Studies show that aggressive hospital action can limit the spread of outbreaks.

This article first appeared April 03, 2018 on Kaiser Health News.

By Liz Szabo

[UPDATED at 3:15 p.m. ET on April 3]

The Centers for Disease Control and Prevention detected more than 220 cases last year of a rare breed of "nightmare bacteria" that are virtually untreatable and capable of spreading genes that make them impervious to most antibiotics, according to a report released Tuesday.

Although the CDC has warned of the danger of antibiotic-resistant bacteria for years, the new report helps illustrate the scope of the problem. Dr. Anne Schuchat, the CDC's principal deputy director, said she was surprised by the extent of the spread.

"As fast as we have run to slow [antibiotic] resistance, some germs have outpaced us," Schuchat said. "We need to do more and we need to do it faster and earlier."

The CDC set up a nationwide lab network in 2016 to help hospitals quickly diagnose these infections and stop them from spreading.

One in 4 germ samples sent to the lab network had special genes that allow them to spread their resistance to other germs, the CDC said. In 1 in 10 cases, people infected with these germs spread the disease to apparently healthy people in the hospital — such as patients, doctors or nurses — who in turn can act as silent carriers of illness, infecting others even if they don't become sick.

Nightmare bacteria — those that are resistant to almost every drug — are particularly deadly in the elderly and people with chronic illnesses. Up to half of the resulting infections prove fatal, Schuchat said.

While those bacteria are terrifying on their own, the "unusual" genes discussed in this report are truly the "worst of the worst," said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security. About 2 million Americans are sickened by antibiotic-resistant bacteria each year and 23,000 die, according to the CDC.

"There are certain bacterial genes that are more worrisome than others, that are much harder to treat," Adalja said. "These genes are lurking in American patients and they are spreading in hospitals and health care facilities."

Many researchers have worried about the emergence of a "post-antibiotic era," in which patients succumb to once-treatable infections. Antibiotics don't just save lives when people develop infectious diseases such as pneumonia. They are also the "safety net" for patients undergoing surgery and cancer treatment, Schuchat said.

Dr. Michael Osterholm compared the problem to a "slow-moving tsunami."

"This isn't an acute crisis where a wave just hits you," said Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy. "But we see these rare cases of resistance in remote areas of the world, and within a year or two, it's everywhere."

As alarming as the new numbers are, Schuchat said there is good news to report.

Studies show that aggressive hospital action can limit the spread of outbreaks.

In one case, the CDC network helped diagnose bacteria carrying resistance genes in an Iowa nursing home resident with a urinary tract infection. Public health staff tested 30 other nursing home residents and found five were infected.

Aggressive measures, such as wearing gowns and gloves while caring for infected patients, prevented anyone else from becoming sick, Schuchat said.

Aggressively diagnosing and containing such infections can reduce infections by 76 percent, the CDC said.

Dr. William Schaffner, a professor of preventive medicine and health policy disease at Vanderbilt University School of Medicine, said the CDC's efforts to contain and slow the spread of nightmare bacteria seem to be working.

The CDC lab "network is working at an absolutely high level of effectiveness," Schaffner said. "It's identifying problems with great precision and initiating the appropriate response with the local health department and hospital staff.

"That's the ‘good news spin' bun around a scary hot dog," Schaffner said.

Maintaining these labs is vital, said Dr. Paul Auwaerter, president of the Infectious Diseases Society of America.

Containing antibiotic resistance "is vital to maintaining the strides made in many areas of modern medicine," Auwaerter said.

Osterholm said world leaders need to do far more to prevent antibiotic resistance.

A 2016 report commissioned by the British government and Wellcome Trust called for investing $40 billion over the next decade to fight the problem. About 700,000 people around the world die due to antibiotic resistance each year. Without immediate action, annual deaths could rise to 10 million by 2050, according to the report.

Bacteria naturally evolve to resist drugs used against them. The more the drugs are used, the faster this happens, Osterholm said.

While developing new antibiotics can help, Osterholm compared that approach to "trying to dig yourself out of a hole."

