Urgent Care Sites Cater To Cancer Patients

KFF Health News, May 2, 2017

This article first appeared May 02, 2017 on Kaiser Health News

By Michelle Andrews 

A small but growing number of hospitals and oncology practices are incorporating urgent care aimed specifically at cancer patients.

On an afternoon a few weeks ago, Faithe Craig noticed that her temperature spiked to just above 100 degrees. For most people, the change might not be cause for alarm, but Craig is being treated for stage 3 breast cancer, and any temperature change could signal a serious problem.

She called her nurse at the hospital clinic where she gets care at the University of Texas Southwestern Medical Center in Dallas, who told her to come in immediately for cancer urgent-care services at the hospital’s hematology oncology clinic.

“I thought I’d be waiting there all night,” said Craig, 33. But the hospital had already lined up a blood draw before she arrived and then sent her directly to get X-rays.

Clinicians had details of her cancer care at their fingertips. “They already knew my story and knew everything about me,” she said. The blood work showed she had severe anemia, requiring a blood transfusion, pronto.

It’s been more than a year since the medical center began providing same-day urgent care services to cancer patients. It’s an effort to help them avoid the emergency department and hospital admissions, said Dr. Thomas Froehlich, medical director of the all the center’s cancer clinics.

Cancer treatment “clearly carries a lot of side effects and toxicity, and there are also complications of dealing with the cancer,” Froehlich said. “Many of these things, if you can intervene early, you keep patients at home and out of the hospital.”

UT Southwestern isn’t alone. A small but growing number of hospitals and oncology practices are incorporating urgent care aimed specifically at cancer patients, in which specialists are available for same-day appointments, often with extended hours, sometimes 24/7.

Keeping cancer patients out of the emergency department makes sense not only because many of them have compromised immune systems that put them at risk in a waiting room full of sick people, but to provide the most efficient and appropriate care.

“What we hear from cancer physicians and administrators is that in the emergency department not all emergency physicians and nurses feel equally confident in their ability to treat cancer patients,” said Lindsay Conway, managing director of research at the Advisory Board, a health care research and consulting firm. “So they may admit them when it’s not necessary.”

Severe pain, nausea, fever and dehydration are not uncommon side effects of traditional chemotherapy. Newer immunotherapy treatments that activate the immune system to fight cancer can cause serious and sudden reactions if the body instead attacks healthy organs and tissues.

It can be difficult for non-cancer specialists to evaluate what these symptoms mean. “Targeted therapies are wonderful, but if you don’t know the drug, you’re going to have a hard time managing the person,” said Dr. Barbara McAneny, CEO of New Mexico Oncology Hematology Consultants in Albuquerque, which operates three cancer centers in New Mexico that together provide same-day urgent care services for more than a dozen cancer patients daily.

Offering same-day services fits in with a broader shift in oncology toward patient-centered care, said Dr. J. Leonard Lichtenfeld, deputy chief medical officer at the American Cancer Society.

“There’s a general sense within the practice of oncology that we need to do a better job of managing pain and side effects, and we need to provide a higher level of care,” Lichtenfeld said.

The federal Centers for Medicare & Medicaid Services is encouraging these efforts through new payment and delivery models designed to reward quality cancer care, Lichtenfeld said. In addition, starting in 2020 hospitals may be penalized financially if patients who are receiving outpatient chemotherapy visit the emergency department or are admitted to the hospital, according to a final rule issued in November.

Avoiding the emergency department makes financial sense for patients and insurers, too.

Johns Hopkins Hospital opened a six-bed urgent care center next to its infusion center a couple of years ago. Of the patients who land there, about 80 percent are discharged home, at an average total hospital charge of $1,600, said Sharon Krumm, director of nursing at Johns Hopkins Kimmel Cancer Center. (The patient and the insurer would divvy up that charge based on the patient’s insurance coverage.) Only 20 percent of cancer patients who visit the hospital’s emergency department are discharged home. Those who are have an average total hospital charge of $2,300. The others face the ER charges plus the hefty cost of a hospital admission.

Rebecca Cohen has been a frequent visitor to the Johns Hopkins urgent care center. Diagnosed more than two years ago with stage 4 lung cancer, Cohen, 68, is receiving immunotherapy. She’s been treated or checked for dehydration, electrolyte abnormalities, low hemoglobin, low sodium, blood clots and infection, among other things.

Before she started going to the cancer urgent care center, “you sat in the waiting room at the emergency room with people who had the most extraordinary diseases,” Cohen said. “Having stage 4 lung cancer, the thought of being exposed to pneumonia or bronchitis is more than scary.”

‘Center Of Excellence’ Designation Doesn’t Rule Out Complications Of Bariatric Surgery

KFF Health News, April 28, 2017

This article first appeared April 28, 2017 on Kaiser Health News

By Michelle Andrews 

The risk of serious problems varied widely among centers, according to research from the University of Michigan Institute for Healthcare Policy and Innovation.

Getting bariatric surgery at a “center of excellence” doesn’t mean that patients can be assured that they will avoid serious complications from the weight-loss procedure at the facility, according to a recent study.

Even though facilities that have been accredited as centers of excellence must all meet minimum standards, including performing at least 125 bariatric surgeries annually, the risk of serious problems varied widely among centers, the study found.

“To become accredited, there’s no measure of outcomes, it’s just a process list,” said Dr. Andrew Ibrahim, a research fellow at the University of Michigan Institute for Healthcare Policy and Innovation and the study’s lead author. In addition to minimum case volumes, accredited centers have to have special surgical equipment to handle overweight patients, such as bariatric operating tables and longer laparoscopic instruments.

Insurers typically restrict coverage of bariatric surgery to procedures performed at accredited facilities, however, and nearly 90 percent of bariatric surgeries are performed at a center of excellence.

Bariatric surgery is used to treat people who are severely obese and have not had success with other weight-loss programs. Surgeons use a variety of methods to make the stomach smaller so that less food can be consumed easily.

For this study, researchers analyzed claims data of more than 145,000 patients at 165 bariatric surgery centers of excellence in 12 states from 2010 to 2013. Nationally, the rate of serious complications following surgery — heart attack, kidney failure or blood transfusion, for example — varied widely among the centers, from 0.6 percent at the low end to 10.3 percent at the high end. The rate varied widely within states as well. Nearly 1 in 3 lower-performing hospitals had a higher-performing hospital in the same service area, the study found.

