For many of the island's most vulnerable residents, the 2017 storm turned a healthcare access challenge into a full-blown medical crisis that cannot be easily reversed.

This article first appeared March 23, 2018 on Kaiser Health News.

By Sarah Varney

To reach the Martinez home in Puerto Rico’s central mountains, social worker Eileen Calderon steers around piles of dirt, treacherous potholes and power company trucks that block the road. Finally, she pulls up to a sagging, cement home, its roof done in by Hurricane Maria. Laundry hangs under a tarp, and a cat is tied to a leash outside the door.

Calderon, who is based in San Juan, and works for VarMed, a company that handles complex medical cases in Puerto Rico, has brought two colleagues — a nurse, Anamelia Velazquez, and a primary care physician, Dr. Carla Rossotti — to check in on Osvaldo Martinez and his son, Osvaldo Daniel Martinez.

Inside a darkened bedroom, the elder Martinez, a 67-year-old former star pitcher in the local baseball league, spoons rice and sausage into his son’s mouth. The younger Martinez lies in a hospital bed, his arms and fingers spasm and his eyes loll around in his head. He’s 37, born in Chicago, a former security guard.

Three years ago, after he and his father moved back to Puerto Rico from Illinois, the younger Martinez started showing early signs of multiple sclerosis. During the past year, his world became this room, then this bed.

His father points to the ceiling — leaking from the morning’s rain and covered in mold.

“All of this leaking that you can see came out because of the hurricane,” he said.

The power came back on in his house about a month ago, and the family has running water, so he is able to keep his son clean. The father carries a plastic basin into the bathroom and draws the water. Then, as he does a few times each day, he returns to the bedroom to bathe his adult son and gently change his diaper.

But Rossotti, whose company, VarMed, has been paid by the Puerto Rican government to help take care of the junior Martinez, said the younger man can’t yet get an appointment to see a neurologist to confirm his multiple sclerosis and start treatment. There is a chronic shortage of neurologists on the island, and those who remained after the storm have few slots in their schedules for Medicaid patients.

Calderon, the social worker, said she has been trying for a year to get an appointment for Martinez, but receptionist after receptionist tells her the neurologists they work for are taking no new patients. “We have a patient who was stable a year ago, and now he’s bedridden,” Rossotti said. “He hasn’t been able to get that neurologist evaluation.”

People here in Puerto Rico talk about life “before Maria” and life after. Accessing medical care here has always been a challenge, given the island’s chronic shortage of physicians and its unusual system for Medicaid — known as a block grant. The government provides a certain amount of money for each citizen in the program, no matter how great the needs are for care.

And for many of the island’s most vulnerable residents, like the Martinez family, the 2017 storm turned a challenge into a full-blown medical crisis that cannot be easily reversed. Since the turn of the century, a number of effective medicines that treat MS have come on the market, transforming the lives of people with the progressive disease, which can damage nerve conduction to anywhere in the body — the eye, the brain, the bladder, the legs. Treatment both helps slow progression and resolves symptoms. But it is less effective once damage to the nervous system is done.

The island’s financial crisis has sent doctors fleeing to the States during the past decade; Hurricane Maria added further fuel to that exodus. There is no exact accounting yet of just how many physicians have left the island, but from 2006 to 2016, the number of doctors dropped from 14,000 to 9,000, according to the Puerto Rico College of Physicians and Surgeons.

Nearly half of Puerto Ricans on the island rely on Medicaid — compared with around 20 percent of the population in the continental U.S. The territory’s government has long struggled to cover the costs of health care.

Currently, Molina Healthcare, a California-based company that provides insurance coverage to low-income people on Medicaid in Puerto Rico and elsewhere in the U.S., is ostensibly responsible for guaranteeing access to needed doctors.

A spokeswoman for Molina, Laura Murray, said the company cannot comment on the Martinez case, or that of any individual patient, because of privacy laws. But in a written statement, the company representative reported that it contracts with 41 neurologists in Puerto Rico’s eastern and southwestern regions, and meets “the network adequacy requirements in our contract.”