It's far more important that countries around the world use antibiotics more judiciously, Osterholm said. Doctors today often prescribe antibiotics when they're not needed.

In developing nations, patients often buy antibiotics on the street, Osterholm said, noting that antibiotics are also widely used in agriculture.

Vaccines can also help fight antibiotic resistance, he said, by preventing people from ever becoming sick and needing antibiotics.

A recent study found that 80 percent of the city's black children live in neighborhoods with high concentrations of poverty, which often have poor access to quality medical care.

This article first appeared April 04, 2018 on Kaiser Health News.

By Virginia Anderson

ATLANTA — While public safety commissioner Bull Connor’s police dogs in 1963 attacked civil rights protesters in Birmingham, Ala., leaders in Martin Luther King Jr.’s hometown of Atlanta were burnishing its reputation as “the city too busy to hate.”

Yet 50 years after the civil rights leader was killed, some public health leaders here wonder whether the city is failing to live up to King’s call for justice in health care. They point to substantial disparities, particularly in preventive care.

“We have world-class health care facilities in Atlanta, but the challenge is that we’re still seeing worse outcomes” for African-Americans, said Kathryn Lawler, executive director of the Atlanta Regional Collaborative for Health Improvement. That group includes representatives of more than 100 nonprofit organizations, governments, hospital systems and other health care providers working to improve access and care for minority communities.

“We did certain things here, we went through the civil rights era, and we did things like desegregation, but we just over the years never kept the conversation going,” said Tom Andrews, president of Mercy Care, a health center that serves mainly homeless Atlantans, the vast majority of whom are African American.

Among the problems:

— Atlanta has the widest gap in breast cancer mortality rates between African-American women and white women of any U.S. city, with 44 black patients per 100,000 residents dying compared with 20 per 100,000 white women, according to a study in the journal Cancer Epidemiology in 2016.

— It is the city with the nation’s highest death rate for black men with prostate cancer, with a rate of 49.7 deaths per 100,000 residents. The mortality rate for white men here is 19.3, the National Cancer Institute reports.

— There’s a 12-year or greater difference in life span among neighborhoods in Fulton County, of which Atlanta is the county seat. Those living in the city’s Bankhead or Northwest neighborhoods, which are predominantly black, fare worse when compared to those who live in affluent, mainly white Buckhead, researchers at Virginia Commonwealth University found.

— Large gaps in mortality exist between African-Americans and whites in such diseases as HIV, stroke and diabetes, according to the Georgia Department of Public Health.

African-Americans make up just over half of the city’s residents. But a recent study found that 80 percent of black children here live in neighborhoods with high concentrations of poverty, which often have poor access to quality medical care, while 6 percent of white children do. Several of the neighborhoods with predominately minority communities have poverty rates higher than 40 percent.

"I think we should be further along in Atlanta, but I think we should be further along in all cities in this country,” said Dr. David Satcher, a former U.S. surgeon general and now senior adviser at the Satcher Health Leadership Institute at Morehouse School of Medicine here.

The health gaps between African-Americans and whites in Atlanta or in any U.S. city are not due necessarily to shortcomings in the health care system, according to people who have studied the issue. Rather, they are the result of decades of discrimination.

“It’s a constellation of things,” said Thomas LaVeist, chairman of the department of health policy and management at the George Washington University's school of public health in Washington, D.C. “African-Americans couldn’t own land, wealth couldn’t transfer from one generation to the next. Those were advantages [for whites] that were formed decades ago.”

"The disparities are really national problems,” he added, “and there really is not a city that's spared."

The result has been, the experts said, lower incomes, lower levels of education, higher stress, unsafe neighborhoods, lack of insurance and a host of other social factors that combine, over the years, to create differences in quality of health.

It starts with a lack of preventive care, said Dr. Otis Brawley, chief medical officer of the American Cancer Society and a longtime Atlanta resident. In addition to not having insurance or money for care, many African-Americans lack trust in the health care system and see it as another part of American life that has let them down.

