Connecticut "stepped up enforcement" of its extreme risk law, the state saw a 14% reduction in firearm suicide. Ten years after Indiana enacted a similar law, the state witnessed a 7.5% reduction in its own firearm suicide rates.
Levin asked witnesses if they would recommend Congress pass an extreme risk law to help address the current suicide crisis.
Data from Indiana and Connecticut are "encouraging," he said, but added that he could not take a stance regarding national legislation.
Responding to the issues of isolation and loneliness, Stone noted that organized sports has been one effective intervention for establishing a sense of connection. Research has shown that 150 minutes of organized exercise can have a really "demonstrable protective effect among veterans."
When asked about specific pilot programs that have proven to be effective in reducing suicides, Franklin highlighted "caring outreach" measures, which involves phone calls to individuals who leave the emergency room after a suicide attempt.
The measure was piloted in about seven facilities, Franklin said, and because of its success has been fast-tracked for "full implementation" across all VA emergency departments.
The National Institutes of Mental Health reported a 30% reduction in future suicide attempts with the program and the VA reported a 50% reduction in subsequent attempts.
VA witnesses stressed the agency's "whole health" approach to healthcare, which Stone's written testimony notes includes providing veterans with "proactive, complementary and integrative health approaches," such as stress-reduction, yoga, nutrition acupuncture, and health coaching.
With regard to homelessness, Stone noted that suicide rates spike dramatically at the point of "impending homelessness." Previous research has reported that homelessness and attempted suicide often go hand in hand.
The VA currently has 444 suicide prevention coordinators and is planning to add another 246, Franklin said. One aspect of their work is "in-person outreach engagement" which involves connecting to vulnerable veterans in the community including those in shelters.
But 'we are still not investing enough in treatment,' one expert says.
This article was first published on Wednesday, April 24, 2019 in MedPage Today
By Elizabeth Hlavinka, Staff Writer, MedPage Today.
From 1998 to 2015, an increasing number of patients with depression received outpatient treatment, and total spending on depression rose in the U.S., researchers found.
In a sample of almost 90,000 respondents with depression, the treatment rate increased from 2.36 (95% CI 2.12-2.61) per 100 in 1998 to 3.47 (95% CI 3.16-3.79) per 100 in 2015, a relative increase of 46.8%, reported Jason Hockenberry, PhD, of Emory University in Atlanta, Georgia, and colleagues.
From 1998 to 2007, the relative growth in prevalence was 21.8% and from 2007 to 2015, it was 20.6%, the authors wrote in JAMA Psychiatry.
Total spending on depression increased by around 2% per year, though this was below the annual growth rate in overall health spending during that time, they noted.
The authors also found that the rate of depression treatment observed in this study was lower than the overall rate of diagnosed depression, which is from 4.8% to 12.8% for varying age groups, according to the 2016 National Survey on Drug Use and Health.
Indeed, there are still many individuals who are not receiving treatment for their depression, said Sherry Glied, PhD, dean of the Robert F. Wagner Graduate School of Public Service at New York University in New York City. However, the findings here are "encouraging" because they demonstrate that efforts to increase Medicaid coverage and include mental health benefits in more private insurance plans have worked, she said.
"This is not the case where there have been new advances in treatment -- there really have not been," Glied, who was not involved in this study, told MedPage Today. "What we are doing is disseminating things we know how to do to people who can benefit from them, and we did that by expanding insurance coverage."
Amir Afkhami, MD, PhD, of George Washington University in Washington D.C., emphasized that although national policies like the Mental Health Parity and Addiction Equity Act or provisions in the Affordable Care Act may have expanded care for certain subgroups, many patients still lack access to affordable treatment, especially those residing in rural areas, young people, and women.
Stigmas and a psychiatrist shortage may also prevent individuals from receiving treatment, he added.
"We are still not investing enough in treatment, despite some of the recent promising advances," Afkhami, who was not involved in this study, told MedPage Today.
Hockenberry and colleagues examined data from the 1998, 2007, and 2015 Medical Expenditure Panel Surveys(MEPS), which comprised data from around 86,000 individuals. Respondents were classified as receiving depression treatment if they had outpatient visits or medication for major depressive disorder, but were excluded if they had bipolar depression.
Pharmacotherapy included antidepressants, antipsychotics, anxiolytics and hypnotics, stimulants, and mood stabilizers.
Respondents were a mean age of around 37. A little over half were women, about three-quarters were white, 28% were Hispanic, and 18% were black.
These trends in treatment were more pronounced among certain demographic groups from 2007 to 2015, with young people ages <18 reporting a 69.4% increase in treated prevalence, followed by a 48.0% increase among adults 18-34, and a 11% increase among adults 50-64.
