Never Too Late To Operate? Surgery Near End Of Life Is Common, Costly

KFF Health News, March 1, 2018

Nearly 1 in 3 Medicare patients undergo an operation in their final year of life.

This article first appeared February 28, 2018 on Kaiser Health News.

By Liz Szabo

At 87, Maxine Stanich cared more about improving the quality of her life than prolonging it.

She suffered from a long list of health problems, including heart failure and chronic lung disease that could leave her gasping for breath.

When her time came, she wanted to die a natural death, Stanich told her daughter, and signed a “do not resuscitate” directive, or DNR, ordering doctors not to revive her should her heart stop.

Yet a trip to a San Francisco emergency room for shortness of breath in 2008 led Stanich to get a defibrillator implanted in her chest — a medical device to keep her alive by delivering a powerful shock. At the time, Stanich didn’t fully grasp what she had agreed to, even though she signed a document granting permission for the procedure, said her daughter, Susan Giaquinto.

That clarity came only during a subsequent visit to a different hospital, when a surprised ER doctor saw a defibrillator protruding from the DNR patient’s thin chest. To Stanich’s horror, the ER doctor explained that the device would not allow her to slip away painlessly and that the jolt would be “so strong that it will knock her across the room,” said Giaquinto, who accompanied her mother on both hospital trips.

Surgery like this has become all too common among those near the end of life, experts say. Nearly 1 in 3 Medicare patients undergo an operation in the year before they die, even though the evidence shows that many are more likely to be harmed than to benefit from it.

The practice is driven by financial incentives that reward doctors for doing procedures, as well as a medical culture in which patients and doctors are reluctant to talk about how surgical interventions should be prescribed more judiciously, said Dr. Rita Redberg, a cardiologist who treated Stanich when she sought care at the second hospital.

“We have a culture that believes in very aggressive care,” said Redberg, who at the University of California-San Francisco specializes in heart disease in women. “We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.”

While surgery is typically lifesaving for younger people, operating on frail, older patients rarely helps them live longer or returns the quality of life they once enjoyed, according to a 2016 paper in Annals of Surgery.

The cost of these surgeries — typically paid for by Medicare, the government health insurance program for people over 65 — involve more than money, said Dr. Amber Barnato, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Older patients who undergo surgery within a year of death spent 50 percent more time in the hospital than others, and nearly twice as many days in intensive care.

And while some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are far more frail.

Eighteen percent of Medicare patients have surgery in their final month of life and 8 percent in their final week, according to a 2011 study in The Lancet.

More than 12 percent of defibrillators were implanted in people older than 80, according to a 2015 study. Doctors implant about 158,000 of the devices each year, according to the American College of Cardiology. The total cost of the procedure runs about $60,000.

Procedures performed in the elderly range from major operations that require lengthy recoveries to relatively minor surgery performed in a doctor’s office, such as the removal of nonfatal skin cancers, that would likely never cause any problems.

Research led by Dr. Eleni Linos has shown that people with limited life expectancies are treated for nonfatal skin cancers as aggressively as younger patients. Among patients with a nonfatal skin cancer and a limited time to live, 70 percent underwent surgery, according to her 2013 study in JAMA Internal Medicine.

When Less Is More

Surgery poses serious risks for older people, who weather anesthesia poorly and whose skin takes longer to heal. Among seniors who undergo urgent or emergency abdominal surgery, 20 percent die within 30 days, studies show.

With diminished mental acuity and an old-fashioned respect for the medical profession, some aging patients are vulnerable to unwanted interventions. Stanich agreed to a pacemaker simply because her doctor suggested it, Giaquinto said. Many people of Stanich’s generation “thought doctors were God … They never questioned doctors — ever.”

According to the University of Michigan's National Poll on Healthy Aging, published Wednesday, more than half of adults ages 50 to 80 said doctors often recommend unnecessary tests, medications or procedures. Yet half of those who'd been told they needed an X-ray or other test — but weren't sure they needed it — went on to have the procedure anyway.

Dr. Margaret Schwarze, a surgeon and associate professor at the University of Wisconsin School of Medicine and Public Health, said that older patients often don’t feel the financial pain of surgery because insurance pays most of the cost.

When a surgeon offers to “fix” the heart valve in a person with multiple diseases, for example, the patient may assume that surgery will fix all of her medical problems, Schwarze said. “With older patients with lots of chronic illnesses, we’re not really fixing anything.”

Even as a doctor, Redberg said, she struggles to prevent other doctors from performing too many procedures on her 92-year-old mother, Mae, who lives in New York City.

Redberg said doctors recently treated her mother for melanoma — the most serious type of skin cancer. After the cancer was removed from her leg, Redberg’s mother was urged by a doctor to undergo an additional surgery to cut away more tissue and nearby lymph nodes, which can harbor cancerous cells.

“Every time she went in, the dermatologist wanted to refer her to a surgeon,” Redberg said. And “Medicare would have been happy to pay for it.”

But her mother often has problems with wounds healing, she said, and recovery would likely have taken three months. When Redberg pressed a surgeon about the benefits, he said the procedure could reduce the chances of cancer coming back within three to five years.

Redberg said her mother laughed and said, “I’m not interested in doing something that will help me in three to five years. I doubt I’ll be here.”

Finding Solutions

The momentum of hospital care can make people feel as if they’re on a moving train and can’t jump off.

The rush of medical decisions “doesn’t allow time to deliberate or consider the patients’ overall health or what their goals and values might be,” said Dr. Jacqueline Kruser, an instructor in pulmonary and critical care medicine and medical social sciences at the Northwestern University Feinberg School of Medicine.

Many hospitals and health systems are developing “decision aids,” easy-to-understand written materials and videos to help patients make more informed medical decisions, giving them time to develop more realistic expectations.

After Kaiser Permanente Washington introduced the tools relating to joint replacement, the number of patients choosing to have hip replacement surgery fell 26 percent, while knee replacements declined 38 percent, according to a study in Health Affairs. (Kaiser Permanente is not affiliated with Kaiser Health News, which is an editorially independent program of the Kaiser Family Foundation.)

In a paper published last year in JAMA Surgery and the Journal of Pain and Symptom Management, Schwarze, Kruser and colleagues suggested creating narratives to illustrate surgical risks, rather than relying on statistics.