Ricardo Farmer, 57, has not been to a doctor for a checkup in almost 30 years, he said. He is uninsured, and his funds are limited. More than anything, however, Farmer said he does not trust the health care system.

“If I don’t have any symptoms, I feel like I don’t need to go,” said the tile craftsman.

Yet he has a back problem that causes him to miss work occasionally, and he has high blood pressure, which he self-treats by reducing his salt intake and giving up meat, and asthma, which sometimes forces him to the emergency room because he has trouble breathing.

An Abundance Of Health Care, For Some

Atlanta is a major health care hub, home to the federal Centers for Disease Control and Prevention, the American Cancer Society, the Arthritis Foundation, two schools of medicine and several universities that offer degrees in public health. And yet health care is still a scarce commodity in many poor neighborhoods.

“Atlanta spends $11 billion on health care in a given year, but much of that is misspent,” said Lawler. Too many patients end up in emergency rooms, for example, because they do not have a primary care doctor or seek treatment after their illnesses are much more advanced, she added.

In addition, after being diagnosed, getting treatment can be difficult for some, said Brawley. African-American women are nearly four times more likely than whites to forgo treatment for breast cancer, which can include a combination of surgery, chemotherapy and radiation, he said.

Adherence to the radiation regimen is particularly challenging, he explained, because a woman typically has to go five days a week for six weeks. That presents problems for those who must rely on public transportation or work in low-wage jobs that don’t offer generous sick leave benefits.

"It takes them 2½ hours to get there every day, and [the treatment] takes 45 seconds," Brawley said, when describing bus commutes for some residents. "So they figure it's not worth it.”

Those involved in seeking better care for Atlanta’s poor say the lack of insurance coverage also plays a huge role in the problem. Yet, that, too, is tied to race, since twice as many African-Americans than whites are uninsured in Georgia.

“One of the greatest barriers to care in all these states that didn’t expand Medicaid [under the Affordable Care Act] is lack of insurance,” said Brawley. “And it happened in all of the states of the ‘Old Confederacy.’ This is a huge racial insult.”

State Rep. Jason Spencer said Republicans’ opposition to Medicaid expansion “had nothing to do with race." He said whites living in parts of northern Georgia also have higher mortality rates. “The common denominator is education and finances. The race card is a worn-out, tiresome excuse."

'I Didn’t Want To Think About Bad Things'

Austin Gilmore, 60, is emblematic of the patients who don’t have a regular physician and therefore ignore their health needs.

He had a roofing business and lived with his wife in a four-bedroom house with two bathrooms. But he lost his bearings when she died in 2011 from kidney disease. Without insurance and with few economic resources, he didn’t know where to turn for help.

“I didn’t even know I was depressed,” said Gilmore. He started drinking and eventually lost his house and his business.

“I had no livelihood, no job, no place to live. I didn’t want to think about bad things, so I drank,” Gilmore said. He knew he was harming his health.

In September 2016, Gilmore decided he could not ignore his health issues any longer. He went to an emergency room and after several days of treatment was referred to Mercy Care for longer-term care. He has been sober for 19 months.

“I thank God for Mercy Care,” Gilmore said. “I can’t think of where I’d be without them.”

Dr. Kathleen Toomey, district health director for the Fulton County Board of Health, said the county has initiatives to help narrow the gaps. But just as the disparities were not caused by the health care system alone, the problems will not be solved solely by the health care system.

“The ownership is not just on public health, but across all sectors of the community that address social, economic and environmental factors that influence health," Toomey said.

McKinley County, N.M., has the nation's highest rate of Medicaid enrollment, and people there say it is vital to battle daunting economic and public health challenges.

This article first appeared April 02, 2018 on Kaiser Health News.

By Phil Galewitz/Photos by Heidi de Marco

GALLUP, N.M. — On a crisp sunny day, Tyson Toledo, a precocious 5-year-old boy, hobbled into a private health clinic to have his infected foot examined.