Bariatric surgery has come a long way from the early days when some low-volume centers experienced 30-day mortality rates approaching 10 percent, according to Ibrahim. In this study, 72 patients died in the hospital following surgery — a rate of less than 1 percent among study participants.

However, while accreditation has had an effect on quality and safety, “at the moment, just going to a center that is accredited does not ensure uniform high-quality care for a patient,” Ibrahim said.

The degree of technical skill of the surgeon performing the procedure may affect post-operative outcomes, the study found, as may the degree to which centers follow accepted best practices for bariatric patient care. Neither of those variables is captured in this study.

The organization that accredits bariatric surgery hospitals collects data from hospitals about serious complications, but the data aren’t publicly available, according to the study. So there’s no way for patients to use the data to learn which bariatric center of excellence in their area has the lowest serious complication rates. “Not yet,” Ibrahim said.

Severe Shortage Of Home Health Workers Robs Thousands Of Proper Care

KFF Health News, April 26, 2017

This article first appeared April 26, 2017 on Kaiser Health News.

By Judith Graham 

The emerging crisis is driven by low wages — around $10 an hour, mostly funded by state Medicaid programs — and a shrinking pool of workers willing to perform this physically and emotionally demanding work

Acute shortages of home health aides and nursing assistants are cropping up across the country, threatening care for people with serious disabilities and vulnerable older adults.

In Minnesota and Wisconsin, nursing homes have denied admission to thousands of patients over the past year because they lack essential staff, according to local long-term care associations.

In New York, patients living in rural areas have been injured, soiled themselves and gone without meals because paid caregivers aren’t available, according to testimony provided to the state Assembly’s health committee in February.

In Illinois, the independence of people with severe developmental disabilities is being compromised, as agencies experience staff shortages of up to 30 percent, according to a court monitor overseeing a federal consent decree.

The emerging crisis is driven by low wages — around $10 an hour, mostly funded by state Medicaid programs — and a shrinking pool of workers willing to perform this physically and emotionally demanding work: helping people get in and out of bed, go to the bathroom, shower, eat, participate in activities, and often dealing with challenging behaviors.

It portends even worse difficulties to come, as America’s senior citizen population swells to 88 million people in 2050, up from 48 million currently, and requires more assistance with chronic health conditions and disabilities, experts warn.

“If we don’t turn this around, things are only going to get worse” said Dr. David Gifford, senior vice president of quality and regulatory affairs for the American Health Care Association, which represents nursing homes across the U.S.

“For me, as a parent, the instability of this system is terrifying,” said Cheryl Dougan of Bethlehem, Pa., whose profoundly disabled son, Renzo, suffered cardiac arrest nearly 19 years ago at age 14 and receives round-the-clock care from paid caregivers.

Rising Demand, Stagnant Wages

For years, experts have predicted that demand for services from a rapidly aging population would outstrip the capacity of the “direct care” workforce: personal care aides, home health aides and nursing assistants.

The U.S. Bureau of Labor Statistics estimates an additional 1.1 million workers of this kind will be needed by 2024 — a 26 percent increase over 2014. Yet, the population of potential workers who tend to fill these jobs, overwhelmingly women ages 25 to 64, will increase at a much slower rate.

After the recession of 2008-09, positions in Medicaid-funded home health agencies, nursing homes and community service agencies were relatively easy to fill for several years. But the improving economy has led workers to pursue other higher-paying alternatives, in retail services for example, and turnover rates have soared.

At the same time, wages for nursing assistants, home health aides and personal care aides have stagnated, making recruitment difficult. The average hourly rate nationally is $10.11 — a few cents lower than a decade ago, according to PHI, an organization that studies the direct-care workforce. There is a push on now in a handful of states to raise the minimum to $15 an hour.

Even for-profit franchises that offer services such as light housekeeping and companionship to seniors who pay out-of-pocket are having problems with staffing.

“All the experienced workers are already placed with families. They’re off the market,” said Carrie Bianco, owner of Always Best Care Senior Services, which is based in Torrance, Calif., with franchises in 30 states.

Finding new employees was so difficult that Bianco started her own 14-week training program for caregivers nine months ago. To attract recruits, she ran ads targeting women who had left the workforce or been close to their grandparents. In exchange for free tuition, graduates must agree to start working for her agency.

“There’s much more competition now — a lot of franchises have opened and people will approach our workers outside our building or in the lobby and ask if they want to come work for them,” said Karen Kulp, president of Home Care Associates of Philadelphia.

Hardest to cover in Kulp’s area are people with disabilities or older adults who live at some distance from the city center and need only one to two hours of help a day.  Workers prefer longer shifts and less time traveling between clients, so they gravitate to other opportunities and “these people are not necessarily getting service,” she said.

It isn’t possible to document exactly how common these problems are nationally. Neither states nor the federal government routinely collect information about staff vacancy rates in home care agencies or nursing homes, turnover rates or people going without services.

“If we really want to understand what’s needed to address workforce shortages, we need better data,” said Robert Espinoza, vice president of policy at PHI.

Hard Times In Wisconsin

Some of the best data available come from Wisconsin, where long-term care facilities and agencies serving seniors and people with disabilities have surveyed their members over the past year.

The findings are startling. One of seven caregiving positions in Wisconsin nursing homes and group homes remained unfilled, one survey discovered; 70 percent of administrators reported a lack of qualified job applicants. As a result, 18 percent of long-term facilities in Wisconsin have had to limit resident admissions, declining care for more than 5,300 vulnerable residents.

“The words ‘unprecedented’ and ‘desperate’ come to mind,” said John Sauer, president and chief executive of LeadingAge Wisconsin, which represents not-for-profit long-term care institutions. “In my 28 years in the business, this is the most challenging workforce situation I’ve seen.”

Sauer and others blame inadequate payments from Medicaid — which funds about two-thirds of nursing homes’ business — for the bind. In rural areas, especially, operators are at the breaking point.

“We are very seriously considering closing our nursing facility so it doesn’t drive the whole corporation out of business,” said Greg Loeser, chief executive of Iola Living Assistance, which offers skilled nursing, assisted living and independent living services in a rural area about 70 miles west of Green Bay.

Like other short-staffed operators, he’s had to ask employees to work overtime and use agency staff, increasing labor costs substantially. A nearby state veterans home, the largest in Wisconsin, pays higher wages, making it hard for him to find employees. Last year, Iola’s losses on Medicaid-funded residents skyrocketed to $631,000 — an “unsustainable amount,” Loeser said.