Instead of telling patients that surgery carries a 20 percent risk of stroke, for example, doctors should lay out the best, worst and most likely outcomes.

"We have a culture that believes in very aggressive care. We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most."

Dr. Rita Redberg, director of women's cardiovascular services at the University of California-San Francisco Division of Cardiology

In the best-case scenario, a patient might spend weeks in the hospital after surgery, living the rest of her life in a nursing home. In the worst case, the same patient dies after several weeks in intensive care. In the most likely scenario, the patient survives just two to three months after surgery.

Schwarze said, “If someone says they can’t tolerate the best-case scenario — which involves them being in a nursing home — then maybe we shouldn’t be doing this.”

Maxine Stanich was admitted to the hospital after going to the ER because she felt short of breath. She experienced an abnormal heart rhythm in the procedure room during a cardiac test —not an unusual event during a procedure in which a wire is threaded into the heart. Based on that, doctors decided to implant a pacemaker and defibrillator the next day.

Dr. Redberg was consulted when the patient objected to the device that was now embedded in her chest. She was “very alert. She was very clear about what she did and did not want done. She told me she didn’t want to be shocked,” Redberg said.

After Redberg deactivated the defibrillator, which can be reprogrammed remotely, Stanich was discharged, with home hospice service. With nothing more than her medicines, she survived another two years and three months, dying at home just after her 90th birthday in 2010.

Tens of Thousands of Medicaid Recipients Skip Paying New Premiums

KFF Health News, March 1, 2018

Advocates say it's unsurprising that significant numbers of Medicaid enrollees fall behind on their payments. Even $13 per month can be burdensome.

This article first appeared March 01, 2018 on Kaiser Health News.

By Phil Galewitz

When Arkansas lawmakers debated in 2016 whether to renew the state’s Medicaid expansion, many Republican lawmakers were swayed only if some of the 300,000 adults who gained coverage would have to start paying premiums.

This “skin-in-the-game” provision — endorsed by conservatives in Washington and in many statehouses — is designed to make Medicaid recipients value their government health insurance more and lead healthier lives.

It’s “to encourage more personal responsibility,” Arkansas Gov. Asa Hutchinson told reporters in 2016. “We want to incentivize better, healthy living.”

Yet few enrollees are paying the $13 monthly premiums, which apply only to Medicaid recipients whose earnings surpass the poverty level. In 2017, just 20 percent of the 63,000 Arkansas enrollees paid. Medicaid enrollees in Arkansas don’t lose coverage for lack of payment.

Arkansas is not the only state where Medicaid recipients who gained coverage under the Affordable Care Act disregard the new premiums. Tens of thousands of Medicaid enrollees in four other states that added premiums during the past four years— Indiana, Michigan, Iowa and Montana — have also opted not to pay, according to state records.

Under the ACA, states received millions of federal dollars to cover everyone with incomes under 138 percent of the federal poverty level (about $16,700 for an individual today). Previously, Medicaid mainly covered only low-income children, disabled adults and parents.

Premiums, which are routine obligations in private health insurance and Medicare, were not a part of Medicaid until that expansion in 2014. In these five states, conservative lawmakers were hesitant to expand the federal-state program unless they secured fees from nondisabled adults.

Kentucky has received approval to add premiums in 2018.

“We believe the premiums are important to prepare these beneficiaries for what would be required of them if they move up the economic ladder and get coverage through an employer or the federal marketplace,” said Arkansas Medicaid spokeswoman Amy Webb. “It’s a small amount, especially considering the benefit they are receiving. Under an employer or at the marketplace, they would lose their coverage for failure to pay.”

Advocates for Medicaid say it is not surprising that significant numbers of Medicaid enrollees fall behind on their payments.

“Premiums are a financial barrier for low-income people, even if you are working,” said Rich Huddleston, executive director of Arkansas Advocates for Children and Families. Even the state’s $13 monthly premium is burdensome. “Families have to make tough choices every day about whether they buy food, pay the electric bill, their rent, or pay premiums.”

Still, the experience in the five states shows converting conservatives’ “skin-in-the-game” mantra into practice has many administrative challenges.

Michigan requires Medicaid enrollees with incomes over the poverty level to pay 2 percent of their income in monthly premiums, though the amount could be decreased if they engage in so-called healthy behaviors, such as getting a flu shot or trying to quit smoking.

A survey of enrollees last year in Michigan found nearly 88 percent said the amount they had to pay was “fair,” and 72 percent said they agreed that they would “rather take some responsibility to pay something for their health care than not pay anything.”

But from January through August last year, fewer than half of Michigan Medicaid recipients who owed a premium — about 77,000 of 175,000 — paid it.

And premiums were not the only new obligation that many of these enrollees are failing to meet. The state’s Medicaid expansion also required them to fill out a health risk assessment form with their doctor and promise to improve their health. In return, members could lower their premiums or gain a $50 gift card.

Of the 900,104 beneficiaries who have been enrolled in Medicaid for at least six months, 19 percent have completed this chore, according to state records.

For most enrollees this is voluntary. But enrollees with incomes above 100 percent of the poverty level could lose Medicaid coverage if they don’t fill out the form to attest they will try to improve their health. Michigan particularly is getting tough: Last month it mailed letters to 13,550 beneficiaries informing them that they failed to meet this requirement and there will be consequences. They will be moved off Medicaid and will have to choose a private plan on the Obamacare insurance marketplace or will be automatically enrolled in one in June.

Dr. Renuka Tipirneni, a researcher with the University of Michigan Institute for Healthcare Policy & Innovation, said it’s unclear if these enrollees will be worse off in the private plans since many will get subsidies to help cover their premium costs. But they may face a larger cost-sharing portion or have to change doctors.

She was surprised by how few people paid their premiums, given the survey findings. “Many people want to pay and want to say they are contributing, but what is the reality of their circumstances?” she asked. The lack of a penalty for not paying, she added, could be a factor.

Michigan officials last year also sent 68,000 Medicaid enrollees who owed premiums a notice that they would garnish any state income tax refunds or lottery winnings. That led about 7,000 recipients to pay. The state last year collected premium money from 19,400 through their tax refunds and another 59 from their lottery winnings, according to a state report.

Arkansas officials also plan to intercept state tax refunds to recoup unpaid premiums, but not until 2019.