Pediatrician Gayle Harrison told his mother to continue to apply antibiotic ointment and reminded them to come back if the swelling and redness worsened.

The appointment at Rehoboth McKinley Christian Health Care Services’ outpatient center comes at no charge for the Toledo family, who live 30 miles away on the Navajo Nation Reservation. That’s because Tyson is covered by Medicaid, the state-federal health insurance program for the poor.

New Mexico leads all other states in Medicaid enrollment, with 43 percent of its residents on the program. That’s partly because the state has a large Native American population, living in communities historically riven with poverty. The numbers offer an eye-popping snapshot of the promotion of Medicaid expansion since 2013: Nearly a third of the 900,000 New Mexico beneficiaries joined as part of the Affordable Care Act’s option to expand Medicaid.

Kaiser Health News is examining Medicaid’s role in the U.S. as the health care program comes under renewed fire from Republicans who generally want to put the brakes on the program, even as many Democrats credit the expansion with reducing the number of uninsured Americans to historic lows. Conservatives view the costs as prohibitive for state and federal budgets.

Nina Owcharenko, a senior research fellow in health policy with the conservative Heritage Foundation, said the enrollment boost is “not a positive story.” While the high enrollment underscores the pervasive poverty in New Mexico, it also signals surging costs for taxpayers, she said.

“I am growing more concerned about the cost of shifting Medicaid dollars to the federal government and without a budget cap on the program. … That is a dangerous fiscal course for the country,” she said.

“This is a problem that needs to be fixed. … We need to find a way that is more rational and more fiscally sustainable,” said Owcharenko, who was a top Health and Human Services official in 2016.

In Gallup, a city of about 23,000 people, Medicaid is as much a part of the fabric as Native American-crafted jewelry and green chile sauce. Recipients include the waitress at the downtown bar, the clerk at a loan store and the maid at the hotel.

And multigenerational families are common in Gallup and surrounding McKinley County. Tyson’s mother, grandmother, aunt and uncle also are enrolled in Medicaid.

Fifty-two percent of the county’s residents have coverage through the program. That’s the highest rate among U.S. counties with at least 65,000 people, according to a KHN analysis of Census data.

“Pretty much everybody is on Medicaid here,” said Libby Garcia, 36, who lives in a trailer overlooking downtown Gallup.

Garcia, who works as a custodian at a local Head Start agency, quit a second job cleaning businesses because that extra income would put her over the eligibility level for coverage. She can’t afford private insurance, and Medicaid gives her free care at a community health center and insulin and other medicines for her diabetes without out-of-pocket costs, she said.

McKinley, where more than 40 percent of the population lives below the federal poverty level ($12,140 for an individual), is the nation’s only county of at least 65,000 people in which more than half the population is on Medicaid. Nationwide, about 23 percent of Americans are enrolled, with more than 16 million people added since the expansion.

In McKinley County, many residents see Medicaid as vital. There’s no stigma around it, and enrollees and providers speak positively about it.

The heavy concentration of Medicaid in this high-altitude desert is a result of two factors: the high poverty rate and the Indian Health Service’s relentless work to enroll patients in the program.

Large swaths of McKinley County lie within the Navajo Nation, the largest Indian reservation in the United States. Nearly 80 percent of McKinley County’s 75,000 residents are Native American.

Medicaid enrollees in Gallup say the coverage has opened up new opportunities for them to get more timely care, especially surgery and mental health services. It has been vital in combating high rates of obesity, teen birth, suicide and diabetes, according to local health officials.

Outside a local Dollar Tree store, Linda James, 55, who sells jewelry she makes, said Medicaid paid for her son’s braces and her teenage daughter’s drug rehabilitation. “It’s a lifesaver for us,” she said, noting it helps her get quicker care than waiting at Indian Health facilities.

‘Safety Net’ For Indian Health Service

For the Gallup Indian Medical Center — the main Indian Health Service facility in the area — Medicaid has stoked the local budget and eased overcrowding. When patients on Medicaid are treated there, the center is reimbursed by the program. That money supplements the Indian Health Service’s annual federal grant, which is set by Congress.

