The number is the highest since the federal government five years ago launched the Hospital Acquired Conditions Reduction Program, created by the Affordable Care Act.

This story was first published Friday, March 1, 2019, by Kaiser Health News.

By Jordan Rau

Eight hundred hospitals will be paid less by Medicare this year because of high rates of infections and patient injuries, federal records show.

The number is the highest since the federal government five years ago launched the Hospital Acquired Conditions Reduction Program, created by the Affordable Care Act. Under the program, 1,756 hospitals have been penalized at least once, a Kaiser Health News analysis found.

This year, 110 hospitals are being punished for the fifth straight time.

The penalties pit hospitals against one another in a race to prevent the most infections, blood clots, cases of sepsis, bedsores, hip fractures and other complications. Each year, the quarter of general hospitals with the highest rates are punished, even if their records have improved from the previous year.

Under the latest round of sanctions, each hospital will lose 1% of its Medicare payments for patients discharged between last October and this September. That comes on top of other penalties created by the health care law, such as annual payment reductions for hospitals with too many patients being readmitted.

The hospital industry has protested the HAC penalties, saying the program's design creates an arbitrary cutoff for which institutions get punished and which don't. The American Hospital Association calculated that only about 4% of the 768 hospitals penalized in 2017 had HAC scores that were statistically significantly higher than hospitals not being penalized.

"There are not statistical differences that would warrant a quarter of the hospitals in America getting a penalty," said Nancy Foster, the association's vice president for quality and patient safety.

Hospitals also complain that the ones that do the best job testing for infections and other threats to patients appear to be among the worst based on statistics, while their more lackadaisical peers look better than they might be.

Supporters of the punishments argue that the penalties are warranted in prodding hospitals to improve quality. The threat of losing money elevates the issue in many hospitals to the attention of directors and owners, said Missy Danforth, the vice president of health care ratings at the Leapfrog Group, a nonprofit devoted to patient safety.

"The fact that everyone's talking about it, from front-line nurses to boards of directors, is positioning patient safety where it should be, which is at the forefront of everyone's minds," Danforth said.

Danforth dismissed hospital complaints that the penalties are not always fairly applied. "There's a lot of really strong, good best practices to getting to zero on these infections," she said.

Hospital patients suffered an avoidable injury in 9 of every 100 patient stays in 2016, about 2.7 million times, according to a June report from the federal Agency for Healthcare Research and Quality. Those included a bad reaction to medication, an injury from a procedure, a fall or an infection.

The frequency of complications has been dropping in hospitals. The report found an overall 8% decrease from 2014 to 2016. However, the report also found a jump in the numbers of bedsores and urinary tract infections in patients with catheters during that time.

The Hospital Acquired Conditions Reduction Program assesses penalties based on a subsection of the injuries examined in the AHRQ report. For each hospital, Medicare judges infection rates related to colon surgeries, hysterectomies, urinary tract catheters and central lines inserted into veins. Medicare also counts the number of infections of methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, known as C. diff.

Finally, the government tracks the rate of blood clots, sepsis, post-surgical wounds, bedsores, hip fractures and five other types of in-hospital injuries. Because the penalties will be applied as hospitals submit claims for reimbursement, the total dollar amount of penalties for each hospital will not be known until the federal fiscal year ends in September.

Medicare excludes from consideration a number of specialized hospitals: those serving children, veterans and psychiatric patients. Maryland hospitals are also exempted because the federal government gives that state leeway in how it pays hospitals. And more than 1,000 "critical access" hospitals, which are the only institutions in their area, are also excluded.

For the remaining hospitals, penalties are assigned to the quarter of institutions with the highest HAC rates. That threshold varies slightly from year to year, and is a major reason that the number of hospitals being punished fluctuates annually. Before this, the largest number of hospitals punished was 769, two years ago.

Jordan Rau: jrau@kff.org, @JordanRau

As 'Medicare-for-all' has become a rallying cry for progressive Democrats, several states are looking at offering consumers a government-sponsored plan to provide a more affordable health option.