Other states have mixed records on collecting Medicaid premiums, according to state reports:

  • In Indiana, about 25,000 Medicaid recipients were kicked off the program from the fall of 2015 to October 2017 for failure to pay — or more than 1 in 3 who owed premiums. The payments range from $1 to $27. Indiana is the only state to lock enrollees out of Medicaid for six months for failure to pay the premium for two months in a row — and about 10,000 recipients fell into that category in 2016. Kentucky recently received federal permission to add a similar lockout provision this year.
  • Iowa disenrolled more than 14,000 Medicaid enrollees from January 2016 to September 2017 for failure to pay a $10 monthly Medicaid premium, though they could re-enroll at any time. More than 40,000 Medicaid enrollees with incomes over 50 percent of the poverty level were subject to a premium in September 2017 and about three-quarters of them had not paid nor completed a health risk assessment form that would have waived the fee.
  • Montana’s Medicaid program dropped 2,884 adults with incomes over the poverty level from coverage in 2017 for failing to pay a premium. The state charges 2 percent of the enrollee’s monthly income. Montana allows those dropped to re-enroll at any time without paying.

ACA's Popularity Grows, Even As GOP Lauds Change To Requirement To Have Coverage

KFF Health News, March 1, 2018

Only 13 percent of respondents were aware that both the requirement to buy insurance was repealed and that it remains in effect for 2018.

This article first appeared March 01, 2018 on Kaiser Health News.

By Phil Galewitz

Despite President Donald Trump’s boasting that “we have essentially repealed Obamacare,” a new poll shows the Affordable Care Act is more popular than ever. In fact, many people don’t know Congress repealed the ACA’s penalty for not having insurance.

The poll from the Kaiser Family Foundation found 54 percent of Americans had a favorable view of the 2010 health law that expanded health coverage to millions. That was up four points from January, and it’s highest point since the monthly survey began in 2010. (KHN is an editorially independent program of the foundation.)

The survey found 40 percent of respondents were unaware that Congress in January repealed the individual mandate penalty as part of the federal tax overhaul. It takes effect in 2019. About one in five people were aware of the repeal but believed incorrectly that it had taken effect this year.

Only 13 percent of respondents were aware that both the requirement to buy insurance was repealed and that it remains in effect for 2018.

The public’s lack of knowledge about the individual mandate likely reflects the fact that few people are affected by it. The majority of Americans have health coverage or are exempt from the mandate because their income is too low, said Ashley Kirzinger, a Kaiser polling expert.

“Confusion over the status of the ACA’s individual mandate stems from a lot of different things, but health care policy is complicated and the public generally doesn’t pay attention to details of health policy until it directly impacts them,” she said.

The poll showed the public is also split on what’s motivating states to add a work requirement to Medicaid.

About 41 percent of those surveyed said states were looking to lower government spending while 33 percent believed states were enacting the new requirements to “lift people out of poverty.”

The Trump administration in February approved requests from Indiana and Kentucky to require some non-disabled adults to work as a condition of having Medicaid coverage. At least eight more states are waiting for a green light.

About two-thirds of Americans said states should not put time limits on how long people can be enrolled in Medicaid as long as they qualify, the poll found. Support for lifetime caps was stronger among Republicans (51 percent) than Democrats (16 percent).

A Kaiser poll from June 2017 found that 70 percent of Americans support states imposing work requirements on non-disabled Medicaid adults.

The latest Kaiser poll of 1,193 adults was conducted Feb. 15 - 20 and has a margin of error of +/- 3 percentage points.

Refusing To Work For Medicaid May Not Translate To Subsidies For ACA Plan

KFF Health News, February 27, 2018

Contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs, for Kaiser Health News.

This article first appeared February 27, 2018 on Kaiser Health News.

By Michelle Andrews

Work requirements for Medicaid coverage. Insurance plans that don’t meet health law standards. Changes to Medicare drug lists. As the ground continues to shift on health care coverage, I answer readers’ queries this week about these three different types of plans.

Q: Im in a state that is looking into work requirements for Medicaid. At sign-up time, can I simply tell the exchange that I intend to be ineligible for Medicaid by refusing to work and get the premium tax credit to buy a private plan on the insurance marketplace?

Federal health law regulations don’t clearly address the situation you describe, but the short answer is probably not, said policy analysts.

In general, people who are eligible for Medicaid — the federal-state health program for low-income people — or employer coverage can’t qualify for federal tax credits that help pay for premiums on plans sold on the health insurance exchanges.

This year, Kentucky and Indiana became the first states to receive federal approval to require some Medicaid recipients to put in 80 hours each month at a paid job, school or volunteer work, among other activities, to receive benefits. Nearly a dozen other states have made similar requests.

If you refuse to work, does that make you ineligible for Medicaid? The rules aren’t clear, said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

States might argue that someone in your situation is eligible for Medicaid, you just have to fulfill the work requirements, said Timothy Jost, an emeritus professor of law at Washington and Lee University in Virginia who is an expert on the health law.

There are other actions people could take — or fail to take — where this issue might come up. “You could argue that someone is not eligible because they haven’t completed the Medicaid application or provided the required documentation,” Jost said. “There are any number of requirements, but I can’t imagine someone saying they didn’t do those things and so they’re not eligible for Medicaid.”

Whatever the rules, it’s unlikely that many people will be in a position to consider taking this stance. To qualify for premium tax credits, your income must be between 100 and 400 percent of the federal poverty level (about $12,000 to $48,500 for one person in 2018). But you’d also have to be eligible for Medicaid, generally with an income limit of 138 percent of poverty (about $16,750) in states that expanded coverage to adults. In addition, the Medicaid work requirements in your state would have to apply to you.

Q: I lost my job last year and my employer coverage ended in January. I bought a new plan through the marketplace that went into effect last month. I just received policy information, and it states that because the plan does not cover major medical services, I may have to pay additional taxes to the government. I was told that the plan didn't cover major medical but wasn't told about any taxes. Will I be fined next year?

It sounds like you bought a plan that doesn’t comply with the Affordable Care Act’s requirements, and if that’s the case you may indeed have to pay a penalty for not having comprehensive coverage when you file your taxes next year.

