California Hospitals See Massive Surge In Homeless Patients

KFF Health News, April 2, 2019

Health officials and homeless advocates attribute the trend to the surging number of people living homeless in California in recent years.

This article was first published April 2, 2019, by Kaiser Health News.

By Phillip Reese, Kaiser Health News

Homeless patients made about 100,000 visits to California hospitals in 2017, marking a 28% rise from two years earlier, according to the most recent state discharge data.

More than a third of those visits involved a diagnosis of mental illness, according to the Office of Statewide Health Planning and Development. By contrast, 6% of all hospital discharges in California during that time involved a mental health diagnosis.

Health officials and homeless advocates attribute the trend to the surging number of people living homeless in California in recent years. From 2015 to 2017, the state's homeless population grew by about 16%, to 134,000, according to point-in-time reports compiled by the U.S. Department of Housing and Urban Development. Those figures cover only a single day, and homeless advocates argue far more Californians experience homelessness at some point over the course of a year.

Many researchers say California's skyrocketing housing costs have helped drive the overall spike in homelessness. Studies also indicate that more than a quarter of people living on the streets are dealing with mental illness.

Besides mental illness, a disproportionate number of homeless were hospitalized for treatment of HIV infections, alcohol and drug addictions, skin disorders, burns, drug overdoses and traumatic injuries.

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"The folks who are living in the streets are sicker than the general public," said Christie Gonzales, director of behavioral health operations for Wellspace Health.

Wellspace Health provides respite care to homeless patients in the Sacramento region after they are discharged from the hospital. "We tend to see more of them with injuries and trauma, co- occurring with alcohol and drug problems," Gonzales said.

Los Angeles County saw the most discharges involving homeless patients in 2017, with 35,234, followed by San Diego, Sacramento, Orange and San Francisco counties. The number of homeless patients treated in L.A. County grew by about 7,500 from 2015 to 2017, the largest numerical increase in the state. (That is largely due to the county's size; the percentage growth in L.A. County homeless discharges was similar to the state average.)

Among places with at least 5,000 hospital discharges in 2017, the counties with the highest proportion of discharges involving homeless patients were San Francisco, Yolo, Santa Cruz and Humboldt. In all four counties, homeless discharges made up at least 4% of all hospital discharges.

"There is no housing out here," said Nicole Ring-Collins, who manages a winter shelter program for Mercy Coalition of West Sacramento in Yolo County. "It is so expensive."

Providers who work with homeless people say it is no surprise they end up hospitalized at disproportionate rates. Living in deep poverty can lead to health problems. Many homeless people are driven to the streets by health issues, particularly mental illness and drug addiction. Most of their inpatient health care is paid for through Medi-Cal, the state-federal insurance program for the poor, or Medicare, the government insurance program for seniors and people with disabilities.

"When folks are forced to live outside with no shelter, the trauma they experience can result in more medical issues," said Noel Kammermann, executive director of Loaves and Fishes, a homeless services agency in Sacramento.

Often, people living homeless do not see the doctor until they have a serious problem, Kammermann said. That lack of preventive care can lead to hospital stays. And living on the streets makes it all the more challenging to follow post-discharge instructions for rehabilitation and recovery.

"You heal better at home," said Peggy Wheeler, a vice president at the California Hospital Association. Homeless patients struggle after discharge when they "have to go right back out to the street for a wound that needs to heal or medicine that needs to be taken on a regular schedule," she added.

Hospitals across the state are working to provide respite care to the homeless after discharge, similar to the collaborative program at Wellspace in the Sacramento region, Wheeler said. Hospitals design such programs to lower readmission rates.

The homeless "are more vulnerable to other things because they don't have a home to go to convalesce," said Trina Gonzalez, director of community integration at UC Davis Health. "We want to make sure they are connected to the appropriate follow up care."

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

Suicide Risk Grew After Missouri Medicaid Kids Shifted To Managed Care, Hospitals Say

KFF Health News, April 1, 2019

The Missouri Hospital Association called on state Medicaid officials to investigate findings about children covered by the state-federal program for low-income families.

This article was first published Monday, April 1, 2019 in Kaiser Health News.

By Phil Galewitz

After more than 2,000 Missouri children diagnosed with mental illness were shifted from traditional Medicaid into three for-profit managed-care companies, the state's hospitals noticed an alarming trend: a doubling in the percentage who had thoughts of suicide or attempted suicide.

Additionally, the average length of stay for these children in psychiatric hospitals dropped from 10 days to seven following the Medicaid change in May 2017, according to a study released this month by the Missouri Hospital Association.

The hospital association called on state Medicaid officials to investigate the study's findings about children covered by the state-federal program for low-income families. The group acknowledged that factors other than the move to managed care could have played a role behind the increase, including social media, cyberbullying and lack of access to specialized mental health care.

While children with suicidal thoughts are at higher risk of suicide, the hospital association said it had no evidence that more children were taking their own lives after the move to managed care.

The growing number of suicides among children and youths has prompted national concern. The suicide rate in Missouri has doubled from 2.8 per 100,000 children in 2003 to 6.4 per 100,000 children in 2017, according to the hospital association. In that same time period, 735 Missouri children died by suicide.

The Missouri Health Plan Association, which represents the three Medicaid managed-care plans in the state, slammed the report. "This study is not peer-reviewed, it is based on a very small sample size and was clearly commissioned to attempt to further a predetermined hypothesis," the group said in a statement.

Despite finding the study "fundamentally flawed," the health plan association added that it was taking the findings "very seriously."

Joan Alker, director of the Georgetown University Center for Children and Families, called the Missouri report "extremely troubling." She said the new data set doesn't prove managed care has caused any problem but does raise questions over whether children are getting adequate treatment.

"Managed care is an effort to save money and that is done by getting rid of unnecessary care or coordinating care better, but a lot of managed-care organizations cut corners," she said.

Missouri's top Medicaid official said he was aware that youth suicides had increased in the state since 2003, but he reacted cautiously to the report's implied connection to the growing use of managed care since 2017. Missouri Medicaid shifted to managed care in the more populous areas of the state around St. Louis and Kansas City nearly a decade ago.

"We welcome collaborative conversations on how to address these problems, but cannot let those conversations devolve into finger pointing," Missouri Medicaid Director Todd Richardson said in a statement. More research is needed into other factors, he said, such as access to follow-up care, medication compliance and differences in outcomes at facilities around the state.

Angela Kimball, national director of advocacy and public policy at the National Alliance on Mental Illness, said Medicaid managed care can be helpful in coordinating treatments and providing special services such as team-based care. But it can also "mean denying access to care or not approving services that are needed."

Managed care works best when states provide strong oversight and clarity about the health plans' goals, she said.

Kimball said that the move to managed care could play a role in more children acknowledging suicidal thoughts or attempts, but that greater awareness of mental health conditions and of suicide could factor in.

The study looked at the impact of the state's shift of 160,000 low-income children living in 61 mostly rural counties from traditional fee-for-service Medicaid to managed care in 2017.

That included 2,152 children ages 5 to 19 who received inpatient mental health services before and after the switch to managed care. The study used hospital insurance claims data for the 18 months before the shift and 19 months after.