Last year, Medicaid funding made up 34 percent of the center’s $207 million budget. Among all U.S. hospitals, Medicaid provided only 18.5 percent of revenue. “Medicaid has become the safety net for the Indian Health Service,” said John Ratmeyer, deputy chief of pediatrics at the Gallup Indian Medical Center. “It’s providing an extra pod of money to pay for services not within our hospital system.”

Medicaid this year is projected to add more than $800 million to Indian Health Service hospital funding, supplementing the $4.8 billion in annual federal appropriation.

The medical center in Gallup looks like a relic of the 1960s, with fading-blue exterior walls, sandstone-colored outpatient trailers, cramped nursing stations and hard plastic seats in its emergency room waiting area. The hospital doesn’t have an MRI machine or any designated private patient rooms.

“One of our biggest challenges is just maintaining the building,” said Dr. Kevin Gaines, acting deputy clinical director at the hospital. The extra money coming from patients covered by Medicaid are helping the center pay for a badly needed $13 million modernization of its ER and urgent care unit, he said.

Another problem is a shortage of nurses and doctors, which leads to long wait times for patients — three or four months for primary care appointments or for dental services or eyeglasses. Some patients seeking specialized care need to go 140 miles to Albuquerque, a hardship for many Native Americans, some of whom don’t have access to cars or money for such transportation. But Medicaid will cover some non-emergency transportation for medical appointments.

State Feels The Pinch

The county has a host of medical challenges related to its economic problems. According to a 2016 report sponsored by Rehoboth McKinley, the county’s suicide rate for ages 10 and up is twice the U.S. average, alcohol-related deaths are nearly four times higher than the national rate, and teen birth rates are three times the U.S. average. Average life expectancy in McKinley is 74 years, four years less than the typical U.S. life span.

Without Medicaid covering doctor visits and substance abuse treatment, the situation would likely be worse, said Larry Curley, director of program development for Rehoboth McKinley.

This kind of care doesn’t come cheap. The federal government paid the full cost of the expansion through 2016, but now New Mexico and other states have to pick up a 5 percent share. To deal with rising costs, the state in 2017 began cutting the fees it pays hospitals, doctors and other providers.

Asked about her Medicaid health plan while at a popular doughnut shop, Corrine Rosales, 60, of Gallup, said it’s invaluable for her and her two young nieces, Mya and Destiny. Medicaid pays for her diabetes medications and helped Mya get treated for attention-deficit disorder.

“I don’t know what we would do without it,” she said.

Medicare does not require that older adults demonstrate improvement in order to receive ongoing therapy.

This article first appeared March 29, 2018 on Kaiser Health News.

By Judith Graham

For years, confusion has surrounded the conditions under which older adults can receive physical, occupational and speech therapy covered by Medicare.

Services have been terminated for some seniors, such as those with severe cases of multiple sclerosis or Parkinson’s disease, because therapists said they weren’t making sufficient progress. Others, including individuals recovering from strokes or traumatic brain injuries, have been told that they reached an annual limit on services and didn’t qualify for further care.

Neither explanation stands up to scrutiny. Medicare does not require that older adults demonstrate improvement in order to receive ongoing therapy. Nor does it limit the amount of medically necessary therapy, for the most part.

The February congressional budget deal eases long-standing concerns by lifting a threat that some types of therapy might be restricted. But potential barriers to accessing this type of care remain. Here’s a look at how Medicare now covers such services.

Medical necessity. All therapy covered by Medicare must be deemed “reasonable and necessary to treat the individual’s illness or injury,” require the services of skilled professionals and be subject to medical oversight.

What isn’t a precondition for receiving services is ongoing improvement — getting measurably better. While this can be a goal for therapy, other goals can include maintaining a person’s current abilities or preventing deterioration, according to a groundbreaking legal settlement in 2013.

The implication for older adults: If your therapist claims that she can’t help you any longer because you aren’t making substantial progress, you may well have grounds for an appeal. At the very least, a discussion with your physician about reasonable goals for therapy is advisable.