Wisconsin Gov. Scott Walker has proposed a 2 percent Medicaid increase for long-term care facilities and personal care agencies for each of the next two years, but that won’t be enough to make a substantial difference, Loeser and other experts say.

The situation is equally grim for Wisconsin agencies that send personal care workers into people’s homes. According to a separate survey in 2016, 85 percent of agencies said they didn’t have enough staff to cover all shifts, and 43 percent reported not filling shifts at least seven times a month.

Barbara Vedder, 67, of Madison, paralyzed from her chest down since a spinal cord injury in 1981, has witnessed the impact firsthand. Currently, she qualifies for 8.75 hours of help a day, while her husband tends to her in the evening.

“It’s getting much, much, much more difficult to find willing, capable people to help me,” she said. “It’s a revolving door: People come for a couple of months, maybe, then they find a better job or they get pregnant or they move out of state. It’s an endless state of not knowing what’s going to happen next — will somebody be around to help me tomorrow? Next month?”

When caregivers don’t show up or shifts are cut back or canceled, “I don’t get proper cleaning around my catheter or in my groin area,” Vedder continued. “I’ll skip a meal or wait later several hours to take a pill. I won’t get my range-of-motion exercises, or my wheelchair cushion might slip out of place and I’ll start getting sore. Basically, I start losing my health.”

Debra Ramacher and her husband have been unable to find paid caregivers since June 2015 for daughter Maya, 20, and son Michael, 19, both of whom have cerebral palsy, epilepsy and other significant disabilities. The family lives in New Richmond in western Wisconsin, about 45 minutes from the Minneapolis-St. Paul metropolitan area.

“At least three agencies told me they’ve stopped trying to hire personal care aides. They can’t find anybody and it costs them money to advertise,” said Ramacher, executive director of Wisconsin Family Ties, an organization for families with children with emotional, behavioral and mental disorders.

“It’s incredibly stressful on all of us, living with this kind of uncertainty,” she said.

Every few months, Ramacher tries to find caregivers on her own by putting ads up on Craigslist, in local newspapers and on job boards.

“We get a few bites,” she said. “Most recently, two people came and interviewed. One never got back to us; the other got a better job that paid more.”

In the meantime, she and her husband are being paid by Medicaid to look after Maya and Michael.

“We don’t want to be the caregivers; we want to have our own life,” Ramacher said. “But we don’t have any option.”

Reluctant Patients, Hispanic Men Pose A Costly Challenge To The Health System

KFF Health News, April 25, 2017

This article first appeared April 25, 2017 on Kaiser Health News.

By Michael Anft 

Women across all races are more likely to seek care than men. But the gender gap in the Hispanic community is especially troubling to health care providers.

BALTIMORE — Peter Uribe left Chile at 21 with his wife and 2-year-old daughter, landing in Baltimore and finding steady work in construction. His social life revolved around futbol, playing “six or seven nights a week in soccer tournaments,” he said.

A couple of years after his arrival, he broke his foot during a game and afraid of the cost, didn’t seek medical care.

“Some of my family warned me that if I went to the hospital and couldn’t pay the bill, I’d get a bad credit record,” said Uribe, 41, who made about $300 a week and had no health insurance. “I wanted to buy a car or a house someday.” Instead, he hobbled through workdays and stayed off the field for three years; the residual pain is sometimes disabling, even two decades later.

For reasons both economic and cultural, Hispanic men are loath to interact with the health system. Women across all races are more likely to seek care than men. But the gender gap in the Hispanic community is especially troubling to health care providers. Studies show that Latino men are much less likely than Latinas to get treatment.

That is true even though Hispanic men are more likely than non-Hispanic whites to be obese, have diabetes or have high blood pressure. Those who drink tend to do so heavily, contributing to the group’s higher rates of alcoholic cirrhosis and deaths from chronic liver disease. Many take risky jobs such as construction workers and laborers, and are more likely to die from on-the-job injuries than other workers, government data show.

Hispanics’ share of the population is expected to widen from nearly a fifth now to a quarter by 2045. As that number grows, researchers worry that the nation could face costly consequences as long-ignored conditions lead to serious illness and disability.

“It could literally break the health care system,” said José Arévalo, board chairman of Latino Physicians of California, which represents Hispanic doctors and others who treat Latinos.

And now, some medical professionals fear the effects of President Donald Trump’s crackdown on illegal immigrants.

“When the community faces this kind of stress, I worry that people will do unhealthy things, like abuse alcohol, to deal with it,” said Kathleen Page, co-director of Centro SOL, a health center at Johns Hopkins Bayview Medical Center, and founder of the city’s Latino HIV Outreach Program. “That means they may not work as much,” she added. “They’ll have less money, which means they’re less likely to seek care.”

Welcomed by Baltimore officials, immigrants have driven the city’s Hispanic population, tripling it to 30,000 since 2000.

Here, as elsewhere, evidence suggests that for many Hispanic men, seeking health care is an extraordinary event. Hospital data show they are more likely than Hispanic women, white women and white men to go to the emergency room as their primary source of treatment — a sign that they wait until they’ve no choice but to get help.

Some care providers say medical institutions haven’t done enough to keep Hispanic men healthy, or to persuade them to get regular exams.

“There’s been an ongoing need for institutions to become more culturally attuned and aware of bias,” said Elena Rios, president of the National Hispanic Medical Association, which represents the nation’s 50,000 Latino physicians.

There are some significant differences in health risk and illness rates among Hispanic subgroups — Puerto Ricans are more likely to be smokers, for example. Compared with Hispanics born in the U.S., those born elsewhere have much lower rates of cancer, heart disease and high blood pressure. Overall, Hispanics live longer than whites.

But these advantages may be dissipating as Latinos become Americanized and adopt unhealthy habits such as smoking and diets high in fatty, processed foods.

“I tell people we live longer and suffer,” said Jane Delgado, a clinical psychologist and Cuban-American who serves as president of the National Alliance for Hispanic Health.

Researchers who investigate gaps in cancer testing have found that all ethnic groups and genders have seen a decrease in late-stage colon cancer diagnoses and deaths in recent years — except Hispanic men, who get screened at the lowest rates of any race or ethnic group.