When these children were getting coverage through traditional Medicaid, about 10 percent had suicidal thoughts or made a suicide attempt in the 90 days after being discharged from an inpatient psychiatric hospital. That figure rose to nearly 19 percent after the move to managed care.

A similar increase was found analyzing children both 30 days and 60 days after discharge, according to the study.

Paul Gionfriddo, CEO of Mental Health America, a nonprofit that advocates for better care, said if managed care was working it would be making children healthier — meaning children with mental health issues would be less likely to think about suicide or attempt it.

"If this was my state where I was a public policy maker, I would be very nervous and concerned and open a public inquiry to examine what is happening," said Gionfriddo, a former Connecticut state lawmaker.

Missouri hospitals and psychiatrists for years have speculated that the state's move to require Medicaid enrollees to get coverage through private managed-care plans reduced their access to mental health services.

That's because many private health plans have tightened the criteria for patients seeking inpatient care or reduced the length of their admission.

Alyson Wysong-Harder, a co-author of the study, called the data shocking. She is the CEO of Heartland Behavioral Health Services, a psychiatric facility in Nevada, Mo., which treats children and is about 90 miles south of Kansas City.

"We get these kids readmitted on a regular basis," she said. "These are very vulnerable patients."

Wysong-Harder said the lack of child psychiatrists in many communities means it's vital that children get adequate time in the hospital to deal with their mental illness.

"They have this one opportunity often to get this critical care and to get their medications done right," she said.

The lack of child psychiatrists is a problem for all health insurers, including Medicaid.

Although about 71 percent of physicians accept new Medicaid patients, only about one-third of psychiatrists do, according to a study released this year by the Medicaid and CHIP Payment and Access Commission.

If you know a child who has talked about contemplating suicide, get help by calling the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Crisis Chat, both available 24 hours a day, seven days a week.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Doughnut Hole Is Gone, But Medicare's Uncapped Drug Costs Still Bite Into Budgets

KFF Health News, March 29, 2019

With the cost of specialty drugs increasing, some Medicare beneficiaries could owe thousands of dollars in out-of-pocket drug costs every year for a single drug.

This article was first published on Friday, March 29, 2019 by Kaiser Health News.

By Michelle Andrews

Three times a week, Tod Gervich injects himself with Copaxone, a prescription drug that can reduce the frequency of relapses in people who have some forms of multiple sclerosis. After more than 20 years with the disease, Gervich, 66, is accustomed to managing his condition. What he can't get used to is how Medicare's coinsurance charges drain his wallet.

Unlike commercial plans that cap members' out-of-pocket drug spending annually, Medicare has no limit for prescription medications in Part D, its drug benefit. With the cost of specialty drugs increasing, some Medicare beneficiaries could owe thousands of dollars in out-of-pocket drug costs every year for a single drug.

Recent proposals by the Trump administration and Sen. Ron Wyden (D-Ore.) would address the long-standing problem by imposing a spending cap. But it's unclear whether any of these proposals will gain a foothold.

The 2006 introduction of the Medicare prescription drug benefit was a boon for seniors, but the coverage had weak spots. One was the so-called doughnut hole — the gap beneficiaries fell into after they accumulated a few thousand dollars in drug expenses and were on the hook for the full cost of their medications. Another was the lack of an annual cap on drug spending.

Legislative changes have gradually closed the doughnut hole so that, this year, beneficiaries no longer face a coverage gap. In a standard Medicare drug plan, beneficiaries pay 25% of the price of their brand-name drugs until they reach $5,100 in out-of-pocket costs. Once patients reach that threshold, the catastrophic portion of their coverage kicks in and their obligation drops to 5%. But it never disappears.

It's that ongoing 5% that hits hard for people, like Gervich, who take expensive medications.

His 40-milligram dose of Copaxone costs about $75,000 annually, according to the National Multiple Sclerosis Society. In January, Gervich paid $1,800 for the drug and another $900 in February. Discounts that drug manufacturers are required to provide to Part D enrollees also counted toward his out-of-pocket costs. (More on that later.) By March, he hit the $5,100 threshold that pushed him into catastrophic coverage. For the rest of the year, he'll owe $295 a month for this drug, until the cycle starts over again in January.

That $295 is a far cry from the approximately $6,250 monthly Copaxone price without insurance. But, combined with the $2,700 he already paid before his catastrophic coverage kicked in, the additional $2,950 he'll owe this year is no small amount. And that assumes he needs no other medications.

"I feel like I'm being punished financially for having a chronic disease," he said. He has considered discontinuing Copaxone to save money.

His drug bill is one reason Gervich has decided not to retire yet, he said.

An annual cap on his out-of-pocket costs "would definitely help," said Gervich, a self-employed certified financial planner in Mashpee, Mass.

Drugs like Copaxone that can modify the effects of the disease have been on a steep upward price trajectory in recent years, said Bari Talente, executive vice president for advocacy at the National Multiple Sclerosis Society. Drugs that used to cost $60,000 annually five years ago cost $90,000 now, she said. With those totals, Medicare beneficiaries "are going to hit catastrophic coverage no matter what."

Specialty-tier drugs for multiple sclerosis, cancer and other conditions — defined by Medicare as those that cost more than $670 a month — account for more than 20% of total spending in Part D plans, up from about 6% before 2010, according to a report by the Medicare Payment Advisory Commission, a nonpartisan agency that advises Congress about the program.

Just over 1 million Medicare beneficiaries in Part D plans who did not receive low-income subsidies had drug costs that pushed them into catastrophic coverage in 2015, more than twice as many as the 2007 total, an analysis by the Kaiser Family Foundation found. (KHN is an editorially independent program of the foundation.)

"When the drug benefit was created, 5% probably didn't seem like that big a deal," said Juliette Cubanski, associate director of the Program on Medicare Policy at the Kaiser Family Foundation. "Now we have such expensive medications, and many of them are covered under Part D — where, before, many expensive drugs were cancer drugs" that were administered in doctors' offices and covered by other parts of Medicare.

The lack of a spending limit for the Medicare drug benefit sets it apart from other coverage. Under the Affordable Care Act, the maximum amount someone generally owes out-of-pocket for covered drugs and other medical care for this year is $7,900. Plans typically pay 100% of customers' costs after that.

The Medicare program doesn't have an out-of-pocket spending limit for Part A or Part B, which cover hospital and outpatient services, respectively. But beneficiaries can buy supplemental Medigap plans, some of which pay coinsurance amounts and set out-of-pocket spending limits. Medigap plans, however, don't cover Part D prescription plans.

Counterbalancing the administration's proposal to impose a spending cap on prescription drugs is another that could increase many beneficiaries' out-of-pocket drug costs.

Currently, brand-name drugs that enrollees receive are discounted by 70% by manufacturers when Medicare beneficiaries have accumulated at least $3,820 in drug costs and until they reach $5,100 in out-of-pocket costs. Those discounts are applied toward beneficiaries' total out-of-pocket costs, moving them more quickly toward catastrophic coverage. Under the administration's proposal, manufacturer discounts would no longer be treated this way. The administration said this would help steer patients toward less expensive generic medications.