Part A therapy services. Often, older adults require therapy after an untoward event brings them to the hospital — for instance, a stroke or a bad fall. If a senior has an inpatient stay in the hospital of at least three days, he or she becomes eligible for up to 100 days of rehabilitation, including therapy, in a skilled nursing facility under Medicare Part A.

Therapy services covered by Medicare Part A also can be obtained in an inpatient, hospital-based rehabilitation facility. In this setting, requirements call for therapy to be “intensive” — at least three hours a day, five days a week. Stays are covered by Medicare up to a maximum 90 days.

If a senior returns home after being in the hospital, he or she may receive therapy from a home health agency under Medicare Part A. To qualify for home health care, an older adult must need intermittent skilled services, such as those provided by a registered nurse or physical therapist, and be substantially homebound. Each episode of home health care can last up to 60 days and be renewed with a physician’s authorization.

“A lot of home health agencies believe, wrongly, that the home health benefit, including therapy services, is limited in duration to a couple of 60-day episodes,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy. The bottom line for beneficiaries: You may have to advocate aggressively for the care you think you need and enlist your physician to intervene on your behalf.

Part B services. Physical, speech and occupational therapy are also covered by Medicare Part B in private practices, hospital outpatient clinics, skilled nursing facilities (when a patient’s Part A benefits have run out) and, less frequently, in people’s homes (when individuals no longer qualify for Part A home health services but still need assistance).

More than 5 million older adults and people with disabilities covered by Medicare receive “outpatient” therapy services of this kind each year. Care can last up to 90 days, with the potential for renewal if a physician certifies that ongoing services are necessary.

Questions about coverage for Part B therapy services have surfaced repeatedly since Congress authorized annual limits on the care that Medicare would cover in 1997 — a cost-saving move.

Faced with criticism, Congress delayed implementation of these “caps” for several years. Then, in 2006, it created an “exceptions” process that allowed caps to be exceeded, so long as therapy was judged to be medically necessary.

The exceptions process had two steps. First, a therapist had to request that services be extended when a patient reached an initial “cap” — set this year at $2,010. Then, another request had to be made when a patient reached another, higher threshold — initially set at $3,700 this year, but reduced to $3,000 in the budget legislation.

Both steps called for therapists to justify additional services by providing extra documentation. At the second, higher threshold, therapists also faced the prospect of intensive medical review of their practices and, potentially, audits.

At that point, therapists were often hesitant to pursue exceptions, which has made it difficult for patients with complex medical conditions to access care. Also, sometimes requests for exceptions have been denied, posing another barrier.

“We use the exceptions process, but we’ve tried to be very vigilant in who we used it for,” said Sarah Gallagher, a physical therapist at South Valley Physical Therapy in Denver, which specializes in treating people with complicated neurological conditions. “The risk is putting your clinic at risk for an audit if you ask for exceptions too often.”

With February’s budget deal, Medicare has gotten rid of the “caps” but retained the notion of “thresholds.” After billing for $2,010 in services (about 20 therapy sessions at $100 per visit) this year, a provider has to add an extra code to a bill. After billing $3,000, targeted medical reviews and the potential for audits can again be prompted.

Eliminating the caps should make things easier for older adults who need a time-limited course of therapy. But whether therapists will be wary about approaching the $3,000 threshold, with its extra administrative burdens and potential risks, remains to be seen. If so, patients recovering from strokes or brain injuries and those with complicated chronic conditions, who need intensive therapy for an extended period, could be affected.

“We fear that there still might be barriers to accessing care,” said Lifschutz, of the Center for Medicare Advocacy. “We suspect some providers will say I don’t want to deal with this process, and if I’m getting anywhere near that $3,000 threshold, I’m just going to give it up.”

“Theoretically, all the uncertainty we’ve been living with, related to the therapy caps and acceptable goals of therapy, has been resolved,” said Kimberly Calder, senior director of health policy at the National Multiple Sclerosis Society. “But only time will tell.”