The tax law repealed the individual penalty for not having health insurance, but that provision doesn’t take effect until 2019. So, for 2018, you may be charged the greater of $695 or 2.5 percent of your household income.

The federal- and state-run marketplaces established by the ACA sell only comprehensive plans that cover 10 essential health benefits, including “major medical” services like hospitalization and prescription drugs.

But some insurance broker websites call themselves marketplaces too, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. These companies may sell other insurance products like short-term or accident coverage alongside comprehensive plans that comply with the law.

Ever since the health law was passed, “There have been opportunistic companies trying to take advantage of consumer confusion to make money,” Corlette said.

If you aren’t happy with your plan, you may still be able to switch. Losing your employer coverage qualifies you for a 60-day special enrollment period to pick a new plan. Since it appears you’re still in that window, you may be able to choose a comprehensive plan.

To ensure you’re using your state’s official marketplace, go to healthcare.gov and click on “see if I can change.” That will take you to your state marketplace, even if you live in one of the dozen or so states that run their own exchanges.

Q: I picked a Medicare Part D drug plan that covered all the drugs I take. But as soon as I got my first Novolin R prescription filled, they notified me that they don’t cover it anymore. Can they just switch it like that?

Medicare drug plans can change their list of covered drugs, called formularies. If they’re doing so at the start of the new calendar year, as appears to have happened in your case, the plan may notify you of the change when you fill the prescription for the first time in the new year. At that time, the plan would typically give you a 30-day “transition” refill so you can switch to another drug that’s on the formulary, according to Juliette Cubanski, associate director of the Program On Medicare Policy at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

If you and your doctor think it’s important that you have Novolin R and not another drug that is similar, you can ask your plan to make an exception to allow you to continue to take the medication.

To go that route, you would need to get your doctor to “make the case for why that formulary drug is not the right drug” for you, said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group.

Evaluations Of Medicaid Experiments By States, CMS Are Weak, GAO Says

KFF Health News, February 23, 2018

States often do not complete their evaluation reports until after the federal government renews their demonstration program.

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

By Phil Galewitz

With federal spending on Medicaid experiments soaring in recent years, a congressional watchdog said state and federal governments fail to adequately evaluate if the efforts improve care and save money.

A study by the Government Accountability Office released Thursday found some states don’t complete evaluation reports for up to seven years after an experiment begins and often fail to answer vital questions to determine effectiveness. The GAO also slammed the federal Centers for Medicare & Medicaid Services for failing to make results from Medicaid evaluation reports public in a timely manner.

“CMS is missing an opportunity to inform federal and state policy discussions,” the GAO report said.

Joan Alker, executive director of the Georgetown University Center for Children and Families, called the report's findings "troubling but not surprising."

"It has been clear for some time that evaluations of Section 1115 waivers are not adequate," she said. "There is some good work going on in this space at the state level, for example in Michigan and Iowa, but as the report makes clear state's evaluations are often incomplete and not rigorous enough."

These experiments are often called “demonstration projects” or “1115 demonstration waivers” — based on the section of the law that allows the federal government to authorize them. They allow federal officials to approve states’ requests to test new approaches to providing coverage. They are used for a wide variety of purposes, including efforts to extend Medicaid to people or services not generally covered or to change payment systems to improve care.

Medicaid demonstration programs often run for a decade or more. Several states that expanded Medicaid eligibility under the Affordable Care Act did so through a demonstration program, including Indiana, Iowa, Arkansas and New Hampshire.

Nearly three-quarters of states have Medicaid demonstration programs, such as those testing providing services through private managed-care firms and requiring enrollees to pay monthly premiums. About a third of the federal government’s $300 billion a year in Medicaid spending goes to these test programs, the GAO said.

The study, requested by top GOP lawmakers including Sen. Orrin Hatch (R-Utah), reviewed demonstration programs in eight states - Arizona, Arkansas, California, Indiana, Kansas, Maryland, Massachusetts and New York.

In five of these states, money from their Medicaid demonstration program makes up more than half their total federal Medicaid budgets. Nearly all of Arizona’s funding — 99.7 percent - is through a demonstration program.

The use of Medicaid demonstration programs accelerated during the 1990s. But in recent years the experiments have often reflected the political leanings of state officials or the party controlling the White House. Under a demonstration program, the Trump administration this year approved requests from Indiana and Kentucky to enact work requirements for some adult Medicaid enrollees.

The GAO report noted that states often do not complete their evaluation reports until after the federal government renews their demonstration program. For example, Indiana’s Medicaid expansion demonstration program, which charges premiums and locks some enrollees out of coverage for lack of payment, was renewed in February even though a final evaluation report is not yet complete.

GAO said Indiana’s evaluation of its Medicaid expansion won’t look at the effect of the state’s provision that locks out enrollees for six months if they fail to pay premiums.

“GAO found that selected states’ evaluations of these demonstrations often had significant limitations that affected their usefulness in informing policy decisions,” the report said.

Alker said that "more sunshine and data are needed" to assess waivers, "especially as they are clearly the vehicle the Trump administration is now using to pursue its ideological objectives for Medicaid."

While states typically contract with independent groups to evaluate Medicaid demonstration programs, the federal government sometimes does its own review.

But the GAO investigators found Indiana’s Medicaid agency wasn’t willing to work with the federal contractor out of privacy concerns. That halted efforts for a federal review.

Joel Cantor, director of the Center for State Health Policy at Rutgers University in New Brunswick, N.J., said the demonstration programs have often shifted from their intended purpose because they are designed by lawmakers pushing an agenda rather than as a scientific experiment to find better ways to deliver care.

“Demonstration programs have been used since the 1990s to advance policy agenda for whoever holds power in Washington and not designed to test an innovative idea,” he said.

The evaluations often take several years to complete, he said, because of the difficulty of getting patient data from states. His center has done evaluations for New Jersey’s Medicaid program.

GAO recommended that CMS require states to submit a final evaluation report after the end of the waiver period, regardless of whether the experiment is being renewed, and that the federal agency publicly release findings from federal evaluations in a timely manner. Federal officials said they agreed with the recommendations.

Matt Salo, executive director of the National Association of Medicaid Directors, said the report highlighted a need to modernize the law dealing with Medicaid so that successful experiments are quickly incorporated into the overall program.