This story was first published Tuesday, February 26, 2019, by Kaiser Health News.

By Michelle Andrews

Laura Lucero Y Ruiz De Gutierrez has a heart condition and fibromyalgia and is in danger of developing diabetes. She has health insurance through her husband's job. But, between the $800 monthly premium for the couple's coverage and the $2,100 deductible she has to pay down before insurance starts picking up the tab, she doesn't feel she can afford to go to the doctor when she needs to.

She hopes that may soon change. Identical bills proposed in recent weeks in the New Mexico House and Senate would make Gutierrez eligible to buy in to a public health plan modeled on Medicaid. She also could receive state-funded assistance that would save her hundreds of dollars a month on premiums.

As "Medicare-for-all" has become a rallying cry for progressive Democrats, New Mexico is one of several states looking at offering consumers a different government-sponsored plan to provide a more affordable health option.

The proposals, often referred to as "Medicaid buy-in" plans, would typically offer benefits similar to what is available in Medicaid, the state-federal health plan for low-income people.

"Medicare-for-all is not going to happen legislatively in the next couple years. But in the meantime states are saying, 'What about "Medicaid for more"?'" said Heather Howard, who directs Princeton University’s state health and value strategies program and is working closely with some of the states.

A report commissioned by New Mexico projected that up to 16,000 people would enroll in a program like the one originally proposed in the bills, and their premiums would be 15% to 28% lower than plans sold on the individual market.

Gov. Michelle Lujan Grisham favors a Medicaid buy-in option. She doesn't have a position on the current bill, but she is following it closely, said Nora Sackett, the governor's deputy press secretary.

In addition to the governor's and lawmakers' interest, other stakeholders have been deeply involved, increasing the odds of success, Howard said.

Lawmakers in Colorado, Oregon, Washington and Minnesota are among others exploring similar options, said Howard. Nevada lawmakers passed a bill last year that would have set up a Medicaid buy-in plan, but the Republican governor vetoed it.

"The proposals take on different flavors depending on the state" and what officials are trying to accomplish, she said, whether it's increasing the number of people with insurance, making coverage more affordable or helping states avoid "bare" counties where no marketplace plans are offered.

States that want to offer a buy-in option might opt to try to expand Medicaid directly, or offer a plan that builds on but is not part of their Medicaid program, with similar benefits, providers and reimbursement rates. Or they may offer a public option insurance plan that isn't based on Medicaid. Depending on how they structure their plan, states may have to get approval from the federal government to move ahead.

A federal bill that would allow states to open up their Medicaid programs to all residents was reintroduced earlier in February by Sen. Brian Schatz (D-Hawaii) and Rep. Ben Ray Luján (D-N.M.).

In New Mexico, the buy-in plan would be similar to the state's Medicaid program. It would be offered outside the exchange and would not require federal approval to implement. The state would provide financial assistance to help low-income people buy in to it.

New Mexico's bill would target individuals who aren't eligible for Medicaid or Medicare or those who can't get the Affordable Care Act's premium subsidies because their incomes are above 400% of the federal poverty level (about $50,000 for one person or $103,000 for a family of four). It also includes immigrants who are in the country without legal status.

The measure would also help people, like Gutierrez, who are vulnerable to the ACA's so-called family glitch. Her husband's $100 monthly premium for single coverage is considered affordable under the law because it costs less than 9.86% of their family income of about $46,000 a year. That makes her ineligible for premium subsidies on the exchange, even though the $800 premium for the two of them far exceeds that affordability percentage. Their three children already have Medicaid coverage.

"Right now, I pay to have the healthcare, but I can't afford to use it," said Gutierrez, 42.

The bill would provide premium and cost-sharing assistance for people with incomes less than 200% of the federal poverty level, or $60,340 for a family of five. The new coverage would take effect by January 2021.

Gutierrez, whose family lives in Albuquerque, would be eligible for financial assistance to help her buy in to the Medicaid option, while her husband stayed on his employer plan. Because their $46,000 annual income is just above 150% of the federal poverty level, her monthly premium would likely be about $160 per month for a comprehensive plan with a $150 deductible, according to estimates by Manatt Health, which did the original state analyses of buy-in options that were published before the bills were introduced in January.