“However,” the statement continued, “we recognize that there is an island-wide shortage of physicians — particularly specialists — and we are proposing suggestions to [the Puerto Rican government] on how we could work together to remediate this.”

The island government recently announced that it will overhaul how Medicaid contracts are awarded.

For now, the younger Martinez languishes — each day and night no different than the next, as the disease lays siege to his central nervous system, disrupting the vital connections between brain and body.

Without a confirmed diagnosis, he can’t get certain public disability benefits. And he isn’t getting medication for his condition or his pain; the agency Rossotti works for can only advocate for patients, not treat them.

The outward perseverance of father and son belies the true terror of their confinement. As the elder Martinez describes his son’s decline, tears come to his eyes; his son, who can understand everything, rolls on his side and begins to weep.

“I have to do all that needs to be done for him,” Martinez said. But he is not in good health himself, with severe arthritis and a painful bulge in his abdomen. During the months they went without power, he said, the hospital bed didn’t go up and down. He showed a photo of his arm — black-and-blue and swollen — from pressing against the metal bars of the bed as he leaned down to tend to his son.

But it’s his son’s withering away that pains him most.

“If something would happen to me,” the father said, clasping his hands together in prayer — “I don’t know.”

The former principal investigator over clinical trials of a treatment vaccine at the Walter Reed Army Institute of Research faces accusations he mishandled HIV research.

This article first appeared March 20, 2018 on Kaiser Health News.

By Marisa Taylor

President Donald Trump’s likely pick to lead the Centers for Disease Control and Prevention is facing significant criticism because of a 20-year-old controversy over shoddy HIV research.

The Army in 1994 acknowledged accuracy issues with HIV vaccine research led by Dr. Robert Redfield, who is expected to head the CDC, but concluded at the time that the data errors did not constitute misconduct.

Yet one of the whistleblowers who first raised the matter to the Army told Kaiser Health News this week that he remains so troubled about Redfield’s handling of the vaccine research that he has decided to speak out publicly.

Redfield was principal investigator over clinical trials of a treatment vaccine at the Walter Reed Army Institute of Research. The research was conducted at a time when there was intense pressure to come up with a treatment for HIV/AIDS, which often killed patients within a matter of months.

“Either he was egregiously sloppy with data or it was fabricated,” said former Air Force Lt. Col. Craig Hendrix, a doctor who is now director of the division of clinical pharmacology at Johns Hopkins University School of Medicine. “It was somewhere on that spectrum, both of which were serious and raised questions about his trustworthiness.”

In a letter to Trump this week, Washington Sen. Patty Murray, the ranking Democrat on the health committee, cited the research controversy as an example of a “pattern of ethically and morally questionable behavior” by Redfield that should prompt the president to reconsider the appointment.

Redfield’s appointment, which does not require Senate confirmation, was leaked to the news media over the weekend. Redfield did not respond to questions, and the Department of Health and Human Services, which oversees the CDC, declined to comment.

Redfield, who denied any scientific misconduct at the time, is now an HIV/AIDS expert at the University of Maryland School of Medicine. He has been praised by his supporters for his care of patients. He oversees a clinical program that treats 6,000 patients in the Baltimore-Washington area, according to an online bio.

But Redfield’s critics said the expected appointment demonstrates that the Trump administration is not vetting appointees thoroughly. The first CDC head, Brenda Fitzgerald, stepped down in January after a controversy over her purchase of tobacco stocks, and former HHS Secretary Tom Price resigned late last year amid criticism over his use of government and private planes for official travel.

“The White House claimed they would do better background checks,” said Dr. Sidney Wolfe, founder and senior adviser of Public Citizen’s Health Research Group. “But that statement is dangerously laughable. If they had done a proper background check, they wouldn’t have chosen Dr. Redfield.”