Often, health problems arise after immigrants come up against an insurance barrier. A few years after Jose Cedillo came to Baltimore from Honduras, the 41-year-old cook noticed his legs were often numb or painful. Worried about finances, he eschewed treatment and continued to work, before finally going to a clinic where he was diagnosed with diabetes.

In the seven years since, his health has so deteriorated he can’t work, is frequently homeless and spends long stints in the hospital. As an immigrant who came to the U.S. illegally, he is not eligible for government-paid insurance or disability payments. And he can’t afford medicine. Instead, he said, “I’ll drink alcohol to numb the pain.”

Part of the problem is that Spanish speakers are underrepresented among medical professionals. After arriving here, Uribe’s family members frequently brought along an English-speaking nephew or niece when they could afford to see doctors. Otherwise, “we’d travel a long ways to find a doctor who spoke Spanish,” he said.

Hospitals frequently lack cultural understanding and bilingual staffing, administrators admit. Though Latinos make up nearly 20 percent of the population, only 5 percent of physicians and 7 percent of registered nurses are Hispanic. That gap has widened as more Hispanics have come to this country during the past three decades, according to a UCLA study released in 2015.

“Too often, people don’t understand what you’re saying, they don’t know what you’re going to charge them, what dietary restrictions you might place upon them,” said James Page, vice president for diversity at Johns Hopkins Medicine. “It creates a trust issue for Hispanics. We’ve got to get better at serving them.”

That is particularly true in mental health. Only 1 percent of psychologists in the U.S. are Hispanic, meaning that Spanish-speaking men who do seek therapy will probably struggle to find it.

In Baltimore, there is only one Spanish-language support group for men who suffer from anxiety and depression, local psychologists and Latino advocates say. The city employs one Spanish-speaking substance abuse counselor. A small handful of bilingual social workers citywide offer reduced-rate counseling sessions, and only three psychiatrists offer therapy sessions conducted in Spanish.

For Peter Uribe, the key to maintaining his family’s health is getting help paying for care. His wife and brother both suffer from epileptic seizures, and his brother’s despondency caused Uribe to become depressed, he said. In 2015, he obtained insurance for his family through a charity program. With the help of now-affordable medicines, his wife’s seizures waned, and he sought help for chronic depression. Since he now speaks English, finding counseling help is easier.

In January, after intervention from a Latino advocacy group, the charity renewed the Uribes’ policy for two years. Peter Uribe calls it a godsend:

“I honestly have no idea what we’d do without it.”

HHS, States Move To Help Insurers Defray Costs Of Sickest Patients

KFF Health News, April 25, 2017

This article first appeared April 25, 2017 on Kaiser Health News.

By Steven Findlay 

In March, HHS Secretary Tom Price sent a letter to all 50 governors soliciting proposals for reinsurance and other options to help cover the costs of consumers with expensive medical conditions.

As congressional Republicans’ efforts to repeal and replace the Affordable Care Act remain in limbo, the Trump administration and some states are taking steps to help insurers cover the cost of their sickest patients, a move that industry analysts say is critical to keeping premiums affordable for plans sold on the law’s online marketplaces in 2018.

This fix is a well-known insurance industry practice called reinsurance. Claims above a certain amount would be paid by the government, reducing insurers’ financial exposure and allowing them to set lower premiums.

Two states — Alaska and Minnesota — that have seen double-digit increases in ACA plan premiums this year have already moved to implement reinsurance policies, and Oklahoma is making plans to seek federal approval to set up a program. The Idaho legislature also recently passed a health care reinsurance law, and Maine is considering taking similar action.

The Trump administration has told other states they should consider doing the same. On March 13, Health and Human Services Secretary Tom Price sent a letter to all 50 governors soliciting proposals for reinsurance and other options to help cover the costs of consumers with expensive medical conditions.

Long an advocate for more state control of health insurance, Price said the administration is “seeking to empower states with new opportunities that will strengthen their health insurance markets.”

“This is one practical way the administration and states can work together to reduce premiums,” said Matthew Fiedler, a health policy specialist at the Brookings Institution. “While it’s the insurers who get the [support] directly, reductions in insurers’ claims costs ultimately translate into lower premiums for consumers.”

The focus on reinsurance comes as insurers must tell state and federal regulators no later than June 21 whether they will participate in the ACA’s marketplaces in 2018, and what plans they will offer at what price. This issue is separate from other highly publicized efforts underway to preserve federal payments to insurers to cover the costs of deductibles and copayments for low-income enrollees.

The federal law offered the security of a reinsurance program to insurers during its first three years. It helped reduce premiums among insurers by 10 percent in 2014, the last year the impact was analyzed, according to the Congressional Budget Office.

But the ACA reinsurance program ended this year. That helped drive premiums up by an average 22 percent across the country, raising concerns about the stability of the state-based marketplaces — also called exchanges — that provide insurance for people who don’t get it through work or public programs such as Medicare or Medicaid.

Now officials from both political parties are eyeing another part of the health law to help reprise and finance reinsurance programs.

In his letter, Price encouraged states to consider a special provision — known as a Section 1332 waiver — that went into effect this year and opens an avenue for them to pursue exemptions from ACA rules as long as the state plan maintains equivalent or better coverage levels for residents and doesn’t raise federal spending.

The Trump administration is betting that some states can set up reinsurance programs with federal funding. Federal spending on the program would be kept in check because the move will reduce government spending on tax credits that the law gives some low-income exchange customers to help defray the cost of premiums.

Need To ‘Stabilize Things Fast’ 

Consider deep-red Oklahoma. State officials have always held the ACA at arm’s length, leaving the insurance marketplace’s management and details to federal officials. But after rate increases averaging 76 percent this year — second only to Arizona — state officials set up a task force to explore how to put a brake on insurance premiums. The group last month published a multifaceted, 60-page plan for a waiver request. State officials say they will submit the plan to HHS later this year. Among the proposed first steps: reinsurance.

“We are in critical condition,” said Buffy Heater, chief strategy officer at the Oklahoma Health Care Authority. “Reinsurance is a way to stabilize things fast and attract additional insurers and more enrollees.”

Enrollment in the Oklahoma marketplace plan grew just 1 percent in 2017, to 146,300, after fairly robust growth in 2014 and 2015. Still, only about 30 percent of eligible Oklahomans are enrolled, and the number of uninsured in the state grew by 20,000 people in 2017.

