The ACA was a game changer for these clinics — it has enabled them to get reimbursement for much more of the care they provided. With repeal of the ACA looming, clinic directors said they stay up at night wondering what's next.

This article first appeared February 24, 2017 on Kaiser Health News. It is part of a partnership that includes KPCC, WXXI, KJZZ, Colorado Public Radio, NPR and Kaiser Health News.

Treating people for free or for very little money has been the role of community health centers across the U.S. for decades. In 2015, 1 in 12 Americans sought care at one of these clinics; nearly 6 in 10 were women, and hundreds of thousands were veterans.

The community clinics — now roughly 1,300-strong — have also expanded in recent years to serve people who gained insurance under the Affordable Care Act. In 2015, community health centers served 24.3 million people — up from 19.5 million in 2010. Most of the centers are nonprofits with deep roots in their communities and they meet the criteria to be a federally qualified health center. That means they can qualify for federal grants and a higher payment rate from Medicaid and Medicare.

The ACA was a game changer for these clinics — it has enabled them to get reimbursement for much more of the care they provided, because more of their patients now had private insurance or were on Medicaid. Revenue at many clinics went up overall, and many of the health centers used federal funding available under the law to expand their physical facilities and add more services, such as dentistry, urgent care or mental health care.

With repeal of the ACA looming, clinic directors said they stay up at night wondering what's next. We spoke with four, who all say their clinics are in a holding pattern as Congress debates the health law's future.

Saban Community Clinic, Los Angeles

Julie Hudman, the CEO of Saban Community Clinic in Los Angeles, Calif., said there's a lot at stake for her patients.

"A lot of the folks that we see are single adults," she explained. "They're maybe more transitional. They're homeless patients. They have behavioral health challenges. They're really, to be honest, some of the most vulnerable and poorest patients of all."

Before the ACA went into effect, eligibility for Medi-Cal, as Medicaid is known in California, depended on a variety of factors, including income, household size, family status, disability and others. Under Obamacare, according to the California Department of Health Care Services, people can now qualify for Medi-Cal on the basis of income alone if their household makes less than 138 percent of the federal poverty level — that's $16,395 for an individual and $33,534 for a family of four.

Prior to the ACA, about half of the Saban clinic's 18,000 patients were uninsured, Hudman said. They paid little for treatment — maybe a copay of $5 or $10. Almost all of those patients qualified for Medi-Cal after the health law expanded eligibility, she said, and that's made a big difference for the clinic's bottom line: Medi-Cal pays the clinic around $200 per patient visit.

These days, more than half of Saban's revenue comes from health insurance. The possibility of losing some of that money, Hudman said, is forcing some hard decisions. She had been looking to lease or buy a fourth facility, she said, but now that plan is on hold; as are her hopes of expanding free help for the homeless.

"I'm not willing to move forward and take some of those risks," she said. "I need to make sure that we're able to pay our bills and pay our staff."

Before the last election, Hudman said, "we had a lot of momentum moving forward. And now we've just sort of stalled." — Rebecca Plevin, KPCC, Los Angeles

Jordan Health, Rochester, N.Y.

In the last few years, funding has been on the rise at Jordan Health, in Rochester, N.Y., and so has the extent of the clinic's services.

The boost in funding has partly come from higher reimbursement rates the ACA authorizes, and from the increased number of patients at the clinic who have insurance. But Jordan Health, which has 10 locations in the area, has also benefited from the federal government's pumping of more money into what are known as section 330 grants that enable expansion of services and facilities.

The 330 grant money gives qualified clinics the option of offering services that aren't billable to insurance plans. At Jordan Health, the funds enabled the hiring of some different types of health practitioners who were not previously part of the team — dietitians, behavioral health specialists and care coordinators. And that, in turn, said Janice Harbin, president and CEO of Jordan Health, means patients can increasingly get the different kinds of care they need in one place.

Almost 90 percent of Jordan's patients are considered a racial or ethnic minority, and over 97 percent live at or below 200 percent of the federal poverty line, according to data gathered by the federal Health Resources & Services Administration.

"When you're dealing with a situation of concentrated poverty," Harbin said, "your patient needs more than just 'OK, let me give you a checkup, and pat you on the back and say now go out and do all these things I told you to do.'"