New Mexico has high levels of poverty, and 40% of all New Mexico residents are already enrolled in the state Medicaid program, compared with about 23% nationwide.

"It's the cornerstone" of our healthcare system, said Colin Baillio, director of policy and communication at Health Action New Mexico, an advocacy group. The legislation would use "those levers that Medicaid has to provide comprehensive coverage and a comprehensive provider network."

The bills were passed by two legislative committees in mid-February, with instructions for further study to examine expanding the buy-in plan to more groups. They now move to two other legislative committees for consideration, Baillio said.

Hospitals and other healthcare providers would be reimbursed at Medicaid rates, which are lower than those for commercial plans. Still, to the extent that people who are uninsured enroll in the new plan, providers stand to gain financially.

"We're obviously very supportive of anything that expands coverage," said Jeff Dye, president of the New Mexico Hospital Association. "It's the issue of getting some payment versus no payment for services rendered."

If the Medicaid buy-in bill passes, Blanca Ivon Rodriguez and her husband, Hugo Montes, could have health insurance for the first time since they moved to New Mexico 14 years ago. The couple and their oldest son, now 18, are immigrants from Mexico who are in the state without proper legal status. Their two younger children, who were born in the United States, are enrolled in Medicaid.

Montes works as a plumber and Rodriguez is studying early childhood development at a community college near their home in Albuquerque. Because they're undocumented, they’re not permitted to buy health insurance on the exchanges, even if they’re willing to pay full price.

Like many people without insurance, they wait until they're really sick before seeking help. When Rodriguez developed pneumonia a few years ago, the waiting lists for an appointment at community clinics that would see her without insurance were long. Finally, when she could no longer breathe comfortably, she went to the emergency department.

"It would bring us peace of mind not having to worry about our healthcare situation," said Rodriguez, 41, through a translator.

Providing healthcare for residents who are undocumented is "an underlying issue with many states that are considering a Medicaid buy-in," said Chiquita Brooks-LaSure, managing director at Manatt Health, who co-authored the reports evaluating Medicaid buy-in options for New Mexico.

The New Mexico bill also would provide some relief for Leah Steimel's family. Neither she nor her husband has employer-sponsored coverage, and with family income of about $100,000 they don’t qualify for ACA premium tax credits. They pay more than $1,900 a month for a silver-level plan with a $10,000 deductible to cover themselves and two of their kids (the third is over age 26).

Buying in to Medicaid would be tempting, said Steimel, 59, who works as a community health consultant with some of the groups advocating for the buy-in. Sure, she said, she wonders if the Medicaid plan would be as easy to use as a regular commercial plan and have access to as many providers.

"But being able to pay into something that would reduce by even a third what I'm paying now, I'd love that," she said.

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

Vaccination exemptions signed by doctors on medical grounds have more than tripled. This suggests that parents who once cited personal beliefs to avoid inoculating their kids might be claiming medical reasons instead.

By Harriet Blair Rowan, Kaiser Health News

This story was first published Friday, February 22, 2019, by Kaiser Health News.

A rash of recent measles outbreaks in New York, Texas, and Washington state shines a light on California's largely successful effort in recent years to suppress the disease—though some of the shine might be fading.

A serious measles outbreak that started at Disneyland in December 2014 and carried over into 2015 contributed to a steep increase in vaccination rates among California kindergartners over the following three years. But the gains stopped last year, according to the most recent available data.

In the 2013-14 school year, which immediately preceded the Disneyland outbreak, the percentage of kindergartners enrolled in schools boasting vaccination rates of 95% or above—considered the optimal level to avoid contagion—stood at 57%. By the 2016-17 academic year, the percentage of kindergarten pupils in schools with optimal vaccination rates had hit 90%. In 2017-18, however, it dipped slightly back below 90%.