Still, beneficiaries would have to pay more out-of-pocket to reach the catastrophic spending threshold. Thus, fewer people would likely reach the catastrophic coverage level where they could benefit from a spending cap.

"Our concern is that some people will be paying more out-of-pocket to get to the $5,100 threshold and the drug cap," said Keysha Brooks-Coley, vice president of federal affairs at the American Cancer Society Cancer Action Network.

"It's kind of a mixed bag," said Cubanski of the proposed calculation change. "There will be savings for some individuals" who reach the catastrophic phase of coverage. "But for many there will be higher costs."

For some people, especially cancer patients taking chemotherapy pills, the lack of a drug-spending cap in Part D coverage seems especially unjust.

These cutting-edge targeted oral chemotherapy and other drugs tend to be expensive, and Medicare beneficiaries often hit the catastrophic threshold quickly, said Brooks-Coley.

Patty Armstrong-Bolle, who lives in Haslett, Mich., takes Ibrance, a pill, once a day to help keep in check the breast cancer that has spread to other parts of her body. But while the medicine has helped send her cancer into remission, she may never be free of a financial obligation for the pricey drug.

Armstrong-Bolle, 68, paid $2,200 in January and February for the drug last year. When she entered the catastrophic coverage portion of her Part D plan, the cost dropped to $584 per month. Armstrong-Bolle's husband died last year, and she used the money from his life insurance policy to cover her drug bills. This year, a patient assistance program has covered the first few months of coinsurance. That money will run out next month and she'll owe her $584 portion again.

If she were getting traditional drug infusions instead of taking an oral medication, her treatment would be covered under Part B of the program and her coinsurance payments could be covered.

"It just doesn't seem fair," she said.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

Older Adults With Joint Replacements Recover At Home, Not Rehab

KFF Health News, March 28, 2019

Home-based recovery appears to be best if the procedure is elective, friends and family are available to help and someone doesn't have serious conditions that could lead to complications.

This article was first published on March 28,2019 in Kaiser Health News.

By Judith Graham

Older adults and their families often wonder: Where's the best place to recover after a hip or knee replacement — at home or in a rehabilitation facility?

Increasingly, the answer appears to be home if the procedure is elective, friends and family are available to help and someone doesn't have serious conditions that could lead to complications.

This trend is likely to accelerate as evidence mounts that recuperating at home is a safe alternative and as hospitals alter medical practices in response to changing Medicare policies.

The newest data comes from a March study in JAMA Internal Medicine of 17 million Medicare hospitalizations of people from 2010 to 2016. All the patients were older adults and went home or to a skilled nursing facility after a medical procedure or a serious illness. Knee and hip replacements were the most common reason for these hospitalizations.

People who were sent home with home health care services demonstrated the same level of functional improvement as those who went to a skilled nursing facility (assessments examined their ability to walk and get up and down stairs, among other activities), the study found. And they were no more likely to die 30 days after surgery (a very small percentage in each group). Overall, costs were significantly lower for patients who went home, while hospital readmissions were slightly higher — a possible signal that home health care services needed strengthening or that family caregivers needed better education and training.

"What this study tells us is it's certainly safe to send people home under many circumstances," said Dr. Vincent Mor, a professor of health services, policy and practice at Brown University's School of Public Health who wrote an editorial accompanying the study.

The new report expands on previous research that came to a similar conclusion. In 2017, experts from New York City's Hospital for Special Surgery published a study that examined 2,400 patients who underwent total knee replacements and were discharged home or to a skilled nursing facility for rehabilitation between May 2007 and February 2011. There were no differences in complication rates at six months or in functional recovery and patient-reported outcomes at two years.

"As a result of these findings, we are encouraging all of our patients to consider home discharge after TKA [total knee replacement]," the authors wrote.

The year before, researchers at New York University reported in JAMA Internal Medicine that from 2009 to 2012 and 2013-14, discharges to rehabilitation facilities fell from 68 to 34 percent for patients undergoing hip and knee replacements, from 71 to 22 percent for patients with cardiac valve replacement surgeries, and from 40 to 30 percent for patients who'd had spinal fusion surgery. Instead, more people were sent home to recover. During this period, NYU Langone Medical Center assumed financial responsibility for "episodes of care" for joint replacements that include the post-hospital recovery period — a policy that Medicare is now promoting.

Diane Rubin, 67, who lives on Long Island, had a hip replacement at the NYU medical center in January. Before the surgery, she got a list of things she'd need to do to prepare for her recovery; afterward, a nurse and physical therapist visited her at home regularly for about three weeks. "I was more comfortable recuperating at home and I've had absolutely no complications," she said.

How do physicians decide where to send patients? "In general, we tend to send patients to skilled nursing facilities who are older, sicker, more deconditioned after surgery, and who have no spouse or caregiver, fewer resources and little social support," said Dr. Leora Horwitz, a co-author of that study and associate professor of population health and medicine at New York University School of Medicine.

Though it's widely believed that people who live alone might not do well going home, last year researchers at The Rothman Orthopaedic Institute at Thomas Jefferson University in Philadelphia published research showing that isn't necessarily the case. At their institution, patients are assigned a nurse navigator who provides assistance before and after hip or knee replacements. Patients who lived alone stayed in the hospital longer and received more home health care services than those who lived with others.

When they recuperated at home, the Rothman Orthopaedics patients didn't have higher rates of medical complications, returns to the hospital or emergency room visits than those who went to rehabilitation facilities. Nearly 90% of people who lived alone said they'd again choose a home discharge.

Dr. William Hozack, a co-author of the study and professor of orthopedic surgery at Thomas Jefferson University Medical School, acknowledged that patients who go to rehabilitation are probably sicker and more debilitated than those who go home, potentially biasing research results. Still, practices have changed considerably. Today, he and his colleagues send 95% of patients who get hip and knee replacements home to recover, instead of directing them to institutions.

People shouldn't underestimate how much help they may require at home, especially in the first few weeks after surgery, said Carol Levine, director of the United Hospital Fund's families and health care project, who has had two hip replacements. The potential downsides to going home include a greater burden on caregivers and the possibility that complications won't be identified as quickly, needs will go unmet if friends and family can't pitch in, and people won't follow through on recommended rehabilitation regimens. And outcomes may not be as favorable if services that support people at home aren't readily available

Utah's Intermountain Healthcare, a health system that operates 23 hospitals and nearly 170 medical clinics, is bringing an array of services — palliative care, dialysis, primary care and hospital care — into the home through its new Intermountain at Home program. Recovering at home after a hospital procedure is also a focus, and Intermountain has created standardized procedures for hip and knee replacements over the past few years, according to Rajesh Shrestha, the system's chief operating officer of community-based care.

Every joint-replacement patient going home after surgery now gets a thorough assessment to determine the resources that are needed. A care plan is created and a case manager, usually a registered nurse, makes sure that physical therapy, durable medical equipment and home health care are supplied. The case manager also coordinates postoperative care with orthopedic surgeons and makes sure that patients reconnect post-surgery with their primary care physicians. And a team of providers is available 24/7.