Blue Cross Blue Shield of Oklahoma, the only carrier now selling on the state’s insurance marketplace, concurs with Heater’s assessment. The company declined through a spokesman to address state officials’ concern that the insurer was poised to exit the market in 2018. But Kurt Kossen, senior vice president at the Illinois-based Health Care Service Corp., which owns the Oklahoma Blues plan, said in a statement: “We agree reinsurance and well-designed high-risk pools help lower premiums and encourage greater competition.”

The two main health insurance lobbying groups in Washington — America’s Health Insurance Plans and the Blue Cross Blue Shield Association — also support efforts to offer reinsurance.

“We are very much in favor of using reinsurance to help insurers pay for the most expensive claims and to stabilize the marketplaces,” said Kristine Grow, senior vice president for communications at America’s Health Insurance Plans.  

Alaska And Minnesota Spurred To Act

Building on its state-funded reinsurance program for 2017, Alaska has asked the federal government to set aside $51.6 million for a reinsurance pool there for 2018. Lori Wing-Heier, director of the state’s division of insurance, said the state’s $55 million fund this year enabled Premera Blue Cross Blue Shield, the sole insurer left on the exchange, to reduce an expected premium increase of 40 percent to just 7.3 percent.  But the state said it cannot keep up the effort alone and needs federal funding.

In Minnesota, where premiums for marketplace plans spiked by around 50 percent this year, the Legislature enacted a law this month that establishes a $271 million reinsurance pool for that state’s troubled ACA marketplace for 2018 and 2019. The funds are contingent on getting the same waiver from the federal government that Alaska seeks and that Oklahoma plans to pursue.

Consumer complaints about the price hikes for 2017 pushed Minnesota to set up a $326 million fund to bail out insurers and help consumers who didn’t qualify for federal premium subsidies. That state-based reinsurance fund reduced premiums by about 25 percent, said Eileen Smith, a spokeswoman for the Minnesota Council of Health Plans. The state’s Department of Commerce has estimated that the 2018 reinsurance fund will reduce premiums by about 20 percent.

About 4 percent of Minnesotans — 235,000 people — get coverage in that state’s individual marketplace.

Back in Washington, D.C., some lawmakers have newfound fervor for insurance market stability and tools such as reinsurance. In their proposed bill to repeal and replace portions of the ACA, House Republicans included a 10-year, $100 billion fund to offset the burden of high-cost patients.

States would be allowed to establish reinsurance pools or set up separate high-risk insurance pools for patients with expensive medical conditions.

And even as the fate of the legislation to repeal the ACA remains uncertain, a group of Republicans in the House of Representatives this month sought to sweeten the pot with an additional $15 billion fund over nine years to help reimburse insurers for high-cost patients with certain preexisting conditions, such as cancer.

Democrats and health policy analysts immediately criticized this latest proposal.

“It’s not enough money to make a serious dent,” said Tim Jost, a professor of health law at Virginia’s Washington and Lee University and an expert on the health law. While the concept is sound, he said that the proposal is flawed because the House Republicans’ bill creates the need for it with “the other damaging changes it makes to the market.”

Jost, other policy analysts and consumer advocates also take issue with Republican proposals that appear to create equivalency between reinsurance and separate high-risk pools for people with preexisting conditions and high claims. In most states that have tried them, said Lynn Quincy, a health insurance specialist and senior policy analyst at Consumer Union, high-risk pools have failed to offer affordable coverage to people who need care the most.

“Reinsurance is the much preferred option,” Quincy said. “It doesn’t segregate sick people into a separate pool, and reinsurance has proved far more efficient and effective over the years.”

Health Care In America: An Employment Bonanza And A Runaway-Cost Crisis

KFF Health News, April 24, 2017

This article first appeared April 24, 2017 on Kaiser Health News.

By Chad Terhune 

Thirty-five percent of the nation’s job growth has come from health care since the recession hit in late 2007, the single-biggest sector for job creation.

In many ways, the health care industry has been a great friend to the U.S. economy. Its plentiful jobs helped lift the country out of the Great Recession and, partly due to the Affordable Care Act, it now employs 1 in 9 Americans — up from 1 in 12 in 2000.

As President Donald Trump seeks to fulfill his campaign pledge to create millions more jobs, the industry would seem a promising place to turn. But the business mogul also campaigned to repeal Obamacare and lower health care costs — a potentially serious job killer. It’s a dilemma: One promise could run headlong into the other.

“The goal of increasing jobs in health care is incompatible with the goal of keeping health care affordable,” said Harvard University economist Katherine Baicker, who sees advantages in trimming the industry’s growth. “There’s a lot of evidence we can get more bang for our buck in health care. We should be aiming for a health care system that operates more efficiently and effectively. That might mean better outcomes for patients and fewer jobs.”

But the country has grown increasingly dependent on the health sector to power the economy — and it will be a tough habit to break. Thirty-five percent of the nation’s job growth has come from health care since the recession hit in late 2007, the single-biggest sector for job creation.

Hiring rose even more as coverage expanded in 2014 under the health law and new federal dollars flowed in. It gave hospitals, universities and companies even more reason to invest in new facilities and staff.  Training programs sprang up to fill the growing job pool. Cities welcomed the development — and the revenue. Simply put, rising health spending has been good for some economically distressed parts of the country, many of which voted for Trump last year.

In Morgantown, W.Va., the West Virginia University health system just opened a 10-story medical tower and hired 2,000 employees last year. In Danville, Pa., the Geisinger Health System has added more than 2,200 workers since July and is trying to fill 2,000 more jobs across its 12 hospital campuses and a health plan. Out West, the University of the UCHealth system in Colorado expanded its Fort Collins hospital and is building three hospitals in the state.

In cities such as Pittsburgh, Cleveland and St. Louis, health care has replaced dying industries like coal and heavy manufacturing as a primary source of new jobs. “The industry accounts for a lot of good middle-class jobs and, in many communities, it’s the single-largest employer,” said Sam Glick, a partner at the Oliver Wyman consulting firm in San Francisco. “One of the hardest decisions for the new Trump administration is how far do they push on health care costs at the expense of jobs in health care.”

House Republicans, with backing from Trump, took the first swipe. Their American Health Care Act sought to roll back the current health law’s Medicaid expansion and cut federal subsidies for private health insurance. The GOP plan faltered in the House, but Republican lawmakers and the Trump administration are still trying to craft a replacement for Obamacare.