“The underlying problem is that the Medicaid statute has fundamentally failed to keep up with the changing reality of health care in the 21st century,” he said. “There’s no way to update the rules to make these changes” a permanent part of the program.

Ten ERs In Colorado Tried To Curtail Opioids And Did Better Than Expected

KFF Health News, February 23, 2018

Rather than opioids like oxycodone, hydrocodone, or fentanyl, doctors used safer and less addictive alternatives, like ketamine and lidocaine.

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

By John Daley, Colorado Public Radio

DENVER — One of the most common reasons patients head to an emergency room is pain. In response, doctors may try something simple at first, like ibuprofen or acetaminophen. If that wasn’t effective, the second line of defense has been the big guns.

“Percocet or Vicodin,” explained ER doctor Peter Bakes of Swedish Medical Center, “medications that certainly have contributed to the rising opioid epidemic.”

Now, though, physicians are looking for alternatives to help cut opioid use and curtail potential abuse. Ten Colorado hospitals, including Swedish in Englewood, Colo., participated in a six-month pilot project designed to cut opioid use, the Colorado Opioid Safety Collaborative. Launched by the Colorado Hospital Association, it is billed as the first of its kind in the nation to include this number of hospitals in the effort.

The goal was for the group of hospitals to reduce opioids by 15 percent. Instead, Dr. Don Stader, an ER physician at Swedish who helped develop and lead the study, said the hospitals did much better: down 36 percent on average.

“It’s really a revolution in how we approach patients and approach pain, and I think it's a revolution in pain management that's going to help us end the opioid epidemic,” Stader says.

The decrease amounted to 35,000 fewer opioid doses than during the same period in 2016.

The overall effort to limit opioid use in emergency departments is called the Colorado ALTO Project; ALTO is short for "alternatives to opioids."

The method calls for coordination across providers, pharmacies, clinical staff and administrators. It introduces new procedures, for example, like using non-opioid patches for pain. Another innovation, Stader said, is using ultrasound to “look into the body” and help guide targeted injections of non-opioid pain medicines.

Rather than opioids like oxycodone, hydrocodone or fentanyl, Stader said, doctors used safer and less addictive alternatives, like ketamine and lidocaine, an anesthetic commonly used by dentists.

Lidocaine was by far the leading alternative; its use in the project’s ERs rose 451 percent. Ketamine use was up 144 percent. Other well-known painkillers were used much less, like methadone (down 51 percent), oxycodone (down 43 percent), hydrocodone (down 39 percent), codeine (down 35 percent) and fentanyl (down 11 percent).

“We all see the carnage that this opioid epidemic has brought,” Stader said. “We all see how dangerous it's been for patients, and how damaging it's been for our communities. And we know that we have to do something radically different.”

Claire Duncan, a clinical nurse coordinator in the Swedish emergency department, said the new approach has required intensive training. And there was some pushback, more from patients than from medical staff.

“They say ‘only narcotics work for me, only narcotics work for me.’ Because they haven't had the experience of that multifaceted care, they don't expect that ibuprofen is going to work or that ibuprofen plus Tylenol, plus a heating pad, plus stretching measures, they don't expect that to work,” she said.

The program requires a big culture change, encouraging staff to change the conversation from pain medication alone to ways to “treat your pain to help you cope with your pain to help you understand your pain,” Duncan said.

Emergency medical staff are all too familiar with the ravages of the opioid epidemic.

They see patients struggling with the consequences every day. But Bakes, the ER doctor at Swedish, said this project has changed minds and allowed health care professionals to help combat the opioid crisis they unwittingly helped to create.

“I think that any thinking person or any thinking physician, or provider of patient care, really felt to some extent guilty, but … powerless to enact meaningful change,” Bakes said.

The pilot project has proven so successful that Swedish and the other emergency departments involved will continue the new protocols and share what they learned. Stader said the Colorado Hospital Association will help spread the word about opioid safety and work toward its adoption statewide by year’s end.

“And I think if we did put this in practice in Colorado and showed our success that this would spread like wildfire across the country,” Stader said.

The 10 hospitals that collaborated on the project include Boulder Community Health, Gunnison Valley Health, Sedgwick County Health Center, Sky Ridge Medical Center, Swedish Medical Center, UCHealth Greeley Emergency and Surgical Center, UCHealth Harmony Campus, UCHealth Medical Center of the Rockies, UCHealth Poudre Valley Hospital and UCHealth Yampa Valley Medical Center.

Couple Makes Millions Off Medicaid Managed Care As Oversight Lags

KFF Health News, February 22, 2018

Evidence is mounting that Medicaid's rapid expansion under the Affordable Care Act has far outstripped the government's ability to monitor the taxpayer money it turns over to insurers.

This article first appeared February 22, 2018 on Kaiser Health News.

By Chad Terhune

CHULA VISTA, Calif. — Norma Diaz and her husband, Joseph Garcia, have dedicated their careers to running a nonprofit health insurer that covers some of California’s neediest residents.

For three decades, they have worked for a Medicaid managed-care plan, Community Health Group, serving nearly 300,000 poor and disabled patients in San Diego County under a state contract funded entirely by taxpayers. They’ve earned above-average ratings for patient care.

And in the process, they’ve made millions of dollars.

Together, Diaz and Garcia made $1.1 million in 2016 and received more than $5 million since 2012, according to the health plan’s tax returns and company data. Diaz’s compensation as CEO exceeded the pay of several peers at bigger plans in 2016.

Garcia, married to Diaz since 1997, is an outside consultant who serves as chief operating officer. Their health plan, with $1.2 billion in annual revenue, had a profit margin of 19 percent in 2016, the highest of any Medicaid insurer in California and more than six times the industry average.

“This is not only a conflict of interest but egregious overpayments,” Frank Glassner, chief executive of Veritas Executive Compensation Consultants in San Francisco, said after hearing of the payments from a reporter and reviewing the tax returns. “It’s the family-and-friends plan.”

Last year, federal auditors examined compensation for the 133 top paid executives at managed-care organizations in seven states, focused on health plans that get more than half of their revenue from Medicaid.

For 2015, the top executives earned $314,278, on average — more than double what state Medicaid directors earned, according to the report. Auditors didn’t find major differences in pay between for-profit and nonprofit Medicaid plans.

Executive compensation has risen as Community Health Group recorded hefty profits.