Jordan Health received an increase of about $1 million since 2013, according to its grant coordinator, Deborah Tschappat.

Tschappat said she expects Jordan will get about the same annual award in 2017, assuming federal funding for the 330 program stays about the same. If federal funding is cut significantly, they would potentially lose some services.

For now, Jordan Health plans to "expand services judiciously, while increasing efficiency and productivity," Tschappat said.

In the coming months Harbin and her colleagues will be lobbying lawmakers in Albany and Washington, D.C., to renew Jordan's funding — including the 330 grant, which is set to end in September.

"We're used to doing a lot with a little, but we increasingly know that we do need to have financial support," Harban said. "And that's keeping us up at night." — Karen Shakerdge, WXXI, Rochester

Adelante Healthcare, Phoenix

Adelante Healthcare has been part of the health safety net in Phoenix for nearly four decades — when its doctors began helping farm workers in the city's surrounding fields. But the Affordable Care Act enabled Adelante to expand like a brand new business.

"Adelante has grown by 35 percent in the last 12 months," said Dr. Robert Babyar, Adelante's assistant chief medical officer. "We've increased our provider staffing — almost doubled our providers. And the number of services we provide has doubled."

Adelante operates nine clinics throughout the Phoenix metro area. The one where Babyar met with me includes play areas for children and a dental office.

Most of their 70,000 patients are low-income and about half are covered by either Medicaid or KidsCare — Arizona's version of the Children Health Insurance Program. In 2014, Arizona became one of the Republican-led states that expanded Medicaid under the ACA. That brought more than 400,000 people onto the state's Medicaid rolls and created big demand for Adelante. Low-income patients who did not have insurance before the expansion had relied on Adelante's sliding fee schedule. Much of that population now has health coverage, either through the ACA marketplace or the state.

"That opened up more options for our patients, more specialists they could see, procedures they could have done," Babyar said.

As Congress moves to repeal and replace the health care law, Adelante is in a holding pattern. It has delayed the groundbreaking of a new site until later this year because of the uncertainty. A full repeal of the ACA — without a replacement that keeps its patients covered — would limit any future growth, and strain the new staff and resources it has added. It wouldn't be the first time Adelante had to scale back its services because of changes to Medicaid. In 2010 and 2011, Arizona lawmakers froze enrollment for its CHIP program and for childless adults in Medicaid. Then, in 2012, Adelante lost more than a million dollars.

Babyar said it has taken several years to get their new patients into the system and working with doctors consistently to manage their conditions.

"All the progress we made with those patients to stay and be healthy — that can fall apart really quick," said Babyar. — Will Stone, KJZZ, Phoenix

Denver Health, Denver

Denver's Federico F. Peña Southwest Family Health Center is part of Denver Health — the safety-net system that takes care of low-income people.

"Definitely this clinic has benefited from Obamacare," said Dr. Michael Russum, who practices family medicine for Denver Health and helps lead the clinic. "And this population has benefited from Obamacare by the expansion of Medicaid."

That's what helped make the economics work as Denver Health put a new $26 million clinic in a high poverty neighborhood in 2016, said Dr. Simon Hambidge, Denver Health's CEO of Community Health Services. With the ACA in place, he said, the health system was able to count on the new clinic having a population of paying patients with insurance that could help support it.

Hambidge predicted the hospital will weather the storm if Obamacare is repealed and there are serious cuts to safety-net programs, like Medicaid and Medicare, as some Republicans have suggested. But it will probably be harder to open new clinics in other high-need neighborhoods, he conceded.

"We'll survive," Hambidge said. "We may not be able to be as expansive, because we would be back to less secure times." — John Daley, Colorado Public Radio

Aetna will stop requiring doctors seek approval before prescribing particular medications―such as Suboxone―that are used to mitigate withdrawal symptoms.

This article first appeared February 21, 2017 on Kaiser Health News.

By Shefali Luthra

Aetna, one of the nation's largest insurance companies, will remove a key barrier for patients seeking medication to treat opioid addiction. The change will take effect in March and apply to commercial plans, a company spokeswoman confirmed, and will make it the third major insurer to make the switch.