Neither the ACA nor the latest Republican attempt at an overhaul tackle what some industry experts and economists see as a serious underlying reason for high health care costs: a system bloated by redundancy, inefficiency and a growing number of jobs far removed from patient care.

Labor accounts for more than half of the $3.4 trillion spent on U.S. health care, and medical professionals from health aides to nurse practitioners are in high demand. But the sheer complexity of the system also has spawned jobs for legions of data-entry clerks, revenue-cycle analysts and medical billing coders who must decipher arcane rules to mine money from human ills.

For every physician, there are 16 other workers in U.S. health care. And half of those 16 are in administrative and other nonclinical roles, said Bob Kocher, a former Obama administration official who worked on the Affordable Care Act. He’s now a partner at the venture capital firm Venrock in Palo Alto, Calif.

“I find super-expensive drugs annoying and hospital market power is a big problem,” Kocher said. “But what’s driving our health insurance premiums is that we are paying the wages of a whole bunch of people who aren’t involved in the delivery of care. Hospitals keep raising their rates to pay for all of this labor.”

Take medical coders. Membership in the American Academy of Professional Coders has swelled to more than 165,000, up 10,000 in the past year alone. The average salary has risen to nearly $50,000, offering a path to the American Dream.

“The coding profession is a great opportunity for individuals seeking their first job, and it’s attractive to a lot of medical professionals burned out on patient care,” said Raemarie Jimenez, a vice president at the medical coding group. “There is a lot of opportunity once you’ve got a foot in the door.”

Some of these back-office workers wage battle every day in clinics and hospitals against an army of claims administrators filling up cubicles inside insurance companies. Overseeing it all are hundreds of corporate vice presidents drawing six-figure salaries.

Administrative costs in U.S. health care are the highest in the developed world, according to a January report from the Organization for Economic Cooperation and Development. More than 8 percent of U.S. health spending is tied up in administration while the average globally is 3 percent. America spent $631 for every man, woman and child on health insurance administration for 2012 compared with $54 in Japan.

America’s huge investment in health care and related jobs hasn’t always led to better results for patients, data show. But it has provided good-paying jobs, which is why the talk of deep cuts in federal health spending has many people concerned.

Linda Gonzalez, a 31-year-old mother of two, was among the thousands of enrollment counselors hired to help sign up Americans for health insurance as Obamacare rolled out in 2014. The college graduate makes more than $40,000 a year working at an AltaMed enrollment center, tucked between a Verizon Wireless store and a nail salon on a busy street in Los Angeles.

In her cramped cubicle, families pull up chairs and sort through pay stubs and tax returns, often relying on her to sort out enrollment glitches with Medicaid. As the sole breadwinner for her two children, ages 9 and 10, she counts on this job but isn’t sure how long it will last.

“A lot of people depend on this,” she said one recent weekday. “It’s something I do worry about.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Conservatives’ Goal To Relax Mandatory Health Benefits Unlikely To Tame Premiums

KFF Health News, April 21, 2017

This article first appeared April21, 2017 on Kaiser Health News.

By Julie Rovner 

Without essential health benefits, “you would either have very crappy benefits without drugs or physicians or hospitalization, or you would have roughly the same costs,” says an actuary who worked in the Obama administration and served on the board of Massachusetts’ health exchange.

As House Republicans try to find common cause on a bill to repeal and replace the Affordable Care Act, they may be ready to let states make the ultimate decision about whether to keep a key consumer provision in the federal health law that conservatives say is raising insurance costs.

Those conservatives, known as the House Freedom Caucus, and members of a more moderate group of House Republicans, the Tuesday Group, are hammering out changesto the GOP bill that was pulled unceremoniously by party leaders last month when they couldn’t get enough votes to pass it. At the heart of those changes reportedly is the law’s requirement for most insurance plans to offer 10 specific categories of “essential health benefits.” Those include hospital care, doctor and outpatient visits and prescription drug coverage, along with things like maternity care, mental health and preventive care services.

The Freedom Caucus had been pushing for those benefits to be removed, arguing that coverage guarantees were driving up premium prices.

“We ultimately will be judged by only one factor: if insurance premiums come down,” Freedom Caucus Chairman Rep. Mark Meadows (R-N.C.) told The Heritage Foundation’s Daily Signal.

But moderates, bolstered by complaints from patients groups and consumer activists, fought back. And a brief synopsis leaked from the intraparty negotiations suggests that the compromise could be letting states decide whether to seek a federal waiver to change the essential health benefits.

“The insurance mandates are a primary driver of [premium] spikes,” wrote Meadows and Sen. Ted Cruz (R-Texas) in an op-ed in March.

But do those benefits drive increases in premiums? And would eliminating the requirement really bring premiums down? Health analysts and economists say probably not — at least not in the way conservatives are hoping.

“I don’t know what they’re thinking they’re going to pull out of this pie,” said Rebekah Bayram, a principal consulting actuary at the benefits consulting firm Milliman. She is the lead author of a recent study on the cost of various health benefits.

Opponents of the required benefits point to coverage for maternity care and mental health and substance abuse treatment as driving up premiums for people who will never use such services.

But Bayram said eliminating those wouldn’t have much of an impact. Hospital care, doctor visits and prescription drugs “are the three big ones,” she said. “Unless they were talking about ditching those, the other ones only have a marginal impact.”

John Bertko, an actuary who worked in the Obama administration and served on the board of Massachusetts’ health exchange, agreed: “You would either have very crappy benefits without drugs or physicians or hospitalization, or you would have roughly the same costs.”

Maternity care and mental health and substance abuse, he said, “are probably less than 5 percent” of premium costs.

Of course, requiring specific coverage does push up premiums to some extent. James Bailey, who teaches at Creighton University in Omaha, Neb., has studied the issue at the state level. He estimates that the average state health insurance mandate “raises premiums by about one-half of 1 percent.”

Those who want to get rid of the required benefits point to the fact that premiums in the individual market jumped dramatically from 2013 to 2014, the first year the benefits were required.

“The ACA requires more benefits that every consumer is required to purchase regardless of whether they want them, need them or can afford them,” Ohio Insurance Commissioner Mary Taylor said in 2013, when the state’s rates were announced.

But Bayram noted most of that jump was not due to the broader benefits, but to the fact that, for the first time, sicker patients were allowed to buy coverage. “The premiums would go down a lot if only very healthy people were covered and people who were higher risk were pulled out of the risk pool,” she said. (Some conservatives want to change that requirement, too, and let insurers charge sick people higher premiums.)