State officials had raised the rates paid to Medicaid plans in anticipation of the Affordable Care Act rollout in 2014, but the costs for newly insured patients weren’t as high as predicted. After the KHN investigation into insurer profits published in November, California’s Medicaid director, Jennifer Kent, vowed to recoup billions of dollars in excessive payments from insurers in coming months.

From 2014 to 2016, Community Health Group recorded profits of $344.2 million, according to state data obtained and analyzed by Kaiser Health News. Diaz said her insurer expects to return more than $100 million to the Medicaid program.

Robert Stern, a government ethics expert and former general counsel of California’s Fair Political Practices Commission, welcomed the scrutiny of Medicaid profits. But he said the business practices at Community Health Group suggest there is much more to be done.

“Taxpayer money should be spent as wisely as possible,” Stern said. “It’s not their money. It’s our money.”

Bad Bedside Manna: Bank Loans Signed In The Hospital Leave Patients Vulnerable

KFF Health News, February 21, 2018

Hospitals are increasingly offering 'patient-financing' strategies, cooperating with financial institutions to offer on-the-spot loans to make sure patients pay their bills.

This article first appeared February 21, 2018 on Kaiser Health News.

By Shefali Luthra

Laura Cameron, then three months pregnant, tripped and fell in a parking lot and landed in the emergency room last May — her blood pressure was low and she was scared and in pain. She was flat on her back and plugged into a saline drip when a hospital employee approached her gurney to discuss how she would pay her hospital bill.

Though both Cameron, 28, and her husband, Keith, have insurance, the bill would likely come to about $830, the representative said. If that sounded unmanageable, she offered, they could take out a loan through a bank that had a partnership with the hospital.

The hospital employee was “fairly forceful,” said Cameron, who lives in Fayetteville, Ark. “She certainly made it clear she preferred we pay then, or we take this deal with the bank.”

Hospitals are increasingly offering “patient-financing” strategies, cooperating with financial institutions to offer on-the-spot loans to make sure patients pay their bills.

Private doctors’ offices and surgery centers have long offered such no- or low-interest financing for procedures not covered by insurance, like plastic surgery, or to patients paying themselves for an expensive test or procedure with a fixed price.

But promoting bank loans at hospitals and, particularly, emergency rooms raises concerns, experts say. For one thing, the cost estimates provided — likely based on a hospital’s list price — may be far higher than the negotiated rate ultimately paid by most insurers. Sick patients, like Cameron, may feel they have no choice but to sign up for a loan since they need treatment. And the quick loan process, usually with no credit check, means they may well be signing on for expenses they can ill afford to pay.

The offers may sound like a tempting solution for scared, vulnerable patients, but they may not be such a great bargain, suggests Mark Rukavina, an expert in medical debt and billing at Community Catalyst, a Boston-based advocacy group.

His point: “If you pay zero percent interest on a seriously inflated charge, it’s not a good deal.”

How The Loans Work

Between higher deductibles and narrower networks, patients are paying larger portions of their medical bills. The federal government estimates consumers spent $352.5 billion out-of-pocket on health care in 2016.

But many patients have trouble coming up with cash to pay bills of hundreds or even thousands of dollars, meaning hospitals are having a harder time collecting what they believe they are owed.

To solve their problem, about 15 to 20 percent of hospitals are teaming up with lenders to offer loans, said Bruce Haupt, CEO of ClearBalance, a loan servicing company. He, along with many other analysts, expects that percentage to grow.

The process begins with a hospital estimate of a patient’s bill, which takes insurance coverage into account. A billing representative then lays out payment plans for the patient, often while he or she is still being treated.

A patient can then sign up for a loan, often without a credit check. Patients write smaller monthly checks to the lender, who has paid the hospital, while keeping a designated percentage of the bill as a fee.

Proponents view financing as a useful alternative to medical credit cards, which can surprise users with high interest rates. The partnerships are tempting for hospitals since they offload the need to administer monthly payment plans and collection efforts.

Federal law requires lenders be transparent about the loan terms, a protection that extends to consumers entering these health care arrangements. That means disclosure of interest rates, other fees and the payment schedule.

Even so, said Gerard Anderson, a Johns Hopkins health policy professor and an expert on health care pricing, “it’s an often gentler version of asking you to pay up.”

But an on-the-stretcher sell leaves patients little opportunity for due diligence.

“What’s the charge they’re using to determine what’s a reasonable amount to pay?” Anderson added.

Cameron was suspicious of the $830 estimate of her bill, since she had good coverage from her job at the University of Arkansas. She and her husband had extensive experience with the health care system and its costs. No one had ever asked her to pay upfront, even when her husband owed tens of thousands for cancer treatment.

“It just felt so uncomfortable to us that they would try to push us through a bank, which is designed to make a profit,” Cameron said.

A Growth Business With Risk Of Default

At Florida-based Orlando Health, which works with ClearBalance, loans typically range from $3,000 to $7,000, said Michele Napier, the health system’s chief revenue officer. The highest debt a patient has taken on — about $13,000 — was because of a high-deductible plan, she said.

“All of a sudden a catastrophic event occurs, and to have $13,000 in the bank account is a lot to ask,” she said. “They’re able to spread those payments.”

Low-income patients without insurance likely will not need loans to finance large bills,because they should quality for aid from the hospital, or be treated as charity care, Napier said.

It’s a conversation that starts at registration, she added. “If a patient shares with us that they have no resources or limited resources to pay, we will provide information on our financial assistance and other programs including screening them for Medicaid.”

The idea is to foster open conversations about cost and help patients and doctors weigh their options, both financial and medical, said Rick Gundling, a senior vice president at the Healthcare Financial Management Association, a trade group.

“The patient may say, ‘Hey, do I need to do this knee surgery now? Can we wait until I save up, or do I have other options, like physical therapy?’” he said. “The doctor may say … let’s look at other options.”

But the loans can be a band-aid solution, leading vulnerable patients to sign up to pay far more than they should, said Kathleen Engel, a research professor of law at Boston-based Suffolk University and an expert in consumer credit and mortgage finance.

“The hospital potentially is charging the patient the full, what I would call ‘whack rate’ for their care,” she said. “They try to collect the debt.”

Since many of these loans come without credit checks or affordability tests, the odds are higher that a loan could be financially unwise, experts warn.