Measles has again gained attention because of five outbreaks so far this year in the U.S., including a serious one in Washington state. Through the first week of February, 101 measles cases have been reported across 10 states. That's compared with a preliminary count of 372 for all of 2018 and 120 in 2017.

California's favorable trend accelerated dramatically after officials, galvanized by the Disneyland-linked infections, implemented a law in 2016 that eliminated a loophole through which parents were allowed to enroll their children in school without vaccinating them if they claimed that vaccinations violated their personal beliefs.

But another kind of exemption was still allowed. Over the past three years, vaccination exemptions signed by doctors on medical grounds have more than tripled, though they are still at a low level. This suggests that parents who once cited personal beliefs to avoid inoculating their kids might be claiming medical reasons instead.

Could this trend be contributing to the loss of momentum in vaccination rates?

"I think that's definitely a concern," said Dr. James Watt, chief of the Division of Communicable Disease Control at the California Department of Public Health. He said, however, that the elimination of personal belief exemptions in the 2016 law still far outweighs the rise of medical excuses. "So that's reassuring to some degree," he said.

Overall, California's measles vaccination rate is now 96.9%, well above the desired threshold. Watt said, "We do have this particular concern, as we have in the past, about places where there may be pockets of low immunization coverage"—such as individual schools.

Three rural Northern California counties—Sutter, Trinity, and Nevada—have measles vaccination rates below the 90% threshold widely considered the minimum level for effectively stopping the spread of the disease, according to data from the public health department.

Measles causes a high fever and a distinctive rash, and can lead in some cases to severe complications in children such as encephalitis and pneumonia, which can be fatal.

The federal Centers for Disease Control and Prevention recommends that children get their first dose of measles vaccine (MMR), which also protects against mumps and rubella, at 12 to 15 months of age and a second dose between ages 4 and 6.

Such co-prescribing mandates are emerging as the latest tactic in a war against an epidemic that has claimed hundreds of thousands of lives over the past two decades.

This article was published on February 21, 2019, in Kaiser Health News.

By Barbara Feder Ostrov

In a growing number of states, patients who get opioids for serious pain may leave their doctors' offices with a second prescription — for naloxone, a drug that can save their lives if they overdose on the powerful painkillers.

New state laws and regulations in California, Virginia, Arizona, Ohio, Washington, Vermont and Rhode Island require physicians to "co-prescribe" or at least offer naloxone prescriptions when prescribing opioids to patients considered at high risk of overdosing. Patients can be considered at high risk if they need a large opioid dosage, take certain other drugs or have sleep apnea or a history of addiction.

Such co-prescribing mandates are emerging as the latest tactic in a war against an epidemic of prescription and illegal opioids that has claimed hundreds of thousands of lives over the past two decades.

The Food and Drug Administration is considering whether to recommend naloxone co-prescribing nationally (an FDA subcommittee recently voted in favor), and other federal health officials already recommend it for certain patients. And the companies that make the drug are supportive of the moves. It's not hard to see why: An FDA analysis estimated that more than 48 million additional naloxone doses would be needed if the agency officially recommended co-prescribing nationally.

Most states have limited the volume of opioids doctors can prescribe at one time and dramatically expanded access to naloxone. In California, for example, pharmacists can provide naloxone directly to consumers who are taking illegal or prescription opioids or know someone who is.

In the states with co-prescribing rules, patients aren't required to fill their naloxone prescriptions, and those with cancer or who are in nursing homes or hospice typically are exempted.

Kristy Shepard of Haymarket, Va., was surprised to find a naloxone prescription waiting for her recently when she went to the pharmacy to pick up her opioid meds. Her first instinct was not to fill it. She did so only after the nurse in her doctor's office pressured her to. The doctor had never talked to her about Virginia's new co-prescribing law, she said.

"It's so silly. I didn't feel like I needed it. Unless I plan to hurt myself, I’m not likely to overdose," said Shepard, 41, a registered nurse and hospital administrator who can no longer work and has applied for disability benefits.

But it may not be as difficult as some people think to overdose on prescription painkillers.