The number of black respondents receiving treatment for depression increased from 1.00 (95% CI 0.58-1.42) per 100 in 1998 to 1.91 (95% CI 1.55-2.28) per 100 in 2015. Still, a "substantial gap" remains across races, as white patients still received treatment at more than double the rate of black individuals, with 4.00 (95% CI 3.58-4.43) per 100 receiving treatment in 2015, Hockenberry noted.
Psychotherapy use among patients with treated depression was 53.7% in 1998 and 50.4% in 2015, and the proportion using pharmacotherapy hovered around 80% across the time period. Although selective serotonin reuptake inhibitor (SSRI) use declined from 60.7% to 47.9%, it was still the most-used pharmacotherapy, the authors added.
Meanwhile, they found that annual per capita expenditures on depression visits were $1,074 in 1998 and $957 in 2015, with a mean number of visits of 7.38 and 6.79, respectively. Total expenditures on depression treatment rose from $12,430,000 in 1998 to $17,404,000 in 2015, while pharmaceutical spending on depression was $848 per year in 1998 and $603 per year in 2015.
"Despite recent concerns about drug costs, in the case of depression, spending on drugs has decreased since 2007, despite a notable increase in the prevalence of treated depression," the authors wrote. "This decrease was likely attributable in part to the multiple blockbuster antidepressants coming off patent in recent years and becoming available as low-cost generics."
This study was primarily limited because analyses on trends are subject to the policies and other extraneous factors that could influence responses, the authors reported. This survey also relies on self-reported healthcare visits, although these responses are supplemented with healthcare professional responses for verification. Lastly, the response rate to the 2015 version of the survey was low (47.7%), so it is possible the results were affected by nonresponse bias.
This study was partially supported by the Commonwealth Fund.
Hockenberry received grants from the Commonwealth Fund.
Labor unions for healthcare workers are ramping up their activity in 2019, pushing for increased charitable activity from non-profit health plans and full staffing of healthcare jobs at the Department of Veterans Affairs.
A group of union workers at Kaiser Permanente—the $80 billion integrated health plan with more than 12 million members and facilities in eight states plus the District of Columbia—has been trying to draw attention to what it says is a failure by the plan's leadership to provide care for the underserved.
In early April, a group of members of the Coalition of Kaiser Permanente Unions—a federation representing more than 80,000 KP employees—protested outside a Washington hotel while the health system's CEO, Bernard Tyson, was inside receiving an award.
The protest was held to raise awareness "that Kaiser is under-serving Medicaid patients," according to a coalition press release.
"Kaiser serves a very low percentage of Medicaid patients, suggesting its profits are boosted by excluding the nation's poorest people. For instance, while Medicaid funds healthcare for 21% of Americans, Kaiser's Medicaid patient volume is only 9.6%." In addition, the workers "are also concerned that Kaiser is operating as a nonprofit in name only," the release said.
"Kaiser made $4 billion in profits last year, is sitting on $31.5 billion in reserves, and pays 30 executives more than $1 million annually, and yet operates as a 'non-profit' organization."
In response, John Nelson, KP's vice president of communications, said in a statement that KP is "disappointed that some union leaders are choosing to make false allegations and pursue an adversarial, destructive approach as part of their bargaining strategy.
"Here are the facts," Nelson said. "Since 2013, our Medicaid enrollment has more than doubled, from 455,000 to over 918,000 this year. That's a 102% increase since 2013. In context, our overall enrollment over the same period rose by 30%. We view Medicaid as critical to achieving our mission of providing care to the communities we serve."
"Kaiser Permanente is an integrated system of healthcare and coverage, and we go well beyond providing charity care in our emergency departments and inpatient areas," Nelson said. "We work to provide the uninsured and underinsured with a medical 'home' where they can get continuity of care and comprehensive treatments."
The protest came about a week before the COKPU was due to begin negotiations with the health plan on a national contract agreement for its workers. The last national contract expired on Sept. 30, 2018, although local union contracts were not set to expire until "mid-to-late 2019 or later," according to a coalition press release. The coalition began bargaining on April 18 and will have another one in mid-May, a spokesman said.
COKPU is smaller today than it was last year. In late March 2018, 22 local unions representing 45,000 KP employees announced that they were splitting apart from COKPU following mounting disagreements between the smaller unions and the coalition's largest union, SEIU United Healthcare West, according to an article posted on the website of the Northwest Labor Press, a union-supported newspaper for union members in Oregon and southwest Washington state.
"SEIU-UHW wanted to have more say over Coalition decision-making, and on its own began to pursue a more confrontational strategy," the article said, adding that the departing unions had a good relationship with KP, which they wanted to maintain.
The new group named itself the Alliance of Healthcare Unions and began its own negotiations, which culminated on Nov. 1, 2018 with a ratified national contract that included wage increases and better benefits, the group said in a press release.