At ClearBalance, loans average about $1,700, Haupt said. In practice, that means some patients are financing $150 bills, while others have them for as large $50,000.

Default rates vary across the country, with the highest default rates — up to 1 in 5 patients — in places such as Texas and Louisiana. In other areas, closer to 6 or 7 percent of patients ultimately cannot pay off their loans.

“Some of these people are destined to default,” Engel said. “If you have to get a loan for $500 for medical care, that means you are really living at the margins.”

Cameron declined the loan — and chose not to hand over any other form of payment. She wanted to wait until she received her insurance statement.

In the end, the couple owed only $150, the copayment for an ER visit. “It felt to us like it could screw someone over who wasn’t aware about how to work that system,” she said, though she admitted to feeling intimidated as she lay on the stretcher.

She added: “It can be scary feeling like you owe someone money.”

Reducing Red Tape For Traveling Nurses

KFF Health News, February 20, 2018

The National Council of State Boards of Nursing launched a new version of the Nurse Licensure Compact (NLC). Twenty-nine states have passed legislation to join.

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

By Anna Gorman

Lauren Bond, a traveling nurse, has held licenses in five states and Washington, D.C. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires.

The 27-year-old got into travel nursing because she wanted to work and live in other states before settling down. She said she wished more states accepted the multistate license, which minimizes the hassles nurses face when they want to practice across state lines.

“It would make things a lot easier — one license for the country and you are good to go,” said Bond, who recently started a job in California, which does not recognize the multistate license.

The license, known as the Nurse Licensure Compact (NLC), was launched in 2000 to address nursing shortages and enable more nurses to practice telehealth. Under the agreement, registered nurses licensed in a participating state can practice in other NLC states without needing a separate license. They must still abide by the laws that govern nursing wherever their patients are located.

About half of the states joined the original compact, which was modeled on the portability of a driver’s license. Some states that declined to sign on cited a major flaw: The agreement didn’t require nurses to undergo federal fingerprint criminal background checks.

Last month, the National Council of State Boards of Nursing launched a new version of the NLC that requires those checks. Twenty-nine states have passed legislation to join the new agreement.

Jim Puente, who oversees the compact for the council, said he expects even more states to sign the agreement now that criminal background checks are required. He noted that nine states have legislation pending to join.

Among states participating in the new nurse licensing compact are Iowa, Kentucky, Tennessee, Delaware, Idaho and Arizona.

California does not plan to join the new compact, largely because of concern about maintaining state training and quality standards. The state, like many others, already requires nurses to undergo background checks. Washington, Oregon and Nevada are among the other states that do not accept the multistate license.

Proponents of the nurse licensing agreement — both the old and new versions — argue that it helps fill jobs in places where there aren’t enough nurses and enables nurses to respond quickly to natural disasters across state lines.

“The nurse shortage tends to wax and wane regionally, so being able to move nurses where the needs are is really, really important,” said Marcia Faller, chief clinical officer at AMN Healthcare, a San Diego-based medical staffing company that employs Bond. The multistate license “really helps with that mobility … to deliver care to patients across state lines.”

Similar cross-state agreements exist for physicians, psychologists, emergency medical technicians and physical therapists.

In some states, the multistate nursing license is helpful because it streamlines the process for nurses doing case management or telehealth, said Sandra Evans, executive director of the Idaho Board of Nursing. Getting nurses to work in the rural areas of Idaho is a challenge, and hospitals often rely on telemedicine in places where the closest health care facility might be in Montana, she said.

Before Idaho joined the original NLC in 2001, nurses doing telehealth or case management needed numerous licenses to work across state lines, but now they “can travel virtually — electronically or telephonically — to help their clients,” she said.

Joey Ridenour, executive director of the Arizona State Board of Nursing, said one of the biggest advantages of the compact for her state is that it allows authorities to share information and collaborate with other states to investigate and discipline problem nurses. “We are able to take action faster,” she said.

Opponents of the compact argue that states have different standards, course requirements and guidelines and that nurses licensed in one state may lack the necessary knowledge or experience to practice in another one.

“The ability to control the standards of training and quality are of some concern to us,” said Linda McDonald, president of United Nurses and Allied Professionals union in Rhode Island, which participated in the original NLC but hasn’t signed on to the new one. “We want them trained in Rhode Island. We want them licensed in Rhode Island.”

Nurses in California have similar concerns. “We really want to make sure that nurses who are entering our state and taking care of our patients are competent and qualified,” said Catherine Kennedy, a Sacramento-area nurse who is secretary of the California Nurses Association. Some traveling nurses haven’t been, she added.

Kennedy said California does not have difficulty recruiting nurses, even without the compact, because of the state’s relatively high salaries and strict nurse-to-patient ratios in hospitals.

Research has shown that California’s minimum nurse staffing requirements, which were the first in the nation, can reduce workloads and burnout, improve the quality of care and make it easier for hospitals to retain their nurses.

Lauren Bond, a traveling nurse who has a temporary position at UCLA Medical Center, Santa Monica, has held licenses in five states and the District of Columbia. She maintains a detailed spreadsheet to keep track of license fees, expiration dates and the different courses each state requires. (Courtesy of Robert Hernandez/UCLA Health)

Massachusetts, which has never participated in the nurse licensing compact, requires nurses licensed there to take courses on treating victims of domestic violence and sexual assault, said Judith Pare, director of the division of nurses for the Massachusetts Nurses Association. If the state allowed out-of-state nurses to practice in Massachusetts without getting a license there, they wouldn’t necessarily have that training, she noted.

Bond, the traveling nurse, said additional courses don’t make her more qualified to do her job. “Across the board, wherever you go to nursing school, everybody comes out with a similar experience,” said Bond, who works at UCLA Medical Center in Santa Monica. “Then most of the training you are going to do is on the job.”

Jenn Stormes works as a nurse and formally cares for her 18-year-old son, who has a severe seizure disorder and developmental disabilities. Stormes is licensed in Colorado, which participates in the multistate compact.

She has been able to use that license in some states. But she has also had to get several individual licenses so she can continue serving as her son’s nurse in other states where the family travels for medical care. Stormes estimated she has spent about $2,000 on licenses.