Meanwhile, most of the research that has been done on required benefits has looked at plans offered to workers by their employers, not policies available to individuals who buy their own coverage because they don’t get it through work or the government. That individual market is the focus of the current debate.

Analysts warn that individual-market dynamics differ greatly from those of the employer insurance market.

Bailey said he “saw this debate coming and wanted to write a paper” about the ACA’s essential health benefits. But “I very quickly realized there are all these complicated details that are going to make it very hard to figure out,” he said, particularly the way the required benefits work in tandem with other requirements in the law.

For example, said Bertko, prescription drugs can represent 20 percent of costs in the individual market. That’s far more than in the employer market.

Bayram said another big complication is that the required benefits do double duty. They not only ensure that consumers have a comprehensive package of benefits but enable other parts of the health law to work by ensuring that everyone’s benefits are comparable.

For example, the law adjusts payments to insurers to help compensate plans that enroll sicker-than-average patients. But in order to do that “risk adjustment,” she said, “all of the plans have to agree on some kind of package. So if you think of essential health benefits as an agreed-upon benchmark, I don’t know how they can get rid of that and still have risk adjustment.”

For Doctors, A Clamp Down On Visas Could Have An Uneven Effect In The U.S.

KFF Health News, April 21, 2017

By Michelle Andrews 

This article first appeared April21, 2017 on Kaiser Health News.

Research published in JAMA found that more than 2,100 U.S. employers were certified to fill nearly 10,500 physician jobs nationwide, in 2016. That represents 1.4 percent of the physician workforce overall.

Limiting the number of foreign doctors who can get visas to practice in the United States could have a significant impact on certain hospitals and states that rely on them, according to a new study.

The research, published online in JAMA this week, found that more than 2,100 U.S. employers were certified to fill nearly 10,500 physician jobs nationwide, in 2016. That represents 1.4 percent of the physician workforce overall. There were wide variations by state and employer, however.

Employers in New York, Michigan and Illinois accounted for the most H-1B visa applications for foreign physicians, nearly a third of the total. North Dakota, however, had the most applicants as a percentage of its physician workforce: 4.7 percent.

The top three employers that submitted applications for the most doctors through the visa program were William Beaumont Hospital in southeastern Michigan, with 470 physician applications, Bronx-Lebanon Hospital Center in New York City, with 213, and Cleveland Clinic foundation in Ohio, with 180.

“People underestimate the fragility of certain hospitals and their reliance on certain physicians for their functioning,” said study co-author Peter Kahn, who’s graduating from Albert Einstein College of Medicine in the Bronx this spring.

The H-1B visa program allows employers to hire highly skilled professionals from abroad to fill employment gaps in the U.S., typically in high-tech, science, engineering and math jobs. But hospitals use the program as well, often to recruit doctors to serve in rural or underserved urban areas. The number of visas is capped at 85,000 annually.

That could change. On Tuesday, President Donald Trump signed an executive order reiterating his administration’s priority to buy American goods and hire American workers. Among other things, it requires federal agencies to suggest reforms to the H-1B visa program to ensure the visas are awarded appropriately.

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.

With Drug Costs In Crosshairs, Health Firms Gave Generously To Trump’s Inauguration

KFF Health News, April 20, 2017

By Jay Hancock and Sydney Lupkin and Elizabeth Lucas 

This story was originally published on Kaiser Health News on April 19, 2017.

Drugmaker Pfizer gave $1 million to help finance the inauguration, according to documents filed with the Federal Election Commission. Amgen, another pharmaceutical company, donated $500,000. Health insurers Anthem, Centene and Aetna all gave six-figure contributions.

Facing acute risks to their businesses from Washington policymakers, health companies spent more than $2 million to buy access to the incoming Trump administration via candlelight dinners, black-tie balls and other inauguration events, new filings show.

Drugmaker Pfizer gave $1 million to help finance the inauguration, according to documents filed with the Federal Election Commission. Amgen, another pharmaceutical company, donated $500,000. Health insurers Anthem, Centene and Aetna all gave six-figure contributions.

They joined a surge of corporate donors from multiple industries to break inauguration-finance records even as then-President-elect Donald Trump promised to “drain the swamp” of Washington influence-peddling.

But the stakes for the health industry were especially high as the new administration prepared to take power.

Two weeks before Pfizer’s donation, Trump told Time magazine: “I’m going to bring down drug prices.” At the same time, one of his top goals was repealing Obamacare — the Affordable Care Act — and its billions in subsidies for insurance companies and hospitals.

Also writing checks for the inauguration were drugmaker Abbott Laboratories, drug wholesaler Caremark, insurer MetLife and Managed Care of North America, a dental benefits manager.

Trump’s inaugural committee raised $107 million, more than twice as much as for any previous presidential investiture. President Barack Obama’s 2009 inauguration held the previous record of $53 million.

Obama banned corporate donations that year and limited individual donations to $50,000 but accepted corporate grants for his 2013 inauguration.

No health company gave more to Trump’s event than Pfizer, whose profits for Lyrica, Prevnar 13 and other high-priced medicines could come under pressure if the Medicare program for seniors is allowed to negotiate on cost, as Trump has suggested.

Lyrica alleviates nerve and muscle pain. Prevnar 13 is a vaccine against pneumococcal pneumonia.

Along with several other pharma companies, Pfizer is the subject of a Justice Departmentinvestigation over donations to charities that help Medicare patients avoid copayments for expensive drugs.

Pfizer CEO Ian Read is also a vocal advocate of cutting corporate income taxes, which Trump has pledged to do. The Obama administration thwarted Pfizer’s $160 billion deal to move its legal residency to low-tax Ireland to merge with Botox maker Allergen.

Pfizer’s $1 million donation entitled it to four tickets to a “leadership luncheon” with “select Cabinet appointees and House and Senate leadership,” according to a solicitation brochure obtained and posted online by the Center for Public Integrity.

“As it has been the case with previous presidential inaugurations, we made a financial contribution to the 58th Presidential Inaugural Committee and a group of our senior leaders participated in various official events,” said Pfizer spokesperson Sharon Castillo. She declined to identify the executives.

Amgen’s inauguration gift of $500,000 was the second-biggest from a health care donor. The company makes Enbrel for arthritis and Epogen for anemia, among other drugs.