Another KP union that was never a part of COKPU—the California Nurses Association, now a part of National Nurses United—reached its own agreement with KP last March on a 5-year contract that features 12% raises for its members, which include 19,000 RNs and nurse practitioners (NPs), according to the Northwest Labor Press article.
The NNU is also involved with another large healthcare employer: the VA. Last Wednesday, the NNU held an event in the Bronx featuring Rep. Alexandria Ocasio-Cortez (D-N.Y.) to draw attention to the Trump administration's plans for increasing privatization of care for veterans.
"For years, we've had the CHOICE program where vets can go outside the VA to get the care they need; the point was for them to access care when they can't get to the VA," Better Omeh, an NP and an NNU delegate to her local chapter, in the Bronx, said in a phone interview.
"But now they want to expand the CHOICE program where even patients [close by] are told they can go outside the VA to get care," Omeh said. "The concern is that they won't get the kind of care they get at the VA because [the VA staff has] been uniquely trained to be able to deliver care to the veterans," she said.
If the issue is that there is a long wait time at the VA, "why not hire more doctors and nurses so patients can get the care they need there?" Healthcare staffing at the VA is already an issue, she said. "Right now over 43,000 vacancies need to be filled; that's not a priority of this administration but it needs to be done."
The VA did not respond to requests for comment on this story.
Anthony Fauci, MD, and colleagues weigh in on the dangers of the 2019 measles epidemic.
This article was first published on Wednesday, April 17, 2019 in MedPage Today.
By Molly Walker, Staff Writer, MedPage Today
The ongoing 2019 measles epidemic threatens a number of highly vulnerable patient populations, as measles has the potential for serious complications, researchers argued.
Growing numbers of measles outbreaks in the U.S., as well as abroad, threaten children, pregnant women, as well as cancer patients and patients living with HIV, according to Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), and colleagues.
Writing in a Perspective in the New England Journal of Medicine, the researchers noted that measles has historically been a disease of children, especially those under age 5, and others "with poor nutritional status, particularly if they have a vitamin A deficiency."
But thanks to vaccination programs, these "seasonal epidemics" in young children no longer exist, Fauci and colleagues wrote. However, the sporadic cases seen in adults may be particularly dangerous to certain populations: immunosuppressed people, for example, may have atypical presentations as well as severe complications such as giant-cell pneumonia and measles inclusion-body encephalitis.
Not surprisingly, measles can lead to serious complications, and even death, in people with HIV infection. But Fauci and colleagues also listed several other patient populations where higher rates of complications and deaths have been reported, including:
Cancer patients
People with solid organ transplants
People receiving high-dose glucocorticoids
People receiving immunomodulatory therapy for rheumatologic disease
Far from a "trivial disease," Fauci and colleagues enumerated some of the most common complications of measles infection. While pneumonia is the leading cause of measles-related deaths, they said, other complications include keratoconjunctivitis, which may lead to blindness in vitamin A-deficient populations, otitis media, and "secondary infections related to measles-induced immunosuppression."
Measles can also have severe neurological complications and "long-term neurologic sequelae" for patients who survive these complications, they said.
Fauci and colleagues described the danger of nosocomial transmission of measles, citing a 2015 measles outbreak in Shanghai, where a single child with measles in a pediatric oncology clinic infected 23 other children, half of whom ended up with severe complications, and a case fatality rate of 21%.
While the U.S. has had 555 cases of measles in 20 states confirmed this year through April 11, the authors also noted recent measles epidemics around the world, citing a 31% increase in the number of measles cases from 2016 through 2017. Indeed, measles is a global problem -- from the >100,000 cases and 1,205 deaths in Madagascar to the tripling of cases in Europe in 2018 versus 2017. The authors also noted that measles is now endemic in Venezuela (where it had previously been eliminated) and likely in a number of European countries, where transmission has been interrupted.
"The recent upsurge in U.S. measles cases, including the worrisome number seen thus far in 2019 represents an alarming step backwards," Fauci and colleagues wrote. "If this trend is not reversed, measles may rebound in full force in both the United States and other countries and regions where it had been previously eliminated."
"Promoting measles vaccination is a societal responsibility," they concluded.
Fauci and co-authors disclosed no relevant relationships with industry.
WASHINGTON -- The FDA ordered an end to sales of all remaining surgical mesh products used for transvaginal repair of pelvic organ prolapse.
According to the announcement, the FDA determined that "manufacturers, Boston Scientific and Coloplast, have not demonstrated reasonable assurance of the safety and effectiveness of these devices."
In 2016, the FDA reclassified the mesh as class III (high risk) devices, requiring manufacturers to obtain approval of premarket approval applications (PMAs), the agency's most stringent level of review. The manufacturers have 10 days to submit a plan to withdraw all remaining products from the market.