During the past few years, discharges to rehabilitation facilities have declined by half at most of Intermountain's Utah facilities, with no notable increase in complications or hospital readmissions, Shrestha said. During 2018, 85 percent of knee replacement patients and 88 percent of hip replacement patients went home after surgery, respectively.

At Kaiser Permanente, a health plan with more than 12 million members, a substantial number of patients who get elective hip and knee replacements are skipping a hospital stay altogether and going home the same day. In Kaiser's Southern California region, same-day joint replacement home discharges now total about 50%, according to Dr. Nithin Reddy, who oversees joint replacements for the region. (Kaiser Health News is not affiliated with Kaiser Permanente.)

Kaiser Permanente has made this possible by changing how procedures are done (an anterior approach for hip replacements, for example), introducing new protocols for pain management (opioids are used less frequently), altering anesthesia protocols (less general anesthesia and more regional anesthesia), reducing blood transfusions and hiring "total joint coordinators" (typically nurses) to help with the transition from the hospital to home. All patients go home with home health care, receive two outreach calls the week after surgery and get comprehensive handbooks with checklists of what to do before and after surgery and common concerns to look out for.

"We have very robust discharge criteria: Patients have to have well-managed pain and be able to get in and out of bed by themselves and in and out of the restroom by themselves. And they need to be able to walk 50 to 75 feet unassisted, using a walker," Reddy said. "If they can't do those things, they aren't safe for a home discharge and [rehabilitation at] a skilled nursing facility would come into play."

Magdalena Ritayik, 66, one of the doctor's patients, had a knee replacement last September after cortisone shots stopped working and pain became a constant companion. Six years before, her husband had both knees replaced, separately, and stayed in the hospital three days each time. By contrast, Ritayik went home the afternoon after her surgery, only to find a nurse and physical therapist waiting there for her.

"The nurse went over all the medications, when to take them and how much. The physical therapist showed me how to do bending and stretching with a chair in the living room and to raise [my leg] while I was lying on the bed," Ritayik said. "The first week you have to stay home. After the second week, I was walking almost like regular. A month after the surgery, I was at full extension and full bending."

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Judith Graham: @judith_graham

Device-Safety Experts To FDA: Make Data Public

KFF Health News, March 27, 2019

Researchers say the agency needs to open the data on scores of medical devices, which have included mechanical ventilators and pacemaker electrodes.

This article first appeared on Wednesday, March 27, 2019 in Kaiser Health News.

By Christina Jewett

Medical device safety researchers are calling on the Food and Drug Administration to release hundreds of thousands of hidden injury and malfunction reports related to about 100 medical devices.

A recent Kaiser Health News investigation revealed that the FDA granted device makers numerous 'exemptions' from the standard rules of publicly reporting harm related to devices.

One such program began about 19 years ago and allowed companies to file alternative summary reports about injuries or malfunctions into a database not visible to doctors, medical researchers or the public.

While the FDA pledged quickly to review the safety of one such device — the surgical stapler — researchers say the agency needs to open the data on scores of other devices, which have included mechanical ventilators and pacemaker electrodes.

"The FDA absolutely should be making all of this information available," said Diana Zuckerman, president of the National Center for Health Research, who has testified to Congress and the FDA about device safety.

During a recent interview, FDA Commissioner Scott Gottlieb said that he had no immediate plans to release the device-safety reports, but that the matter is under review. In an updated statement Tuesday, he added that "we are looking at ways to make ASR [alternative summary reporting] data received prior to 2017 more easily accessible."

"I think that the imperative of the agency is to make as much of this information available to the public as possible," Gottlieb said during the interview last week. "I think these databases by and large should be searchable to the public."

An agency spokeswoman said the FDA revoked most of the "alternative summary reporting" exemptions in mid-2017 and asked device makers who kept their exemptions to file a public report summarizing what information they'd send in a spreadsheet directly to the agency. That new approach doesn't affect the hidden reports dating to 2000.

Agency data show that more than 2 million alternative summary reports have been filed since the start of 2014.

In a February guidance statement for device makers, the FDA said summary reporting can streamline reporting for the industry and simplify the agency's review process "while maintaining or enhancing the quality, utility, and clarity of MDRs [device reports] through a more holistic view of reportable event trends."

Makers of about 100 devices filed reports that way over the years, and the FDA has not disclosed the reports' content beyond responding to KHN's questions about specific devices. Among the devices involved are implantable defibrillators and the staplers, which in 2016 were linked to under 100 public reports of harm, even as nearly 10,000 malfunction reports were filed discreetly within the FDA.

Asked for more detail on staplers and other devices with exemptions, the agency referred to the Freedom of Information Act process, which can take nearly two years.

That's not soon enough for organizations like the ECRI Institute. Chief policy officer Ronni Solomon said the nonprofit does device-safety analyses for the government and evidence-based reports for hospitals and performs device-related accident investigations.

Having thorough data on device-related harm is key on all fronts, she said, noting that the organization is exploring ways to get access to more FDA data. 

Dr. Alan Shapiro, an associate professor at the New York University School of Medicine who has used the agency's public device-safety database, called MAUDE, in his research, said paring down patient-safety data and keeping it in-house is the wrong move in the current era of artificial intelligence and automation.

He noted that an important safety tenet in hospitals is: the more eyes on the patient the better. He said there's a clear parallel to the work researchers do with agency data to identify device-safety lapses.

"The FDA isn't so capable that they can afford to hide data," he said.

Hani Elias, chief executive of Lumere, said his consulting company uses the open FDA device data to advise health systems across the nation on device safety for purchasing decisions. He co-founded the company after seeing hospitals make device-buying decisions based on the effectiveness of the sales force rather than on quality and safety.

"There's a lot of benefit in opening up this data," Elias said.

Among the benefits of greater transparency would be the peer pressure among device makers — stripped of reporting exemptions — to make their products safer.

"You don't want to be the people known for the products known for hurting people," said Alan Card, an assistant professor and patient-safety researcher at the University of California-San Diego School of Medicine.

In 2018, the FDA approved a new pathway for makers of 5,600 device types to file malfunction reports in summary format. That program relieves the device makers of seeking a special exemption. It requires one public report detailing a novel or unique type of malfunction. Information about subsequent, similar malfunctions can be sent straight to the FDA in a spreadsheet.

The agency has also quietly granted device makers other summary-reporting exemptions for injury information gleaned from litigation and from device-specific registries used for research. Device makers filing such reports also have to file a public report summarizing the data that is sent directly to the FDA and isn't readily available to the public.

Agency records show that some cardiac device makers have filed hundreds of death reports under the registry exemption. The FDA confirmed that nearly 12,000 litigation summary reports related to injuries associated with pelvic mesh were filed in 2017 alone.

Prior to the KHN investigation, Zuckerman said she was aware the FDA granted reporting exemptions but the sheer number of reports 'takes my breath away.'

In the interview, Gottlieb said he "wasn't aware of the full scope of the reports that weren't going into MAUDE." Gottlieb has announced his resignation; his last day will be April 5.

Card also said the KHN report was a surprise, but now that it's out, it's time for the FDA to open the records to help doctors and patients make the safest choices. "There are a lot of people out there who are trying to make reasonable decisions on data that isn't what it was purported to be," he said.