Specifically, Aetna will stop requiring doctors seek approval before prescribing particular medications ― such as Suboxone ― that are used to mitigate withdrawal symptoms, and typically given along with steady counseling. The insurance practice, called "prior authorization," can result in delays of hours to days in getting a prescription filled.

The change comes as addiction to opioids, which include heavy-duty painkillers and heroin, still sweeps the country. More than 33,000 people died from overdosing on these drugs in 2015, the most recent year for which statistics are available. And it puts Aetna in the company of Anthem and Cigna, which both recently dropped the prior authorization requirement for privately insured patients across the country. Anthem made the switch in January and Cigna this past fall.

Both companies took the step after facing investigation with New York's attorney general, whose office was probing whether their coverage practices unfairly barred patients from needed treatment. They made this adjustment as part of larger settlements.

It sounds like just a technicality ― a brief delay before treatment. But addiction specialists say this red tape puts people's ability to get well at risk. It gives them a window of time to change their minds or go into withdrawal symptoms, causing them to relapse.

"If someone shows up in your office and says, 'I'm ready,' and you can make it happen right then and there ― that's great. If you say, 'Come back tomorrow, or Thursday, or next week,' there's a good chance they're not coming back," said Josiah Rich, a professor of medicine and epidemiology at Brown University and doctor at Providence-based Miriam Hospital, who frequently treats patients with opioid addictions. "Those windows of opportunity present themselves. But they open and close."

As these major carriers drop the requirement, treatment specialists hope a trend could be emerging in which these addiction meds become more easily available. In New York, for instance, the attorney general's office will be following up with other carriers who still have prior authorization requirements, an office spokesperson said. The office would not specify which carriers it will next examine.

Meanwhile, though little research pinpoints precisely how widespread this coverage practice is for drugs that treat opioid addiction, experts say it's a fairly common practice.

"Just think of any big health insurance company that hasn't recently announced they're doing away with this, and it's a pretty safe bet they've got prior authorization in place," said Andrew Kolodny, a Brandeis University senior scientist and the executive director of Physicians for Responsible Opioid Prescribing, an advocacy group.

How does the problem manifest? Take Boston Medical Center, located in a region that's been particularly hard hit by opioid addiction. Doctors there wanted to launch an urgent care center focused on this patient population. Less than a year old, the program's treated thousands of people.

But prior authorization requirements have been intense, said Traci Green, an associate professor at Boston University's School of Medicine and deputy director of the hospital's injury prevention center. To help people get needed care ― before it was too late ― the center hired a staffer devoted specifically to filling out all the related insurance paperwork.

"It was like, 'This is insanity,'" Green said, adding that "navigating the insurance was a huge problem" for almost every patient.

But defenders of the requirement maintain that such controls have value. Insurance plans using prior authorization may view it as a safeguard when prescribing a potentially dangerous drug. "[It's] not a tool to limit access. It's a tool to ensure patients get the right care," said Susan Cantrell, CEO of the Academy of Managed Care Pharmacy, a trade group.

Other large insurance carriers ― such as United Healthcare and Humana ― list on their drug formularies a prior authorization requirement for at least some if not all versions of anti-addiction medication. A spokesperson from Humana said the practice is used "to ensure appropriate use."

Also, though, it is generally agreed that the practice is used to control the prescribing of expensive medications. Per dose, the cost of these drugs varies based on brand and precise formulation, but it can go as high as almost $500 for a 60-pack dose, which can last a month.

Regardless of intent, critics say, those extra forms and hoops do make it more difficult for patients in need to get these medications ― ultimately, they say, doing more harm than good.

"If you would like a physician to not do a particular treatment, put a prior authorization in front of it," Rich said. "That's what they're used for."

Meanwhile, addiction treatment advocates and health professionals are hoping to build on what they see as new momentum.

Earlier this month, the American Medical Association sent a letter to the National Association of Attorneys General, calling for increased attention to insurance plans that require prior authorization for Suboxone or other similar drugs.

Minnesota's attorney general has written to health plans in the state, asking they end prior authorization for addiction treatment. New York has also heard from other states interested in tackling the issue, the attorney general spokesperson said. And another project, called Parity Track, is soliciting complaints from consumers.

They're arguing based on a requirement that insurance plans, thanks to so-called "parity laws," must cover addiction treatment, and cover it at the same level as they do other kinds of health care.