"In order for these mesh devices to stay on the market, we determined that we needed evidence that they worked better than surgery without the use of mesh to repair POP," Jeffrey Shuren, MD, of the FDA Center for Devices and Radiological Health, said in a statement. "That evidence was lacking in these premarket applications, and we couldn't assure women that these devices were safe and effective long term."
In use since the 1950s for hernia repair, surgical mesh's clinical applications expanded in repair of POP, initially abdominal procedures in the 1970s and then transvaginal repair in the 1990s, according to the FDA. The agency cleared the first mesh device for transvaginal repair of POP in 2002.
About 10%-15% of women have surgery to repair POP in their lifetimes. The proportion of transvaginal procedures using surgical mesh decreased after the FDAissued warnings about risks associated with transvaginal mesh.
In February, an FDA advisory committee concluded that a favorable recommendation for the mesh devices' benefit-risk profile would require a demonstration of superior effectiveness versus native tissue repair at 36 months and at least comparable safety outcomes.
"The FDA agreed with these recommendations, and because such data were not provided by manufacturers in their PMAs, the FDA decided not to approve them," according to the FDA statement.
Boston Scientific and Coloplast will be required to continue follow-up of patients who underwent transvaginal repair procedures using the mesh products in "522" clinical studies. Women with the mesh in place should continue with annual or routine check-ups and follow-up care, and no action is needed so long as they remain satisfied with the surgery and are not having complications, the FDA advised.
"Patients should notify their healthcare professionals if they have complications or symptoms, including persistent vaginal bleeding or discharge, pelvic or groin pain, or pain with sex," according to the statement.
In response to the FDA announcement, representatives of Boston Scientific issued the following statement:
"We are deeply disappointed by the FDA's decision on our premarket approval applications for the Uphold™ LITE Vaginal Support System and the Xenform™ Soft Tissue Repair Matrix, and believe the inaccessibility of these products will severely limit treatment options for the 50% of women in the U.S. who will suffer from pelvic organ prolapse during their lives."
"Patient safety is always our highest priority and we will work closely with the agency to understand its direction and determine next steps."
A spokesperson for Coloplast said the company will comply with the FDA decision to halt sales of the products, but noted that the FDA action is not a recall and has no impact on other Coloplast products.
PHILADELPHIA -- Physicians need to remember that self-care is a necessity, not just a luxury, Richard Wardrop III, MD, PhD, said here at the American College of Physicians (ACP) annual meeting.
"The way I think about this is -- you've got to put your mask on first," just like flight attendants tell you before an airplane flight, said Wardrop, who is vice-chair of medicine at the University of Mississippi in Jackson, and a member of the ACP Physician Wellness Task Force. "You've got to take care of yourself before you take care of somebody else."
He also decried the use of the term "work/life balance." "I think that's a horrible term; I don't like it. I like 'work/life integration' because as soon as you say 'balance,' you're insinuating one is worth keeping away from the other ... Work and life -- I want them to come together. I think that's really what we need to aim for."
Professionally, that means trying to find that "sweet spot" where you're doing something that you like, that you're good at, and that you can get paid for doing, said Wardrop. "Keep this in mind as you change jobs -- What are your personal and professional needs, and personal and professional values?"
And while you're trying to get to your ideal vision, "don't let perfect be the enemy of the good," said Wardrop. "Remember, just be kind to yourself. If this were easy, everybody would be doing it perfectly ... It's really about making progress."
Wardrop presented a number of suggestions aimed at preventing burnout and increasing resilience, including:
Mindfulness: "Mindfulness is the practice of learning how to slow down and nurture calmness and self-acceptance; it's a form of meditation," Wardrop explained. "This alone is not sufficient to be well; this alone is not sufficient to produce a legion of non-burned-out physicians, but this is something that can be done to promote your own personal well-being."One study of 42 doctors found that mindfulness was associated with better heart rate control and more positive energy, he added.
Practicing positive psychology: Whether learned through coaching or another program, "this is another way to promote well-being," said Wardrop. "Humans tend to remember the thing that went wrong -- 'I did everything right today except I didn't give that patient in the ICU enough fluids.' We think about that one thing over and over again, and keep bringing it up again days later." Instead, try to focus on what you did right, he said.
Showing gratitude: "There's an app for that: Three Good Things," he said, explaining that the app reminds you to think about the three good things that happened that day. "I know it seems simple, and it may be too straightforward, but there actually is something to this taking a pause [to think about this] ... [Think about] 'What am I grateful for in my life? What is going well in my life? What is working well for me?' Do it for 7-14 days; get in a pattern. That's how good habits are established."
Wardrop also recommends that physicians work within their institutions to develop a culture of wellness, as discussed by the National Academy of Medicine. "One big step that needs to be done ... is we recognize as a profession that our own well-being is a professional competency," he said. "Also, [we should] recognize this national [burnout] epidemic is not a personal failure at all; this is something that's a systemic problem." Also, once burned-out people get help, "they need to be able to come back, so people aren't feeling like it's a one-way street out of the profession."