Public Citizen, a Washington watchdog group, was a leading critic of the Army’s handling of Redfield’s data at the time and obtained and published documents that detailed the controversy.

Hendrix, who was the director of an Air Force HIV clinical unit when he raised the concerns, said: “Two members of his [Redfield’s] team told me they had tried to replicate the analysis, but they couldn’t. When they tried to go to the Army, they said they were ignored.”

After Hendrix couldn’t replicate the results, he drafted a letter to his superiors reporting the data problems.

Hendrix said Redfield’s superiors initially told him not to send a letter detailing the concerns. Instead, the military scheduled a meeting with Redfield and other researchers so Hendrix could discuss the concerns. In the meeting, Hendrix recalled, Redfield acknowledged he had overstated how promising the results were.

“I thought it was resolved,” said Hendrix, who said he later called Redfield to say he was proud to work in an organization that could openly discuss such concerns.

However, Hendrix soon heard Redfield make the same inaccurate representations of the data at a conference and decided to file an official complaint requesting an investigation into scientific misconduct.

An Air Force institutional review board also recommended that the Army launch an inquiry stating: “The committee agreed the information presented by Dr. Redfield seriously threatens his credibility as a researcher and has the potential to negatively impact AIDS research funding for military institutions as a whole.”

But the Army did not appear to launch a full investigation, said Hendrix, who was interviewed at the time by the military official who conducted the inquiry. The military official declined Hendrix’s attempts to provide documented evidence, telling him the investigation was “informal.”

Hendrix later asked the commander of his hospital about the outcome of the investigation. He recalled that the commander called another officer to ask.

“I just remember him saying “Yes, sir,” he said. “When he hung up, he told me, ‘We will not be discussing this again.’”

Redfield was transferred from the laboratory he headed and assigned to treat patients, although the Army said he was not being punished. The Army also said the data would be corrected, and the military scrapped the program.

The project had earlier drawn criticism because Congress had set aside $20 million for the vaccine after lobbying by a former senator on behalf of the manufacturer.

Hendrix said he occasionally interacted over the years with Redfield and holds no grudges.

“Before this happened, he made important contributions to HIV-prevention efforts,” he said. “I respected him.”

However, he said, he remains disturbed by the military’s handling of the matter. He teaches a class on medical ethics and uses his own experience without naming Redfield to describe to his students the ethical quandaries faced in research.

Faulty data can lead other scientists to repeat the same mistakes and prompt participants to seek out trials for drugs and vaccines that don’t work.

“It’s a huge waste of funds,” he said. “But just as importantly, it diminishes trust, which is essential in science. If truth is eroded, then the whole enterprise falls apart.”

While the health care field overall has far more women than men, in many stations of power the top of the pyramid is overwhelmingly male, with women occupying the vast base.

This article first appeared March 08, 2018 on Kaiser Health News.

By Christina Jewett, Kaiser Health News

Annette Katz didn’t expect to be part of a major social movement. She didn’t set out to take on a major health organization. But that all began to change when a co-worker saw her fighting back tears and joined Katz to report to her union what amounted to a criminal sexual offense at a Cleveland Veterans Affairs Medical Center in 2012 and 2013.

Four years later, Katz, a licensed practical nurse at the hospital, testified in a court deposition that a male nursing assistant had shoved her into a linen closet and groped her and subjected her to an onslaught of lewd comments.

In speaking out and taking legal action, Katz joined a growing group of women who are combating sexual harassment in the medical field at every level, from patients’ bedsides to the executive boardroom.

Much as the #MeToo moment has raised awareness of sexual harassment in business, politics, media and Hollywood, it is prompting women in medicine to take on a health system where workers have traditionally been discouraged from making waves and where hierarchies are ever-present and all-commanding. While the health care field overall has far more women than men, in many stations of power the top of the pyramid is overwhelmingly male, with women occupying the vast base.