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

 

Medicaid Expansion Boosts Hospital Bottom Lines — And Prices

KFF Health News, March 27, 2019

While Colorado hospitals are financially better off since the expansion, they have increased the costs they shift to commercial health plans since 2009.

This article first appeared on Wednesday, March 27, 2019 in Kaiser Health News.

By Phil Galewitz

The Medicaid expansion promoted by the Affordable Care Act was a boon for St. Mary's Medical Center, the largest hospital in western Colorado. Since 2014, the number of uninsured patients it served dropped by more than half, saving the nonprofit hospital more than $3 million a year.

But the Grand Junction hospital's prices did not go down.

"St. Mary's is still way too costly," said Mike Stahl, CEO of Hilltop Community Resources, which provides insurance to about half of its nearly 600 employees and their families in western Colorado. "We are not seeing the decreases in our overall health bills that I believe the community overall should be feeling."

Stahl and other employers in Colorado hoped that as hospitals saved millions of dollars in charity care from the Medicaid expansion, it would lead to a curb in consumer and employer health costs and insurance premiums.

A new state report found that didn't happen.

While hospitals are financially better off since the expansion, they have increased the costs they shift to commercial health plans since 2009, the state researchers said.

The state report noted the average hospital profit per each patient discharge rose to $1,359 in 2017, twice the amount in 2009. For patients covered by commercial and employer-based health plans, margins per discharge rose above $11,000 in 2017 compared with $6,800 in 2009.

Julie Lonborg, a spokeswoman for the Colorado Hospital Association, said the state agency that did the study was biased against hospitals and had a "predetermined conclusion." Hospitals in the state are not doing as well as the report suggests, she added, noting that a third of them face operating losses.

And some insurers have not passed along savings to customers that hospitals give them, she said.

Hundreds of thousands of state residents gained coverage under the Medicaid expansion, lowering Colorado's uninsured rate by half to 7 percent. In addition, hospitals' uncompensated care costs dropped by more than 60%, or more than $400 million statewide.

Kim Bimestefer, executive director of the Colorado Department of Health Care Policy & Financing, said that hospitals have used their expanded revenues to focus on adding services that provide high profits or expanding operations in wealthier areas of the state that often duplicate what is already available.

"They used those dollars to build free-standing [emergency departments], acquired physician practices, build new facilities where there was already sufficient capacity," she said. "Hospitals had a fork in the road to either use the money coming in to lower the cost shift to employers and consumers or use the money to fuel a healthcare arms race. With few exceptions, they chose the latter."

Hospital's Profit Margin Doubles

In written testimony to the state legislature last year, Colorado officials pointed to St. Mary's as an example of a hospital with high overhead and operating costs — factors they said can lead to higher insurance premiums.

The facility's profit margin was above 14 percent from 2015 to 2017, according to the latest available tax returns. Those figures are nearly double St. Mary's margin before expansion and twice the margin of the average U.S. hospital in 2017, according to American Hospital Association data.

Colorado is the first state to analyze whether hospital cost-shifting — often referred to as a "hidden tax" on health plans — dropped following Medicaid expansion.

But a conservative think tank in Arizona said hospitals there did not cut prices following that state's Medicaid expansion.

"Not only did [it] fail to deliver on the promises of alleviating the hidden healthcare tax, it allowed urban hospitals to increase charges on private payers dramatically," said a report from the Phoenix-based Goldwater Institute.

Some critics point out that hospitals are also benefiting because Congress has repeatedly delayed a key ACA provision that would have cut federal funding for hospitals with large numbers of Medicaid and uninsured patients.

The continuation of the program — called Medicaid disproportionate share payments — has provided Colorado hospitals a total of $108 million.

How Outside Costs May Factor In

The hospital industry disputes reports that it has merely pocketed profits from Medicaid expansion. They say many factors influence how much they charge employers and private insurers, including the need to upgrade technology and meet rising health and drug costs.

Lonborg of the state hospital association said hospitals need to shift costs to private employers to make up for lower prices paid by Medicare and Medicaid and to make up for care hospitals give for free to the uninsured.

But, she added, other factors, including the need to keep up with rapid population growth, have kept costs from dropping.

Janie Wade, chief financial officer for SCL Health, the Broomfield, Colo., hospital chain that owns St. Mary's and seven other facilities, said its costs are higher because it has sicker and older patients than most.

She said looking at just the hospital profit margins on St. Mary's IRS-990 form is not a fair assessment because it doesn't take into account costs that are outside the hospital, such as its 93 physician practices. The hospital lost nearly $12 million on those doctor practices in 2017, she said.

Across all operations, she added, the hospital's operating margin fell from 9.5 percent in 2015 to 4.5 percent in 2018.

Wade said the hospital used some of its new revenue to purchase 14 physician practices in recent years. That was designed, she added, not to ensure they send their patients to St. Mary's but to help keep those doctors in the city so they can staff important services such as trauma and maternity care.

"Medicaid expansion was a good thing and, of course, we supported it," Wade said.

But she pointed out that the hospital loses money on Medicaid and Medicare, which together cover more than three-quarters of its patients.

St. Mary's has sought to keep price increases for commercial insurers and employers to no more than the general inflation rate and made it even lower for some, according to Wade. If employers' rates were rising more than that, she said, it was likely because insurers were adding price increases.

Officials from Rocky Mountain Health Plans, which was recently acquired by UnitedHealthcare and is one of Grand Junction's largest insurers, would not comment.

Dave Roper, who used to oversee employee benefits for the city of Grand Junction and now heads a local employer coalition, said the state report confirms what local businesses leaders have long known. "St. Mary's has no incentive to reduce its costs," he said.

Edmond Toy, a senior adviser for the nonprofit Colorado Health Institute, said the argument that pursuing the ACA policy would help lower insurance premiums "broadened the appeal of Medicaid expansion … and conceptually it makes total sense."

But he noted health experts have long debated whether the higher prices hospitals charge people with private insurance are designed to make up for the losses they take on with Medicare, Medicaid and uninsured patients.

He said the state report shows how hospitals in heavily consolidated markets don't have to cut prices as their bottom lines improve. "They can charge whatever the market will bear."

Marianne Udow-Phillips, director of the Center for Health and Research Transformation at the University of Michigan, said hospitals have considerable bargaining power in many places because of health system consolidations and their purchases of many physician practices.

"It does appear Colorado hospitals have a strong negotiating position with payers, or payers there are not negotiating very effectively," said Udow-Phillips. "Hospitals are not going to give it away."

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Price Of A Brace Brings Soccer Player To His Knees

KFF Health News, March 26, 2019

After a sports injury, Esteban Serrano owed $829.41 for a knee brace purchased with insurance through his doctor's office. The same kind of braces sell for less than $250 online.

This article first appeared Tuesday, March 26, 2019 in Kaiser Health News.

By Paula Andalo

Last October, Esteban Serrano wrenched his knee badly during his weekly soccer game with friends.

Serrano, a software engineer, grew up playing soccer in Quito, Ecuador, and he has kept up his sport since moving to the United States two decades ago.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR's Bill-of-the-Month Club and tell us about your experience. We'll feature a new one each month.