The AMA's Steps Forward program is designed to help with this, including topics on professional satisfaction and well-being in continuing education, having "meetings with meaning," not just about practice efficiency, and having social events, said Wardrop. "There's data for this. It's good to get together and have a meal ... but we have to find ways to do that so we're not taking time away from life, family, and things that don't involve work."
But not everyone was convinced by the "culture of wellness" idea. "This is nibbling at the edges," Greg Poland, MD, a vaccinologist at the Mayo Clinic, in Rochester, Minnesota, said during the audience participation part of the session. "I've seen far too many of you who suffer in unfathomable ways."
"No matter how much you give and how hard you work, the institution is never going to love you back," Poland said, turning the stand microphone around so he could face the audience. "That is not where you go for love and acceptance." He urged audience members to "learn to say No" to unreasonable demands made by practice administrators, and suggested that perhaps "that may [mean] -- I don't ever want to use the word 'union' [but] that may be that we have to collectively organize in some ways outside of these bureaucracies to develop boundaries that make their way into contracts and negotiations. Too many of you are suffering and I want to see that suffering end," he said to applause.
PHILADELPHIA -- Don't just blame the drug manufacturers for causing the opioid crisis, Charles Reznikoff, MD, said here at the American College of Physicians annual meeting.
"I actually don't blame the pharmaceutical companies; I blame our healthcare system, which left an opening for industry, and they took the opening," said Reznikoff, assistant professor of medicine at the University of Minnesota in Minneapolis.
Countries other than the U.S. are handling the opioid crisis much differently than we are, said Reznikoff. For example, in 1995, France began allowing any doctor to prescribe buprenorphine for opioid use disorder (OUD); "Now the majority of patients [there] with OUD are receiving buprenorphine from their primary care physicians." These changes led to a 10-fold increase in buprenorphine prescribing in France "and the overdose death rate dropped by 80%," he added, noting that half of all people with OUD in France are on addiction medications, compared with 15% in the U.S.
In Portugal, the country shifted its approach toward opioid addiction in 2001 from a criminal justice approach to a public health approach; "They basically stopped incarcerating people with opioid addiction," Reznikoff said. As a result, active heroin users dropped from 100,000 to 25,000. "Portugal had the highest rate of opioid death in Western Europe and they now have the lowest rate -- and it's 1/50th of the death rate in America." In addition, new HIV diagnoses attributable to IV drug use dropped by 90%, he said.
One thing that makes it easier for these countries to tackle this problem is that they all have universal healthcare, Reznikoff noted. In the U.S., with a more fragmented system, "we have efforts at mental health and addiction parity, but we have a long way to go. The ideal is that the patient, the doctor, the clinic, the insurer, public health, and the government all have incentives aligned, and that is not the case right now. But it's easier to get that done when more people are covered and there is a more coherent healthcare policy."
What is a good medication to make available to people at risk of addiction? It's not naloxone -- as many people may think -- but buprenorphine or methadone, "because the literature for mortality is more robust" for those two drugs, Reznikoff said. What naloxone does do is delay an increase in mortality rates -- "it stalls the deaths and gives us time to implement other policies; but it's not going to turn the [upward] curve down."
So why is naloxone so frequently used? "You can give naloxone to patients without changing the underlying systems of care," he said. "It can be given to ambivalent patients, it's easy for the busy provider, it avoids the stigma of medication-assisted treatment (MAT), and there is a perception that adding it makes a risky opioid regimen safer," even though there's actually no evidence for that, he said.
Reznikoff also faulted the U.S. for not using MAT with opioid-addicted patients who are incarcerated, as is done in other countries. "The risk of opioid use disorder-related death increases 20-fold after release from incarceration," he said. "We are not going to get out of this [problem] without wrestling with that tough issue."
Each state is also responding to the opioid crisis in its own way, said Rebecca Haffajee, JD, PhD, MPH, assistant professor of health management and policy at the University of Michigan in Ann Arbor. "A policy that's working in one state doesn't work in another," she said. "States and localities are at the forefront and have been very active in the policy-making space."
Over 1,300 bills related to the crisis have been introduced in state legislatures, and more than 500 of those have been enacted, she said. The "heavy hitters" in this area include legislation around the use of prescription drug monitoring programs (PDMPs), funding for media campaigns about opioid abuse, and laws increasing access to naloxone, as well as "Good Samaritan" laws that hold people harmless if they call the police regarding someone who has overdosed. Regulation of pain clinics has also been enacted in 11 states; those laws have plateaued, likely because penetration of these clinics varies greatly from state to state, Haffajee said.