“It took me over a year to get all these licenses,” she said. “I had to prove to every state the same education, the same experience, the same fingerprints. I think it is a duplication of efforts and is a waste of everybody’s time and money.”

In An Effort To Curb Drug Costs, States Advance Bills To Prod Feds On Importation

KFF Health News, February 16, 2018

For years, American consumers have tried to buy cheaper drugs from their northern neighbor. But the practice is illegal.

This article first appeared February 14, 2018 on Kaiser Health News.

By Shefali Luthra

Norm Thurston is a “free-market guy” — a conservative health economist in Republican-run Utah who rarely sees the government’s involvement in anything as beneficial.

But in a twist, the state lawmaker is now pushing for Utah to flex its muscle to spur federal action on ever-climbing prescription drug prices.

“This is something that a red state like Utah could do. I don’t think this is a partisan issue,” Thurston said. “Those outrageous cost increases are not the result of the free market.”

The approach: Let the state contract with wholesalers in Canada, importing cheaper prescriptions from up north and distributing them to the state’s health care system.

Other states — Vermont, West Virginia and Oklahoma, among them — are following similar paths, pushing legislation that would seek permission from the Trump administration to launch their own plans to import drugs from Canada.

For years, American consumers have tried to buy cheaper drugs from their northern neighbor, sometimes packing into buses for day trips to Canadian pharmacies, or patronizing American stores that help them order drugs from abroad. But the practice is illegal.

The states want to change that, and set up a formal process that nets broader savings. The idea is for the state health department to set up a wholesale program that buys drugs from Canada and resells them to local pharmacies and hospitals. Individual states would be responsible for ensuring that the medications are safe and that importing them does save money.

“This statute is putting pressure on the federal government to take a harder look at these questions,” said Rachel Sachs, an associate law professor at Washington University of St. Louis, who researches drug price regulations. “The state legislatures can say, ‘Look, we’re doing everything we can, but we do need the federal government to help us out on this.’”

The federal government has been slow to act on this issue, and skeptics say a 30-page Trump administration memo on drug pricing released late last week would likely have only limited impact.

But states, whose budgets for Medicaid and state employee health programs are squeezed by these costs, are moving forward.

In Vermont alone, drug spending has gone up by 35 percent from 2010 to 2015, the most recent year for which data are available.

Backers of the state plans say the strategy is a no-brainer that could save hundreds of millions of dollars. They discount concerns about drug safety, arguing that drugs from Canada are made by reputable companies, often in the same facilities and by the same firms that sell them in the U.S. — but at much higher prices.

“We would be bringing in drugs intended for the Canadian market, and therefore at Canadian pricing,” Thurston said. “One would assume if we could come up with a program that meets the recommendations of federal law, what justification would the [Health and Human Services] secretary have for saying no?”

The state measures follow model legislation developed by the National Academy for State Health Policy that uses a framework put in place by the 2003 federal law that created the Medicare Part D program. That law says the U.S. Department of Health and Human Services can approve drug importation plans if it is convinced the plans will save money and will not create any public health concerns.

Once passed, these laws task state health departments with overseeing the development of these programs. After the health department settles on the specifics, state officials must negotiate implementation with HHS. That could take years.

It is also likely to be an uphill battle.

In 15 years, HHS has never acted upon the 2003 law by approving any drug importation program.

Last spring, when members of Congress pushed a national bill, a bipartisan group of former Food and Drug Administration commissioners came out in opposition, arguing it would be impossible to verify drug safety absolutely. That bill ultimately failed to garner a majority vote.

It’s unclear where the current administration stands on this issue.

Alex Azar, the newly confirmed HHS secretary, has been coy on the subject — though in a confirmation hearing last fall, he said importing drugs from Canada could create safety concerns. Despite multiple requests, HHS did not provide comment for this story by the publication deadline.

The pharmaceutical industry echoed the cautions about safety.

“The proposals we are seeing in states across the country threaten the safety of patients and families and will not deliver the savings they promise,” said Priscilla VanderVeer, a spokeswoman for the trade group Pharmaceutical Research and Manufacturers of America (PhRMA).

In the states, though, backers say their bills address that concern.

And other analysts argued that, regardless, safety of Canadian drugs isn’t a real issue.

“A lot of the drugs used in the United States and in Canada are made in the same plants, in countries like India or Europe,” said Michael Law, a pharmaceutical policy expert and associate professor at the University of British Columbia’s Center for Health Services and Policy Research. “The U.S. FDA and other regulatory agencies rely on other agencies’ inspections — the idea that Canadian drugs are these dangerous drugs is a red herring.”

A bigger question, he said, is the amount of savings these bills would generate.

Thurston pointed to Utah state analyses that suggest the state could save $70 million in the private sector, and another $20 million to $30 million in state-funded insurance programs. If approved, he said, the state would target 15 to 20 drugs to import — insulin, for instance, because it is bought in large quantities, or expensive drugs that treat hepatitis C or HIV.

Others expressed skepticism.

For one thing, the true price of prescription drugs isn’t always clear. There’s the list price — and generally, those are much higher in the United States. But insurance plans often negotiate rebates, or discounts, from the drug company — meaning they can end up paying far less than what’s advertised. Those discounts aren’t public, making it much harder to compare prices between the two countries.

The drug industry would also likely employ strategies to counter importation.

Pharmaceutical companies, Law noted, stand to lose if American states are importing cheaper drugs. That could motivate them to tamp down how many prescriptions they sell in Canada, or find other ways to discourage Canadian wholesalers from participating.

“My guess is any Canadian distributor to engage in that would find their [medication] supply dwindle quickly, because the drug companies would stop supplying,” he said. “The supplier systems in the United States would probably find it hard to get a [Canadian drug] supply in the long term.”

That’s certainly a real concern, said Claire Ayer, a Vermont state senator and Democrat who chairs her legislature’s Health and Welfare Committee.

“We can’t tell drug companies or wholesalers what to do in Canada,” she added.

VanderVeer said PhRMA could not speculate on how individual drug companies may react to importation.

Still, these state efforts could spur the federal government to take action, Sachs suggested — even if it’s unclear how large an impact importation would have.

“Importation will not solve all the problems — and I don’t think states see it as such,” she said. “But it could be a useful way to put pressure on a federal government and White House that has thus far largely been inactive on this topic.”

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