He hobbled off the field and iced the knee. But the pain was so severe, he made an appointment with Rothman Orthopaedic Institute, a network of orthopedists practicing in Greater Philadelphia, New Jersey and New York.

The doctor diagnosed a strain of the medial collateral ligament, or MCL, and prescribed over-the-counter pain medication as well as a hinged knee brace, which he used for several weeks until he'd healed.

He expected his insurance to cover his treatment as a plan from a previous job had covered him when he needed surgery to fix a broken nose sustained in another soccer game in 2017.

Then the bill came.

 "The doctor told me that he thought I didn't have damage, that it was more of an inflammation, but he ordered an MRI just to make sure," said Serrano. (The MRI confirmed that suspicion.)

Serrano said the brace did ease the discomfort and stabilized his knee as it healed. However, the shocking bill was almost more painful — he owed the orthopedic practice $829.41.

"You can find the same brace for less than $250 online," he said.

The bill came close to Christmas, when Serrano's 12-year-old daughter wanted her first iPhone. "I told her 'Sorry, honey, but I already paid a price of an iPhone for the hinged knee brace,'" Serrano joked.

Serrano emphasized that he felt lucky to have the money to handle a bill that for many people could equal a month's rent or three months of groceries.

Knee braces fall into a category of products called "durable medical equipment," whose prices can vary widely. Items range from slings and braces to wheelchairs and commodes to glucose meters and breast pumps for new mothers. Doctors and hospitals that dispense and prescribe such equipment for patients to take home almost always bill for them and add hefty markups that can catch patients unaware.

Bottom of Form

Braces and other products "are often marked up two or three times what the cost is, and unfortunately, that is the standard practice," said Dr. Matthew Matava, an orthopedic surgeon and chief of sports medicine for Washington University Physicians in St. Louis.

Rothman Orthopaedic didn't respond to requests for comments.

The type of hinged knee brace Serrano bought was a Donjoy Playmaker. Donjoy is one of the nation's largest producers of braces. A customer service representative for the company said it charges a retail price of $242.51 for the model Serrano got. Serrano paid more than three times that price.

In an emailed statement about the case, an Aetna spokesman wrote that "while the cost of a knee brace, or any other health care service, is determined by the negotiated rate between the health care provider and the health plan, the starting point is the charge from the health care provider."

It is not even clear that such an elaborate knee brace was needed for Serrano's injury.

Dr. Elizabeth Matzkin, chief of Women's Sports Medicine at Brigham and Women's Hospital in Boston and an assistant professor at Harvard Medical School, said that while it is helpful to give patients some kind of knee brace for support after MCL injuries, the use of a hinged knee brace does not influence recovery, according to studies. She called hinged braces "luxury products." Simpler, cheaper braces also offer support.

Resolution: Serrano recalled that when he received the brace, the practitioner showed him a form with its estimated cost in writing. He remembered his share was more than $700, but he didn't pay too much attention because he assumed his insurance would cover it.

After receiving the bill, he made several phone calls to the doctor's practice to get a copy of the form he'd signed. It stated that the product could be returned within seven days. A month had already passed. Because he had not met his deductible, his $829.41 balance was even more than the estimate.

The Takeaway: These days, many types of equipment dispensed by doctors' offices or hospitals involve a charge. Don't assume generosity. Ask the doctor to identify precisely what you need and explain why you need it.

When a doctor or hospital offers you a piece of equipment to help your healing, decide if you really need it or will use it. Say "no" if you will not. Ask if you will be billed for it and how much.

Many items can be purchased at a fraction of the cost online or from a pharmacy just down the block.

Know your insurance plan's copay for medical equipment (often 20 percent). The cost of purchasing the equipment yourself online may well be less than the copay if you purchase through a medical office.

NPR produced and edited the interview with KHN Editor-in-Chief Elisabeth Rosenthal for broadcast.

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR Bill-of-the-Month Club and tell us about your experience.

Paula Andalo: paulaA@kff.org, @paula_andalo 

New Rules Will Ease Patients' Access To Electronic Medical Records, Senate Panel Says

KFF Health News, March 26, 2019

The rules proposed by HHS take aim at data blocking, in which tech companies or health systems limit the sharing or transfer of information from medical files.

This article first appeared Tuesday, March 26, 2019 in Kaiser Health News.

By Fred Schulte and Erika Fry, Fortune

The chairman of the Senate health committee on Tuesday backed new federal regulations to remove roadblocks patients can face in obtaining copies of their electronic medical records.

"These proposed rules remove barriers and should make it easier for patients to more quickly access, use and understand their personal medical information," Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor & Pensions Committee, said in a statement prepared for a hearing on the rules that kicks off Tuesday at 10 a.m.

The rules, proposed last month by the Department of Health and Human Services, take aim at so-called information blocking, in which tech companies or health systems limit the sharing or transfer of information from medical files.

Alexander said HHS believes the new rules should give more than 125 million patients easier access to their own records in an electronic format.

"This will be a huge relief to any of us who have spent hours tracking down paper copies of our records and carting them back and forth to different doctors' offices. The rules will reduce the administrative burden on doctors so they can spend more time with patients," Alexander said.

The proposal requires manufacturers to fashion software that can readily export a patient's entire medical record — and mandates that healthcare systems provide these records electronically at no cost to the patient.

Congress jump-started the nation's switch from paper to electronic health records in 2009 using billions of dollars in financial stimulus funding to help doctors and hospital purchase the equipment. Officials expected the shift to cut down on medical errors, reduce unnecessary medical testing and other waste and give Americans a bigger role in managing their health care.

Yet in the decade since the rollout, critics have argued that the government spent billions financing software that can cause some new types of errors and typically cannot share information across health networks as intended.

"Botched Operation," a recent investigation published by KHN and Fortune, found that the federal government has spent more than $36 billion on the initiative. During that time, thousands of reports of deaths, injuries and near misses linked to digital systems have piled up in databases — while many patients have reported difficulties getting copies of their complete electronic files.

Jonathan Lomurro, a medical malpractice attorney in New Jersey, said his clients usually have to go to court to get their complete medical record. The information that health care providers fight most bitterly to keep from them, he said, are the audit logs — or the data that show every time a record has been accessed or edited, and by whom and when.

Related: Death By A Thousand Clicks: Where Electronic Health Records Went Wrong

That "metadata," he and other plaintiff attorneys argue, is critical for patients to understand the history of their care, particularly in cases where something has gone wrong.

In an interview prior to Tuesday's hearing, Lomurro criticized the HHS proposal, saying it limits a patient's ability to obtain these logs. While the proposed rule requires the systems to share most data from a medical record with a patient, it excludes audit trails from that classification.

"While the proposal talks about the need of patient access … they then strip the greatest protections from the patient," said Lomurro. "I am at a loss on how this could ever be a beneficial change to the rules and help patients."

Seema Verma, who heads the Centers for Medicare & Medicaid Services, agreed that patients should be entitled to audit log information. "At the end of the day, it's all of the patient's data. If it affects and touches their medical record, then that belongs to them," Verma said in an interview last month.