The prior authorization requirement "doesn't meet the sniff test for parity," said Corey Waller, an emergency physician who chairs the American Society of Addiction Medicine's legislative advocacy committee. "It's a first-line, Food and Drug Administration-approved therapy for a disease with a known mortality. Every other disease with a known mortality ― the first-line drugs are available right away."

But the justification for legal cases like New York's could get weaker. The 2010 health law, which lawmakers are working to repeal, included requirements that mental health and addiction treatment be considered an "essential health benefit." If that disappears, robust coverage for addiction could be less widely available, several noted.

Meanwhile, the stakes are substantial, Rich said. He recalled a patient who was taking a version of buprenorphine ― the active ingredient in Suboxone ― who had a brief relapse with heroin. That led to complications in the paperwork for renewing his prescription for treatment.

"Now he's out of the office, in the street, using more," Rich said of that case. "Incumbent upon [effective treatment] is the ability to get people started right away. If there's prior authorization? It's infuriating."

Low-wage workers were less likely to get preventive care even though many of those services are available without cost-sharing under the 2010 health law.

This article first appeared February 17, 2017 on Kaiser Health News.

By Michelle Andrews

Low-wage workers with job-based health insurance were significantly more likely than their higher-income colleagues to wind up in the emergency department or be admitted to the hospital, in particular for conditions that with good primary care shouldn't result in hospitalization, a new study found.

At the same time, low-wage workers were much less likely to get preventive care such as mammograms and colonoscopies, even though many of those services are available without cost-sharing under the 2010 health law.

There's no single reason for the differences in health care use by workers at different wage levels, said Dr. Bruce Sherman, an assistant clinical professor at Case Western Reserve University in Cleveland and the study's lead author, which was published in the February issue of Health Affairs.

Finances often play a role. Half of workers with employer-sponsored insurance are enrolled in plans with a deductible of at least $1,000 for single coverage. As deductibles and other out-of-pocket costs continue to rise, low-wage workers may opt to pay the rent and put food on the table rather than keep up-to-date with regular doctor visits and lab work to manage their diabetes, for example.

Likewise, convenient access to care can be problematic for workers at the lower end of the pay scale.

"Individuals are penalized if they leave work to seek care," Sherman said. "So they go after hours and their access to care is limited to urgent care centers or emergency departments."

The study examined the 2014 health care claims, wage and other data of nearly 43,000 workers at four self-funded companies that offered coverage through a private health insurance exchange. Workers were stratified into four categories based on annual maximum wages of $30,000, $44,000, $70,000 and more than $70,000.

Workers in the lowest wage category were three times more likely to visit the emergency department than top earners, and more than four times more likely to have avoidable hospital admissions for conditions such as bacterial pneumonia or urinary tract infections. But they used preventive services only half as often, the study found.

There are no easy solutions. Varying premiums or deductibles based on workers' wages could take some of the bite out of low-wage workers' out-of-pocket costs, but very few employers have adopted that strategy, Sherman said. Offering plans that pay for certain services, such as care related to chronic conditions, before the deductible is met could boost the use of care. But preventive services are available without cost-sharing in most plans and many low-wage workers aren't getting recommended services.

"Health literacy concerns are important," said Sherman, but it may not be the only barrier. "Some focus groups I've participated in, employees have said, 'I understand the services are free, but if an abnormality is found that requires further services, I'll have to [pay for it]. So because I feel fine, I'm not going to go.'"

Nearly 14,000 providers billed almost $35 million—including nearly $16 million paid by Medicare—for advance care planning conversations from January through June.

This article first appeared February 15, 2017 on Kaiser Health News.

By JoNel Aleccia

End-of-life counseling sessions, once decried by some conservative Republicans as "death panels," gained steam among Medicare patients in 2016, the first year doctors could charge the federal program for the service.

Nearly 14,000 providers billed almost $35 million — including nearly $16 million paid by Medicare — for advance care planning conversations for about 223,000 patients from January through June, according to data released this week by the Centers for Medicare & Medicaid Services. Full year figures won't be available until July, but use appears to be higher than anticipated.