In a recent survey, 30 percent of women on medical faculties reported experiencing sexual harassment at work within the past two years, said Dr. Reshma Jagsi, who conducted the poll. That share is comparable to results in other sectors and, as elsewhere, in medicine it had been mostly taboo to discuss before last year.

“We know harassment is more common in fields where there are strong power differentials,” said Jagsi, who is director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. “And we know medicine is very hierarchical.”

Workers in the health care and social assistance field reported 4,738 cases of sexual harassment from fiscal 2005 through 2015, eclipsed only by fields such as hospitality and manufacturing, where men make up a greater proportion of the workforce, according to data gathered by the Equal Employment Opportunity Commission.

A Kaiser Health News review of dozens of legal cases across the U.S. shows similar patterns in the waves of harassment cases that have cropped up in other fields, from entertainment to sports to journalism: The harassers are typically male. The alleged harasser supervises or outranks the alleged victim. There are slaps on the butt, lewd comments and requests for sex. When superiors are confronted with reports of bad behavior, the victims, mostly women, are disbelieved, demoted or fired.

But recently, physicians have taken to Twitter using the #MeTooMedicine tag, sharing anecdotes and linking to blogs that chronicle powerful doctors harassing them or disrobing at professional conferences.

Women who work in cardiology recently told the cardiology trade publication TCDMD that they felt the problem was particularly widespread in their specialty, where females account for 14 percent of the physicians. A Los Angeles anesthesiologist made waves in a blog post urging “prettier” women to adopt a “professional-looking, even severe, hair style” to be taken seriously and to consider self-defense classes.

Among those speaking out is Dr. Jennifer Gunter, a San Francisco obstetrician-gynecologist, who recently wrote a blog post about being groped in 2014 by a prominent colleague at a medical conference — even naming him.

“I think nothing will change unless people are able to name people and institutions are held accountable,” she said in an interview. “I don’t think without massive public discourse and exposure that things will change.”

Lawsuits, many settled or still making their way through the courts, describe encounters.

A Florida nurse claimed that in 2014, a surgeon made lewd comments about her breasts, asking her in a room full of people if he should “refer to her as ‘JJ’ or ‘Jugs,’” the nurse’s lawsuit says. The nurse said she “responded that she wished to be called by her name.”

In other cases: A phlebotomist in New York alleged in a lawsuit that a doctor in her medical practice gave her a box of Valentine’s Day candy and moved in for an unwanted kiss on the mouth. A Florida medical resident alleged that a supervising doctor told her she looked like a “slutty whore.” A Nebraska nurse claimed that a doctor she traveled with to a professional conference offered to buy her a bikini, if he could see her in it, and an extra night in a hotel, if they could share the room. She declined.

A Pennsylvania nurse described the unsatisfying response she got after reporting that a colleague had pressed his pelvis against her and flipped through her phone for “naked pictures.” A supervisor to whom she reported the conduct expressed exasperation, saying “I can’t deal with this” and “What do you want?”

Dr. Kayla Behbahani, chief psychiatry resident at University of Massachusetts Memorial Medical Center, did not file a lawsuit but recently wrote about sexual harassment by a subordinate. In an interview, she said her instincts were to pity the man, and also to follow a dictate that’s drilled into medical students: Don’t make waves. So, she disclosed the harassment only after another woman’s complaint launched an investigation.

“As a professional, I come from a culture where you go with the flow,” Behbahani said. “You deal with what you’re dealt. In that regard, it was a dilemma for me.”

Annette Katz, the Veterans Affairs nurse, initially didn’t complain about the harassment. A single mother with two children, she needed her job. Her attacker, MD Garrett, was also a nursing assistant but had more seniority, was a veteran and was friends with her boss.

“I really did feel that I would lose my job,” Katz said in an interview. “I would be that troublemaker.”

But as the abuse escalated, she went to the VA inspector general and the Cleveland police.

She estimated that five times Garrett pushed her into a closet where he would ask for sex. She would “tell him ‘no’ and fight my way out of [his] grip,” her statement said. He shoved her into an unconscious patient’s bathroom and would “try to restrain me, but I eventually could break free.”