Amgen’s contribution bought it two tickets to “an intimate dinner” with then-Vice President-elect Mike Pence and his wife, Karen Pence. Amgen CEO Robert Bradway was among seven pharma executives who met with Trump in the White House on Jan. 31, although that wasn’t part of the inauguration package.

Amgen spokesperson Kelley Davenport declined to comment beyond describing the company as joining “numerous other donors from a diverse group of industries and individuals” supporting the event.

Pfizer also got entrée to the Pence inaugural dinner. Both companies had access to balls, receptions, luncheons, concerts and other events available to lesser donors.

Neither Pfizer, Amgen nor other large, health care donors to Trump’s inauguration made contributions to Obama’s 2013 inauguration, which did accept corporate money. Pfizer gave $250,000 to President George W. Bush’s 2005 inauguration.

The biggest health care corporate donor to Obama’s 2013 investiture was drugmaker Genentech, which gave $750,000, records show. The company did not contribute to Trump’s inauguration. “Prior to the 2016 election, we made a decision not to sponsor any inaugural activities for the foreseeable future,” said Genentech spokesperson Susan Willson.

Contributors for this year’s event also included insurer Anthem, one of the largest participants in the Affordable Care Act’s online marketplaces, and Centene, which also sells insurance plans through the online exchanges. Anthem gave $100,000 while Centene gave $250,000.

Both companies’ marketplace businesses depend on generous federal subsidies that would be jeopardized by an ACA repeal or other actions by the administration. Anthem has pressed the administration to preserve the subsidies and tighten rules for marketplace enrollment.

Anthem CEO Joseph Swedish was one of a group of insurance executives who met with Trump in February. Swedish met again with Trump in the White House last month, Modern Healthcare reported.

Centene, which manages state and federal Medicaid programs for low-income people in many states, also benefited from the ACA’s Medicaid expansion. Analysts see the company as especially vulnerable to a potential repeal of Obama’s health law.

KHN’s coverage of prescription drug development, costs and pricing is supported in part by theLaura and John Arnold Foundation.

Sen. Grassley Demands Scrutiny Of Medicare Advantage Plans

KFF Health News, April 19, 2017

By Fred Schulte 

The Iowa Republican has asked CMS officials to explain why they failed to collect nearly $125 million in potential overcharges identified at five Medicare Advantage plans audited in a single year.

Sen. Chuck Grassley (R-Iowa) wants federal health officials to tighten scrutiny of private Medicare Advantage health plans amid ongoing concern that insurers overbill the government by billions of dollars every year.

Grassley, the influential chairman of the Senate Judiciary Committee, has asked Centers for Medicare and Medicaid Services (CMS) officials to explain why they failed to collect nearly $125 million in potential overcharges identified at five Medicare Advantage plans audited in a single year.

In an April 17 letter to CMS Administrator Seema Verma, Grassley cited an article on alleged overcharges published in January by Kaiser Health News. The article said that Medicare had potentially overpaid five health plans $128 million in 2007, but under pressure from the insurance industry collected just $3.4 million and settled the cases.

“The difference in the assessment and the actual recovery is striking and demands an explanation,” Grassley wrote.

Medicare Advantage is a popular alternative to traditional Medicare. The privately run health plans have enrolled more than 18 million elderly and disabled people — about a third of those eligible for Medicare — at a cost to taxpayers approaching $200 billion a year. The plans also enjoy strong support in Congress.

Medicare is supposed to pay the health plans higher rates for sicker patients and less for people in good health using a formula called a risk score.

Yet CMS records reveal that billions of tax dollars are wasted annually partly because some health plans exaggerate how sick their patients are by inflating risk scores and boosting their payments improperly.

Grassley asked in his letter what steps CMS is taking “to ensure that insurance companies are not fraudulently altering risk scores” and how many audits are now being conducted.

“By all accounts, risk score gaming is not going to go away. Therefore, CMS must aggressively use the tools at its disposal to ensure that it is efficiently identifying fraud and subsequently implementing timely and fair remedies,” he wrote.

Grassley also noted that CMS needs to step up oversight audits because Medicare Advantage plans are expected to grow substantially in coming years.

“The use of these tools is all the more important as Medicare Advantage adds more patients and billions of dollars of taxpayer money is at stake,” Grassley’s letter said.

The Government Accountability Office, the watchdog arm of Congress, has sharply criticized CMS for its failure to ferret out overcharges and in April 2016 called for “fundamental improvements” in audits of Medicare Advantage plans. GAO also found that CMS has spent about $117 million on Medicare Advantage audits, but recouped just under $14 million in total.

Medicare Advantage plans have been the target of at least a half-dozen whistleblower lawsuits alleging patterns of overbilling and fraud. In March, the Justice Department joined one such suit against insurance giant UnitedHealth Group. The suit alleges that the health plan submitted claims for underpayments to the government, but ignored examples in which it had received too much money.

The audits disclosing the $128 million in overpayments to health plans were part of a cache of confidential CMS documents released through a Freedom of Information Act lawsuit filed by the Center for Public Integrity.

The CMS records identify the companies chosen for the initial Medicare Advantage audits as a Florida Humana plan, a Washington state subsidiary of United Healthcare called PacifiCare, an Aetna plan in New Jersey and an Independence Blue Cross plan in the Philadelphia area. The fifth one focused on a Lovelace Medicare plan in New Mexico, which has since been acquired by Blue Cross.

In the audits, CMS repeatedly found that the health plans couldn’t document their patients were as sick as the insurer had claimed.

For example, auditors couldn’t confirm that one-third of the diseases the health plans had been paid to treat actually existed, mostly because patient records lacked “sufficient documentation of a diagnosis.”

Overall, Medicare paid the wrong amount for nearly two-thirds of patients whose records were examined; all five plans were far more likely to charge too much than too little. For 1 in 5 patients, the overcharges were $5,000 or more for the year, according to the audits.

America’s Health Insurance Plans, an industry trade group, has denied that Medicare Advantage plans overcharge. The group argued in a June 2016 position paper that the auditing method used by CMS was “not yet stable and reliable.” The group also said that conducting audits “could disrupt the care being provided by plans that are working hard to meet the needs of their enrollees.”

Grassley cited reports by the Center for Public Integrity that improper payments to Medicare Advantage plans cost taxpayers as much as $70 billion from 2008 to 2013. He said that CMS’ estimate that it had overpaid the five health plans $128 million “appears low and could very well be just the tip of the iceberg.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

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