The HHS proposal also encourages doctors and other users of EHR technology to share information about software problems they encounter by prohibiting "gag clauses" in sales contracts. Critics have long argued that the clauses have prevented users from freely discussing flaws, including software glitches and other breakdowns that could result in medical errors and patient injuries. In 2012, an Institute of Medicine report blamed the confidentiality clauses for impeding efforts to improve the safety of health information technology.

But a major remaining problem in wiring up medicine is the lack of interoperability across rival data systems, said Christopher Rehm, chief medical informatics officer of LifePoint Health, a hospital system in Brentwood, Tenn. In testimony prepared for the Tuesday hearing, Rehm called it "the equivalent of telling people they must buy cars and move those cars from place to place, but there are no roads and no agreed-upon design for the roads, let alone the funding to actually pay for the construction."

According to Rehm, the average-sized community hospital (161 beds) spends nearly $760,000 a year on information technology investments needed to meet federal regulations. He said the costs "are crushing our industry where margins are already thin."

Fred Schulte: fschulte@kff.org, @fredschulte

States Push For Caregiver Tax Credits

KFF Health News, March 25, 2019

AARP is pushing bills in eight state legislatures that would give home caregivers tax credits to help offset the cost of care.

This article first appeared Monday, March 25, 2019 in Kaiser Health News.

By Samantha Young

Gloria Brown didn't get a good night‘s sleep. Her husband, Arthur Brown, 79, has Alzheimer‘s disease and had spent most of the night pacing their bedroom, opening and closing drawers, and putting on and taking off his jacket.

So Gloria, 73, asked a friend to take Arthur out for a few hours one recent afternoon so she could grab a much-needed nap. She was lucky that day because she didn't need to call upon the home health aide who comes to their house twice a week.

The price of paying for help isn't cheap: The going rate in the San Francisco Bay Area ranges from $25 to $35 an hour. Gloria Brown estimates she has spent roughly $72,000 on caregivers, medications and supplies since her husband was diagnosed four years ago.

"The cost can be staggering," said state Assemblyman Jim Patterson (R-Fresno), author of a bill that would give family caregivers in California a tax credit of up to $5,000 annually to help offset their expenses.

A 2016 study by AARP found that the average caregiver spends $6,954 a year on out-of-pocket costs caring for a family member. The expenses range from $7 for medical wipes to tens of thousands of dollars to retrofit a home with a walk-in shower or hire outside help.

AARP, a lobbying organization for people 50 and older, is pushing similar bills in at least seven other state legislatures this year, said Elaine Ryan, the group‘s vice president of State Advocacy and Strategy Integration. Arizona, Illinois, Nebraska, New Jersey, New York, Rhode Island and Wisconsin are considering legislation, and AARP expects measures also to be introduced in Florida, Massachusetts and Ohio.

In Wisconsin, two Republicans and two Democrats are behind that state's tax credit measure.

"We need a whole discussion about how we can best keep people at home and meet their needs," said state Rep. Debra Kolste, a Democrat who explained that most people know someone who is caring for a family member. She hopes the measure can make it through the Republican legislature and be signed by Wisconsin's Democratic governor.

New Jersey approved a state income tax credit in 2017 specifically for caregivers of wounded veterans. However, efforts in other states have failed, including in Arizona last year and Mississippi and Virginia this year.

At the federal level, bills that would have created a federal income tax credit of up to $3,000 never got out of congressional committees last year.

"Whether I'm in Billings, Mont., or in Mississippi, the caregiver tax credit is something that people are asking for," Ryan said. "All they're asking for is a little financial help to offset these costs."

A tax credit, said Brown and other caregivers, would be welcome relief to the estimated 4.5 million family caregivers in California who care for a loved one with a chronic, disabling or serious health condition. Nationwide, the AARP estimates there are about 40 million people caring for family members.

As her husband's disease progresses, Gloria Brown expects costs to escalate. For instance, she wants to install bars in the bathroom to help prevent her husband from falling, and anticipates she will need more professional help.

"I think we're just moving into that stage where I'm going to see the dollars going out for things that will help to make things easier for him at home and more comfortable," Brown said. "It's a cost you just hadn't anticipated."

Long-term caregiving has emerged as one of the major issues in California's Capitol this year, with proposals ranging from naming a state "Aging Czar" to funding a new cash benefit for long-term care services. In his State of the State address last month, Gov. Gavin Newsom called for a master plan for aging.

"I've had some personal — and painful — experience with this recently," Newsom told the joint session of the legislature.

Newsom, whose father had dementia and died last year, also has tapped former first lady Maria Shriver to lead a new Alzheimer's Prevention and Preparedness Task Force, and has asked lawmakers to approve $3 million in state funds for Alzheimer's disease research.

Patterson's bill would provide up to a $5,000 state income tax credit to family caregivers for five years, starting in tax year 2020. They would be reimbursed for 50% of eligible expenses, such as retrofitting a home, hiring an aide and leasing or buying specialty equipment. The credit would be available to individuals who make up to $170,000 a year, or joint income tax filers who make up to $250,000.

Patterson, a Republican in the minority, is hopeful he can convince his colleagues that giving people a tax credit is financially sound because it would enable caregivers to keep their loved ones at home rather than relying on more expensive government services.

"If members of the legislature and the governor would look through the eyes of their own families, friends and neighbors … I think it can be passed and be signed," Patterson said.

But the measure faces competition for a slice of California's $21 billion surplus, from proposals by the governor and lawmakers to boost funding for education, healthcare, housing and dozens of other programs.

For Pam Sogge of Oakland, Calif., a tax credit would allow her to hire a home health aide for an additional three hours a week.

Her husband, Rick Sogge, 61, has early-onset Alzheimer‘s and becomes frantic when left by himself. Sometimes when she leaves him alone in another room of their home, he searches for her every two minutes.

Because Rick Sogge is still physically healthy, most of the couple's caregiving expenses pay for part-time help to take him on outings so Pam can work, run errands or go to the doctor's office.

"You have a very uncertain financial future. You don't know what‘s going to happen. You don't know how long it‘s going to take. So you're very conservative," said Pam Sogge, 56, who has been caring for her husband for five years. "A tax credit, in a way, it's permission and encouragement to get some help."

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Samantha Young: syoung@kff.org, @youngsamantha

She Was Dancing On The Roof And Talking Gibberish. A Special Kind Of ER Helped Her

KFF Health News, March 25, 2019

ERs increasingly have become the care of first and last resort for people in the grips of a psychiatric episode. Now, hospitals around the country are opening emergency units that calmly cater to patients with mental health needs.

This article first appeared on Monday, March 25, 2019 in Kaiser Health News.

By Anna Gorman

For decades, hospitals have strained to accommodate patients in psychiatric crisis in emergency rooms. The horror stories of failure abound:

Patients heavily sedated or shackled to gurneys for days while awaiting placement in a specialized psychiatric hospital, their symptoms exacerbated by the noise and chaos of emergency medicine. Long wait times in crowded ERs for people who show up with serious medical emergencies. High costs for taxpayers, insurers and families as patients languish longer than necessary in the most expensive place to get care.