After one such assault, a colleague noticed tears in Katz’s eyes. The co-worker shared with Katz that she, too, had been a target of Garrett’s lewd behavior.

Katz and the colleague filed complaints in March 2013 with their union, the police and with their managers. That July, Garrett was indicted by a grand jury and later pleaded guilty to three counts of sexual imposition and one count of unlawful restraint. He was also dismissed from his job.

Reached by phone, Garrett said he agreed to the plea because he was facing multiple felonies and didn’t know what a jury would do. He said that even though he pleaded guilty to four misdemeanors, he did not commit the crimes of which he was accused. “There was no harassment; she and I were friends,” he said.

Speaking quietly, going to HR — if that worked, we wouldn’t be here.

In 2013, Katz sued the VA, alleging that it failed to protect her from harassment and retaliated against her by refusing to give her a job-site transfer before firing her for not showing up to work.

The VA attorneys argued that the department had no direct knowledge of harassing behavior before Katz reported it, and that once it was informed, immediate action was taken. Veterans Affairs deputy press secretary Lydia Blaha said in an email that anyone engaged in sexual harassment is swiftly held accountable.

The U.S. Department of Veterans Affairs agreed in February to pay $161,500 to settle Katz’s lawsuit.

Katz said it was costly and emotional to press on with her legal case but hopes it helps other women see that seeking justice is worthwhile. “I do think there are a lot of women who just suffer in silence,” she said.

Gunter, the San Francisco physician-blogger, said that needed change will come only when people who are more established across all professions stand up for those who are more junior. “Speaking quietly, going to HR — if that worked, we wouldn’t be here,” she said.

It’s ironic, she said, that as a gynecologist she’s trained to believe patients’ claims about sexual assault. In the workplace, though, it’s well-known that raising such matters can backfire. She added: “Physicians should be setting a standard on this.”

Analysts often describe the change as the most far-reaching attempt in the nation to control the medical costs driving up insurance premiums and government spending.

This article first appeared March 19, 2018 on Kaiser Health News.

By Jay Hancock

Saturdays at Mercy Medical Center used to be perversely lucrative. The dialysis clinic across the street was closed on weekends.

That meant the downtown Baltimore hospital would see patients with failing kidneys who should have gone to the dialysis center. So Mercy admitted them, collecting as much as $30,000 for treatment that typically costs hundreds of dollars.

“That’s how the system worked,” said Mercy CEO Thomas Mullen. Instead of finding less expensive alternatives, he said, “our financial people were saying, ‘We need to admit them.’”

Maryland’s ambitious hospital-payment overhaul, put in place in 2014, has changed such crass calculations, which are still business as usual for most of American health care. A modification of a long-standing state regulation that would be hard to replicate elsewhere, the system is nevertheless attracting national attention, analysts say.

As soon as Mercy started being penalized rather than rewarded for such avoidable admissions, it persuaded the dialysis facility to open on weekends, saving government insurance programs and other payers close to $1 million annually.

In the four years since Maryland implemented a statewide system of pushing hospitals to lower admissions, such savings are adding up to hundreds of millions of dollars for the taxpayers, employers and others who ultimately pay the bills, a new report shows.

Maryland essentially pays hospitals to keep people out of the hospital. Analysts often describe the change as the most far-reaching attempt in the nation to control the medical costs driving up insurance premiums and government spending.

Like a giant health maintenance organization, the state caps hospitals’ revenue each year, letting them keep the difference if they reduce inpatient and outpatient treatment while maintaining care quality. Such “global budgets,” which have attracted rare, bipartisan support during a time of rancor over health care, are supposed to make hospitals work harder to keep patients healthy outside their walls.

Maryland’s system, which evolved from a decades-old effort to oversee hospitals as if they were public utilities, regulates all hospital payments by every private and government insurer. That makes it radically different from piecemeal attempts to lasso health spending, such as creating accountable care organizations, which seek savings among smaller groups of patients.