Controversy is threatening to reemerge in Congress over the funding, which pays doctors to counsel some 57 million Medicare patients on end-of-life treatment preferences. Rep. Steve King, R-Iowa, introduced a bill last month, the Protecting Life Until Natural Death Act, which would revoke Medicare reimbursement for the sessions, which he called a "yet another life-devaluing policy."

"Allowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years," King said on Jan. 11.

While the fate of King's bill is highly uncertain — the recently proposed measure hasn't seen congressional action — it underscores deep feelings among conservatives who have long opposed such counseling and may seek to remove it from Medicare should Republicans attempt to make other changes to the entitlement program.

Proponents of advance care planning, however, cheered evidence of program's early use as a sign of growing interest in late stage life planning.

"It's great to hear that almost a quarter million people had an advance care planning conversation in the first six months of 2016," said Paul Malley, president of Aging with Dignity, a Florida nonprofit. "I do think the billing makes a difference. I think it puts it on the radar of more physicians."

Use of the counseling sessions is on track to outpace an estimate by the American Medical Association, which projected that about 300,000 patients would receive the service in the first year, according to the group, which backed the rule.

Providers in California, New York and Florida led use of the policy that pays about $86 a session for the first 30-minute office-based visit and about $75 per visit for any additional sessions.

The rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions.

The new reimbursement led Dr. Peter Sutherland, a family medicine physician in Morristown, Tenn., to schedule more end-of-life conversations with patients last year.

"They were very few and far between before," he said. "They were usually hospice-specific."

Now, he said, he has time to have thorough discussions with patients, including a 60-year-old woman whose recent complaints of back and shoulder pain turned out to be cancer that had metastasized to her lungs. In early January, he talked with an 84-year-old woman with Stage IV breast cancer.

"She didn't understand what a living will was," Sutherland said. "We went through all that. I had her daughter with her and we went through it all."

The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians' assistants may also seek payment for end-of-life talks.

The idea of letting Medicare reimburse such conversations was first introduced in 2009 during debate on the Affordable Care Act. The issue quickly fueled allegations by some conservative politicians, such as former Republican vice presidential candidate Sarah Palin and presidential candidate John McCain, that they would lead to "death panels" that could disrupt care for elderly and disabled patients.

The idea was dropped "as a direct result of public outcry," King said in a statement.

"The worldview behind the policy has not changed since then and government control over this intimate choice is still intolerable to those who respect the dignity of human life," he said.

But in 2015, CMS officials quietly issued the new rule allowing Medicare reimbursement as a way to improve patients' ability to make decisions about their care.

End-of-life conversations have occurred in the past, but not as often as they should, Malley said. Many doctors aren't trained to have such discussions and find them difficult to initiate.

"For a lot of health providers, we hear the concern that this is not why patients come to us," Malley said. "They come to us looking to be cured, for hope. And it's sensitive to talk about what happens if we can't cure you."

A 2014 report by the Institute of Medicine, a panel of medical experts, concluded that Americans need more help navigating end-of-life decisions. A 2015 Kaiser Family Foundation poll found that 89 percent of people surveyed said health care providers should discuss such issues with patients, but only 17 percent had had those talks themselves. (KHN is an editorially independent program of the foundation.)

Use of the new rule was limited in the first six months of 2016. In California, which recorded the highest Medicare payments, about 1,300 providers provided nearly 29,000 services to about 24,000 patients at an overall cost of about $4.4 million — including about $1.9 million paid by Medicare.

The data likely reflect early adopters who were already having the talks and quickly integrated the new billing codes into their practices, said Dr. Ravi Parikh, an internal medicine resident at Brigham and Women's Hospital in Boston, who has written about advance care planning. Many others still aren't aware, he said.

Data from Athenahealth, a medical billing management service, found that only about 17 percent of 34,000 primary care providers at 2,000 practices billed for advance care planning in all of 2016.

The numbers will likely grow, said Malley, who noted that requests from doctors for advance care planning information tripled during the past year.

To counter objections, providers need to ensure that informed choice is at the heart of the newly reimbursed discussions.

"If advance care planning is only about saying no to care, then it should be revoked," Malley said. "If it truly is about finding out patient preferences on their own turf, it's a good thing."

Table at page bottom: Medicare Spending And Utilization Data For Advanced Care Planning Services By State, Jan. 1 — June 30, 2016