"If you are living with schizophrenia or bipolar disorder, that is a really tough way to begin that road to recovery," said Dr. Jack Rozel, president of the American Association for Emergency Psychiatry.

In pockets across the country, hospitals are trying something new to address the unique needs of psychiatric patients: opening emergency units specifically designed to help stabilize and treat patients and connect them to longer-term resources and care. These psychiatric ERs aim to address the growing number of patients with mental health conditions who end up hospitalized because traditional emergency rooms don't have the time or expertise to treat the crisis.

The rate of ER visits involving psychoses, bipolar disorder, depression or anxiety jumped more than 50% from 2006 to 2013, according to the federal Agency for Healthcare Research and Quality. Roughly 1 in 8 emergency department visits now stem from mental illness or substance use disorders, the data show.

The psychiatric ERs, staffed with nurses, social workers and psychiatrists, work to treat and release patients in under 24 hours, much as traditional emergency rooms handle physical ailments. Those who are well enough to go home get discharged, while those who need more treatment are admitted to the hospital or transferred to an inpatient facility.

There are now roughly 100 such units across the country, said Dr. Scott Zeller, vice president of acute psychiatry at Vituity, a physician-led organization that provides staffing and consulting services to medical centers nationwide.

Zeller pioneered the approach while working as chief of psychiatric emergency services at John George Psychiatric Hospital in Alameda County, Calif. Over time, he transformed the center from a traditional ward where restraints were common into one that treated patients in a more supportive, living-room like setting. The results — in terms of both patient outcomes and cost-savings — made Zeller a believer.

He is helping design 10 new units, including in California, Florida, Illinois and Tennessee. Each is distinct, accepting patients in somewhat different circumstances and offering a slightly different range of services.

Patients who arrive at an emergency room for psychiatric or substance use disorders are more than twice as likely to be admitted than other patients, federal data show. And yet about 80 percent of the time, Zeller said, patients‘mental health crises can be resolved without a costly inpatient hospital stay. A patient may be having a psychotic episode because he fell off his medications, for example, or having drug-induced hallucinations.

"We need to treat people at the emergency level of care," he said. "The vast majority of psychiatric emergencies can be resolved in less than 24 hours."

Nowhere To Hide

Wearing a hospital gown, Rachel Diamond lay back in her recliner in a spacious room in a relatively new ward at Providence Little Company of Mary Medical Center San Pedro, a hospital near the Port of Los Angeles. Nearby, a few patients slept on identical recliners, draped in soft blankets. Others communed at a kitchen table over microwaved meals. A nurse walked through the locked unit with a rolling cart, dispensing medications.

Except for a nursing station in the middle of the room, the unit didn't look much like a health care facility. The room was divided into men's and women's sides, with separate TVs. A few smaller rooms — where patients could meet with a psychiatrist or social worker — lined the unit's edge.

Anya Price, interim clinical supervisor and a nurse, said the unit was designed to feel more like a home than a hospital. "We're operating from an understanding that they're coming here to get better," Price said.

The open design of the unit, known as the "Outpatient Behavioral Health Center," allows patients to move freely. Staff said it also helps reduce problems because they can quickly spot a patient who may be getting agitated. Dr. Herbert Harman, a psychiatrist and medical director for the facility, said violence and the need for restraints are rare.

The unit is in a building a short walk from the medical center emergency room. It opened in 2017 and accepts patients from emergency rooms across Los Angeles County once they are deemed stable medically. So far this year, its staff has treated about 400 patients, Price said.

One recent morning, the patients included a man in his 40s found on the railroad tracks after an alcohol binge, and a woman with a history of schizophrenia who said she was seeing spirits. Some were there on involuntary holds because authorities had decided they were at risk of hurting themselves or others because of their illness.

Diamond, 30, said she has been diagnosed with depression and anxiety and has landed in multiple ERs over the past decade when her symptoms spiked out of control. During those stays, she said, she often felt isolated and in the dark about her treatment. Doctors typically numbed her with medications and consigned her to a guarded room. "No one really talked to me," said Diamond, who lives in Torrance, Calif. "It was like I was a caged animal."

She had been living in a car and fighting with her boyfriend in late February when she decided she wanted to end her life. She tried jumping out of a moving car, and when that didn't work, she grabbed a bottle of pills. She gets help for her mental health issues, but sometimes, she said, the stress becomes too much. This time, she was taken to a hospital emergency room in Torrance before being transferred to the San Pedro unit.

During her time in the behavioral health center — about 26 hours — she slept, received medications and met with nurses, a social worker and a psychiatrist. She said it was calmer than a regular ER, and the staff had time to talk, listen and help her through the worst of the crisis.

"I genuinely feel better enough to leave," she said. "I haven't been able to say that in a while."

A Return On Investment

Zeller argues that the use of emergency psychiatric clinics is both humane and cost-effective. Research on the Alameda County model found such units can dramatically reduce how long patients spend in medical emergency rooms, and that about three-quarters of patients treated in the units can be discharged to the community rather than to inpatient care. That, Zeller said, can lessen the overwhelming demand for inpatient psychiatric beds and preserve available spots for those who truly require them. The model saves money for hospitals in part because the patients spend less time in emergency care.

"The return on investment is exponential," he said.

In Montana, the Billings Clinic opened a psychiatric stabilization unit last April across the street from the traditional ER. Dr. Eric Arzubi, psychiatry department chair, said nearly 10 percent of the visits in the Billings Clinic emergency room involve people in psychiatric crisis. Since the new unit opened, wait times for psychiatric patients have dropped from about 10 hours to four hours, and fewer patients are being admitted to the inpatient unit. Arzubi said his staff isn't trying to cure people of their mental illness but rather stabilize them and get them the care they need.

"Just like in the emergency room, you don't get comprehensive care," Arzubi said. "But you can stop the bleeding, you stabilize the patient and get them to the right level of care."

In some cases, that means a transfer to an inpatient facility.

Staff at the San Pedro unit decided soon after Chantelle Unique arrived that she would be one of those patients. Unique, who is 23, has been diagnosed with bipolar disorder and schizophrenia. She had been dancing on the roof and speaking gibberish when her mother called 911.

Unique said she has had a hard time in regular emergency rooms. "There are a million people," she said. For most of a morning at the San Pedro facility, she sat calmly watching TV, talking to nurses and eating spaghetti. But at one point, she started pacing and yelling at other patients. Nurses and security guards quickly surrounded her and persuaded her to return to her recliner and take additional medication.

Finding an inpatient bed for a patient like Unique with more progressed mental illness is not always easy, said clinical social worker Mark Tawfik. But he's committed to finding a way. "We have to make sure we find them adequate resources," he said. "Otherwise, they will come right back."

For Price, the clinical supervisor, even when a patient requires a transfer for more intensive care, there's satisfaction in knowing that person is headed in the right direction. If Unique hadn't been brought in, Price said, she would have been out in the community, lost to her delusions, putting herself at risk of accident or arrest.

In the unit, staff made sure she was safe, Price said, in addition to providing "a warm bed, some food and some compassion."

Heidi de Marco: heidid@kff.org, @Heidi_deMarco

Anna Gorman: agorman@kff.org, @AnnaGorman

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