From the program’s launch in 2014 through 2016, per capita hospital spending by all insurers grew by less than 2 percent a year in Maryland. That’s below the economic growth rate, according to new results from the state’s hospital regulator and the federal Department of Health and Human Services.

Keeping hospital spending below economic growth — defined four years ago as 3.58 percent annually — is a key goal for the program and something that rarely happened.

Counting The Savings

The state plan saved the Medicare program for seniors and the disabled about half a billion dollars over three years and achieved “substantial reductions in hospitalization and especially improvements in quality of care,” said a Medicare spokesman.

In the three years measured so far, he added, “the state has already exceeded the required performance for the full five years of the model.”

As high costs for hospital care have been growing more slowly nationwide, Maryland hospital costs over that period rose even less.

“It looks like it has very strong results,” said John McDonough, a Harvard health policy professor who helped craft the federal Affordable Care Act.

What Maryland is doing, he said, “is pretty bold and it’s pretty thoughtfully done and has generated a huge amount of interest around the country.”

Comprehensive results through 2016 are the most recent available from Maryland and HHS, although savings continued last year, Maryland officials said. Independent researchers found mixed results for savings in the earlier years of Maryland’s system.

Maryland’s global budgets saved Medicare $293 million — 1.8 percent of total Medicare spending — in 2014 and 2015, research firm RTI International reported in August.

A separate paper from a team led by Eric Roberts at the University of Pittsburgh found that Maryland’s program in those years couldn’t be clearly credited for reducing hospital use.

The system’s advocates say several years of results are needed to show it’s working.

“These are not fake savings,” said Joseph Antos, an economist at the conservative-leaning American Enterprise Institute who sits on Maryland’s hospital-payment commission. “It didn’t happen instantaneously. It’s taken this number of years to achieve the kinds of savings that you see” for 2016 and beyond.

Even boosters such as Joshua Sharfstein, the former Maryland health secretary who got approval for global budgets from the Obama administration, say the system is far from perfect or finalized.

“There is a range of responses. Some hospitals have been able to do more than others,” said Sharfstein, now an associate dean at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “Change in health care is notoriously slow.”

Hospitals have lagged in delivering primary, preventive care to people with chronic conditions such as asthma, diabetes and heart failure, especially in low-income neighborhoods.

Maryland’s system does little to control soaring costs of drugs or nursing home care, doctors’ office treatments and other care not connected to hospitals, although policymakers are working on proposals to do both.

Even so, “what Maryland has done is just so far ahead of many of these other models” to try to control costs, said Dan D’Orazio, a management consultant who has worked with hospitals across the country. One Maryland hospital CEO told him: “This has fundamentally changed how we wake up and do business every day,” D’Orazio said.

Seeing A Difference

At Mercy, described by policymakers as more aggressive than many hospitals in watching costs, about a third of the patients now leave the hospital with medications in hand, said Dr. Wilma Rowe, the hospital’s chief medical officer. That bypasses the tendency for patients to skip a follow-up pharmacy visit and risk landing back in the emergency room.

A statewide data network notifies Mercy and other hospitals when one of their patients ends up in an emergency room somewhere else. That helps coordinate care.

Greater Baltimore Medical Center, north of the city, has hired dozens of primary care doctors to track around 1,000 people with diabetes — staying in touch, advising on diets and keeping them on insulin so they avoid the hospital.

Often clinicians visit elderly patients’ homes to prevent what might turn into an ambulance call and admission, said the hospital’s CEO, Dr. John Chessare.

Before global budgets, “I’d look at the waiting room in the [emergency department], and if it wasn’t full I’d get scared,” he said.

Now he worries it might be full of people who could be better treated elsewhere — including Gilchrist, a GBMC affiliate delivering hospice care for those at the end of life.

These days, he said, “we consider it a defect if someone with chronic disease dies in the hospital.”