"You can take pain meds responsibly, and you can be at risk for an accidental overdose even when you’re doing everything right," said Dr. Nathan Schlicher, an emergency medicine physician in Washington state and a member of the state hospital association's opioid task force.

Two million Americans have an addiction to prescription painkillers, according to the FDA. And nearly 218,000 people in the U.S. died from overdosing on them from 1999 to 2017, according to the Centers for Disease Control and Prevention. During that same period, prescription opioid deaths rose fivefold, the CDC data show.

In California, doctors wrote nearly 22 million opioid prescriptions in 2017 and 1,169 people died that year from overdosing on prescription opioids. Common prescription opioids include Vicodin, OxyContin, Percocet, morphine, codeine and fentanyl.

To counter this trend, "states are scrambling for any policy lever they can find," said Kitty Purington, senior program director at the National Academy for State Health Policy.

Even before the state mandates, pain specialists considered it good practice to prescribe naloxone along with opioid painkillers for some patients, particularly those with a history of substance abuse.

Doctor lobbying groups typically resist government rules regarding their practice, but medical associations in some states supported or at least remained neutral on naloxone co-prescribing mandates.

The companies that make the drug have spent hundreds of thousands of dollars collectively lobbying for their interests at the state level.

Kaléo, which makes the naloxone auto-injector Evzio, spent $77,200 in 2017-18 lobbying California lawmakers on bills expanding access to naloxone, including the state's co-prescribing law, which requires doctors to offer prescriptions for naloxone to high-risk patients who get opioids.

In December, Kaléo introduced a lower-cost generic version of the injector after a Senate investigation found the company had raised the price of its branded version 600% from 2014 to 2017, to $4,100 for two injectors.

Adapt Pharma, which makes the naloxone nasal spray Narcan, spent $48,000 to lobby California lawmakers on the co-prescribing legislation.

One advantage of the co-prescribing rules is that they foster important doctor-patient conversations about the risks of opioids, said Dr. Farshad Ahadian, medical director at the UC San Diego Health Center for Pain Medicine.

"Most providers probably feel that it’s better for physicians to self-regulate rather than practice medicine from the seat of the legislature," Ahadian said. "The truth is there's been a lot of harm from opioids, a lot of addiction. It's undeniable that we have to yield to that and to recognize that public safety is critical."

But some doctors — not to mention patients — have reservations about the new requirements. Some physicians say it will be nearly impossible for states to enforce the mandates. Others worry that prescribing naloxone to patients who live alone is useless, because it typically must be administered by another person — ideally one who has been trained to do it.

Patients fear that naloxone prescriptions could unfairly stigmatize them as drug addicts and cause life insurers to deny them coverage.

Shepard, the disabled Virginia nurse and a mother of four, said she worries that her naloxone prescription could affect her chances of getting additional life insurance — a pressing question, she said, as her lupus worsens over time.

And a Boston-area nurse who worked at an addiction treatment program was turned down by two life insurers simply because she carried naloxone for her patients.

The decision to prescribe naloxone "is something that should be between a doctor and a patient, because every situation is unique," said Katie O'Leary, a 31-year-old movie production company office manager who lives in Los Angeles and was diagnosed with complex regional pain syndrome about five years ago.

"So many patients already jump through so many hoops to get their meds," O'Leary said. "And if you live alone and don’t have family or friends to take care of you, the naloxone might not be something that could actually help."

Opioid addiction and overdoses are a complex problem, and naloxone is just one part of the solution, said Dr. Ben Bobrow, a professor of emergency medicine at the University of Arizona College of Medicine.

"In the past, pain was the fifth vital sign; we thought we were doing a bad job if we were undertreating pain," Bobrow said. "Inadvertently, we were harming people. We ended up getting all these people hooked. Now it's our job to help them find other [ways] of treating their pain."

California Healthline digital reporter Harriet Blair Rowan contributed to this report.

KHN’s coverage of these topics is supported by KHN

Barbara Feder Ostrov: barbarao@kff.org, @barbfederostrov