The best evidence for state policies that work has so far come from pain clinic regulation laws, which are usually combined with laws regulating PDMPs, she continued. "Those did seem to reduce opioids prescribed and dosages dispensed ... We also find that drug supply management -- which we define as something that limits opioid prescribing by quantity or dosages, or [requiring] prior authorization -- particularly those prior authorization policies in Medicaid, those did seem to decrease higher-risk opioid prescribing and 'doctor shopping' as well. But other state policies: opioid prescription guidelines, doctor shopping laws, continuing medical education requirements, Good Samaritan laws, naloxone access laws -- there's really not good evidence to demonstrate their effects."
State laws that limit the number of days a prescription can be written for or the dosage amount "are controversial because they're very blunt instruments," but their effects are still not known. "We have done some initial evaluations on earlier [such laws]; they don't seem to be having a big effect, but it's too early to make that determination," she said. "We need to generate more evidence about these state policies."
One barrier to getting more MAT is a workforce issue, Haffajee said. "What we're hearing is that [people] need peer support -- 'I don't want to be the only prescriber in my practice. I want back-up, and I want institutional support.' How do we get healthcare systems and employers to foster these environments? We don't have nearly enough addiction specialists."
WASHINGTON -- The Trump administration's message is clear: in Medicaid, block grants are the way to go.
"The budget ... proposes to give states additional flexibility over their Medicaid programs by transferring control of Medicaid transformation efforts locally where it belongs," the White House said in its message accompanying its fiscal year 2020 budget proposal. "The administration recognizes that the only way to reform Medicaid and set it on a sound fiscal path is by putting states on equal footing with the federal government to implement comprehensive Medicaid financing reform through a per-capita cap or block grant."
"A new federal-state partnership is necessary to eliminate inefficient Medicaid spending, including repeal of the Medicaid expansion, and reducing financing gimmicks such as provider taxes," the document continued. "The budget would empower states to design state-based solutions that prioritize Medicaid dollars for the most vulnerable, and support innovation."
The block-grant proposal isn't likely to get approved by Congress, given that the House is under Democratic control, but the administration also has other ways of pursuing its block-grant agenda. The Centers for Medicare & Medicaid Services (CMS) is reportedly working on a plan to encourage states to apply for what's known as Section 1115 waiver authority to implement their own Medicaid block grants.
In particular, CMS Administrator Seema Verma urged Alaska to be the first state to apply for block grants, according to a letter that Alaska Gov. Mike Dunleavy (R) wrote to President Trump on March 1. "We are eager to do this, but your support of her on this 'first' will keep the proper focus and speed on the application," Dunleavy wrote.
Several other Republican-led states, such as Utah, are also considering some form of block grants for the Medicaid program, according to news reports. As part of its request to partially expand its Medicaid program, the state is thinking about asking that the federal government's share of funding the newly eligible Medicaid beneficiaries be paid using a per-capita cap – a fixed dollar amount per enrollee.
Per-capita caps are a more flexible form of block-granting, since the amount of money being spent can increase as the number of beneficiaries increase. The other type of block-granting referred to in the president's budget proposal is a "hard cap" – fixed amount of money overall, with no increase in funding if more beneficiaries enroll than anticipated.
Block-granting of either kind worries some Medicaid supporters.
"Block grants would really undermine the current guarantee of health insurance that the Medicaid program provides to the people eligible for it [such as children, people with disabilities, seniors who need long-term care]," Joan Alker, executive director of the Georgetown University Center for Children and Families here, said in an email.
"These are vulnerable populations and the Medicaid program is a critical part of the healthcare system, really serving folks for whom the private insurance system is not working, either because it's too expensive or not comprehensive enough to address their needs in the case of people with disabilities. So limiting the amount of funding is very problematic."
"Obviously if there are ways to save Medicaid in the right way, i.e., like prescription drug costs, let's work on those together," she added. "But undermining states' ability to provide coverage or limiting coverage folks are getting, or limiting or capping enrollment, all of those issues are very problematic from a beneficiary perspective."
This is especially true if a state suffers from an unexpected problem such as a flu epidemic or a natural disaster, she added. "Right now [the financing] structure is designed to respond to unanticipated events like a disaster or a flu epidemic, and to expected events like a recession. State budgets are very challenged during recessions; it's very important when a recession comes along that federal funding for Medicaid is not capped."
The left-leaning consumer group Families USA also dislikes block grants. "If a state's costs exceed the amount of the block grant, it will have to use its own funds to make up the difference, or, more likely, cut services for low-income residents," the group wrote on its website. "Block grants would make it harder for states to serve their residents' healthcare needs."
But proponents say block grants allow states to adapt to changing circumstances. "Direct block grants to the states would enable states to better target assistance to those in need," according to the supporters of the Healthcare Choices proposal, a plan being advocated by a variety of conservative groups, including the Heritage Foundation and the Galen Institute.
That proposal calls for using block grants to replace the money states are now getting from the federal government to implement Affordable Care Act programs such as Medicaid expansion and premium subsidies for private insurance. "States would receive block grants from the federal government, which they would use to stabilize their markets and provide assistance to those with low incomes and to the sick and needy," the proposal authors wrote.
Clay Farris, a Medicaid consultant in Birmingham, Alabama, said that block-granting will help states to better target their efforts at serving the Medicaid population. "The 'pros' will true up any time an organization or program has to get more efficient," he said in a phone interview. "I think it will focus [the program]; in a lot of ways Medicaid has drifted in terms of its original intent [of] serving the most vulnerable populations."
The biggest "con" to block grants is a psychological one "in that we are accustomed to Medicaid money never running out," he added. "States have to balance their budget, but the federal [Medicaid] money has always been there and is always increasing, with few questions asked, so it's terrifying [when] all of a sudden there's an actual limit on it. That's a very fearful thing ... We don't know how to operate without unending streams of financing."
The annual estimated visits to EDs for suicide attempts and suicidal ideation in 2007 was 580,000 for children, which jumped to 1.12 million in 2015.
This article first appeared on Monday, April 8, 2019 in MedPage Today.
By Kristen Monaco, Staff Writer, MedPage Today.
Emergency department (ED) visits for suicide attempts and suicidal ideation doubled among U.S. children and adolescents from 2007 to 2015, researchers reported.
In a cross-sectional analysis, the annual estimated visits to EDs for suicide attempts and suicidal ideation in 2007 was 580,000 for children (median age 13 years), which jumped to 1.12 million in 2015 (92.1%, 95% CI 68.9%-130.3%; P=0.004 for trend), according to Brett Burstein, MDCM, PhD, MPH, of Montreal Children's Hospital, and colleagues.
Kids, ages 5 to 11 years, accounted for the largest proportion of those ED visits, they reported in JAMA Pediatrics:
Ages 5 to <12: 43.1% (95% CI 39.6%-46.6%)
Ages 12 to <15: 24.3% (95% CI 21.4%-27.6%)
Ages 15 to <18: 32.6% (95% CI 29.5%-35.8%)
"Findings suggest a critical need to augment community mental health resources, ED physician preparedness, and post-emergency department risk reduction initiatives to decrease the burden of suicide among children," Burstein's group noted.
However, there was no statistically significant change in total ED visits during the time period at 26.9 million to 31.8 million (18.2%, 95% CI -5.4% to 42.2%, P=0.67 for trend).
Suicide attempts and suicidal ideation grew to account for a larger proportion of all ED visits for youth over this nine-year period from 2.17% to 3.50% (61% increase; P=0.001 for trend), the researchers reported.
A previous retrospective review of hospital database records also showed a doubling in the annual percentage of hospital visits for suicide ideation and suicide attempts among U.S. children from 2008 to 2015.
Drawing on data from the National Hospital Ambulatory Medical Care Survey database, the researchers looked at samples of ED visits from 300 randomly selected U.S. hospitals.
"A strength of the NHAMCS is its inclusion of hospitals other than academic centers, which are the settings for most published research, thereby giving a more complete picture of health care trends," they noted, adding that in "this broader setting, NHAMCS data suggest more at-risk young children than described among pediatric hospitals alone."
Burstein and colleagues pointed out that "no conclusions can be drawn regarding the cause for the observed increase, which is likely multifactorial."
They used multistage probability sampling to generalize the data to calculate U.S. population-level estimates.
The analysis included children, ages 5 to 18 years, who had either a chief complaint or a discharge diagnosis of a suicide attempt or suicidal ideation. The researchers cautioned that one limitation to this method was the possibility of a nonsuicidal self-harm being incorrectly coded as either a suicide attempt or suicidal ideation by a physician.
The majority of the visits were for a suicide attempt, accounting for over 87% (95% CI 84.1%-89.7%) of cases, while 12.8% of ED visits were for suicidal ideation without a suicide attempt. Looking at just suicide attempts only, ED visits rose from 540,000 in 2007 up to 960,000 in 2015 (79.3% increase, 95% CI 62.2%-137.8%, P=0.02 for trend).
Burstein told USA Today that "The majority of the patients tracked in the data did not go to specialized pediatric centers. Most EDs "are not, in general, adequately equipped to deal with this problem," he added. "They lack the resources to deal with this mental health crisis."
WASHINGTON -- Overturning the Affordable Care Act, maintaining women's access to birth control, and taking better care of unaccompanied minors entering the country without papers were just a few of the issues Health and Human Services Secretary Alex Azar addressed during a Senate Appropriations committee budget hearing on Thursday.
"The fact is the administration is doing everything it can to sabotage healthcare, and this budget appears to be just more of the same," said Sen. Patty Murray (D-Wash.), ranking member of the Senate Appropriations Subcommittee on the Departments of Labor, Health and Human Services, and Education, and Related Agencies, which was holding the hearing. "Your budget calls for repealing and replacing the ACA with the failed Trumpcare bill, which was rejected by the last Congress, and ... last week President Trump sided with the [district court] ruling that all of the ACA should be struck down -- all of it."
"According to reports, you initially opposed President Trump on that and issued a statement of support," she continued. "Did you initially object to the president's decision to side with the Texas court because you know the impact this would have; it would be devastating for so many families?"
'Reasonable Minds Can Differ'
Azar did not answer the question directly. "The advice of a Cabinet member to the President of the United States is highly confidential and it wouldn't be appropriate for me to comment on that," he replied. "The position the administration took in the ACA litigation is an appropriate position; it's supporting a district court's decision ... Reasonable minds can differ on this question of legal issues. This is not our policy position; that is a legal conclusion about the ACA ... We want to protect preexisting conditions; if the litigation ends up in that position we want to work with you to secure better care for people and make sure all the issues you raised are taken care of."
Sen. John Kennedy (R-La.) was a little more friendly to the secretary. "I remember when Congress passed [the ACA], we were promised ... that it would make health insurance more affordable. Has it done that?" he asked.
"No it has not," Azar said. "We were promised health insurance would cost half what it cost at the time; in fact, during President Obama's tenure, it doubled in cost for people having to buy insurance."
"Congress also promised us it would make health insurance more accessible," Kennedy said. "Has it done that?"
"No it has not; in fact it has restricted choices for individuals now, with a large percentage of states having only one carrier in the individual market," said Azar. Kennedy then asked whether the president supported repealing the ACA without a replacement. "The president has always supported replacing the Affordable Care Act with something else that is better," Azar said.
Changing the Rating Bands
Sen. Joe Manchin (D-W.Va.) asked how -- given that the ACA is already integrated into a sixth of the U.S. economy -- the Trump administration would fix the program. Azar said he would lift the 3-to-1 age band restriction that requires insurers to charge their oldest enrollees no more than three times what they charge their youngest ones; that restriction "has made insurance for [those who are] healthy and young unaffordable, and [so] they walk away from the market," he said.
Manchin said that such a change -- which would allow insurers to charge older patients much more than they do now -- might make insurance unaffordable for older patients. Azar responded that one fix for that was providing insurers with reinsurance for high-cost patients. Several Senate bills have attempted to address the reinsurance issue but have gotten bogged down by various issues, including provisions related to abortion.
The secretary was also asked questions from both Republican and Democratic committee members related to how the agency treated unaccompanied children seeking asylum in the U.S. "I was especially appalled by the great lengths former ORR [Office of Refugee Resettlement] director Scott Lloyd went to [in order] to prevent minors in ORR custody from accessing reproductive care, including cases where pregnancies were the result of sexual assault," said Murray.
"Despite the fact that a federal judge issued an injunction in March of 2018 barring ORR from obstructing access to abortion, a recently released spreadsheet shows ORR continued to track minors' private reproductive health information [such as their menstrual periods] through June 2018 ... Does ORR still keep [such] a spreadsheet?"
"I'm not aware of any centralized spreadsheet," Azar said. "I believe the intention [was to collect] the last menstrual period date ... which is vital to prenatal care just to know the age of the child ... I believe we're fully compliant with the court's order and injunction."
Concerns Over Title X
Murray also asked Azar about his department's recent announcement of grants that were issued under HHS's Title X program, which funds birth control and other women's reproductive health services for low-income patients. She noted that one grant went to "an ideologically driven organization that doesn't even offer FDA-approved birth control ... Is birth control an evidence-based family planning option?" she asked.
"We support the full range of family planning; that's why we kept the Title X program at flat funding even as we cut other parts of the budget," said Azar. "We do support access to contraception and birth control and the full range of family planning options."
Sen. Jerry Moran (R-Kan.) wanted to discuss the controversy over the allocation of donated organs, specifically livers. "Let me first ask if you believe enough is being done to help individuals with end-stage liver disease who are not yet on a waitlist; is enough being done to advance their well-being?" he asked.
"The number one thing we can all be doing is working to increase the supply of livers we have for transplantation," said Azar. Moran asked whether Azar would commit to public disclosure of the process being used to allocate livers. Azar responded that organ allocation was a challenging topic for his office because "Congress took that out of my hands to make it a nonpolitical issue ... but I'm happy to work with you and your staff on any vehicle to ensure [a public process]."
Moran appeared unsatisfied with that response; he noted that the HHS secretary appoints the director of the Health Resources and Services Administration, who oversees the transplant allocation process. "It was only after a lawsuit was filed, as I understand it, that this allocation process was then considered for change," he said. "This process has been flawed. You're right -- the issue is more organ donation and the policy being developed is contradictory to what you said was the goal."