Even some Republicans who supported legislation in committee warned they may not back the sweeping package in a full Senate vote. They object in particular to a provision that would cap drug prices paid by Medicare based on the rate of inflation.

This article was published by Kaiser Health News on Thursday, July 25, 2019.

By Emmarie Huetteman

The fight between policymakers intent on lowering prescription drug prices and the drugmakers who keep raising them intensified Thursday, as a slew of Republican senators threatened to side with manufacturers against legislation supported by their own committee chairman and president.

After months of closed-door meetings and high-profile hearings, the Senate Finance Committee voted 19-9 to advance legislation introduced by Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore.) to rein in drug costs in the Medicare and Medicaid programs.

But even some Republicans who supported it warned they may not back the sweeping package of proposals in a full Senate vote. They object in particular to a provision that would cap drug prices paid by Medicare based on the rate of inflation.

Other obstacles have piled up. Wyden announced that Democrats, who provided most of the bill's support in committee, would not allow a Senate vote without the Republicans agreeing to hold votes on cementing insurance protections for people with preexisting conditions. Democrats have complained for months that GOP efforts to kill the Affordable Care Act will leave people with these medical problems without any recourse to get affordable health care. Democrats also want to empower federal health officials to negotiate drug prices.

Here are the three major problems revealed in Thursday's hearing.

Many Senate Republicans disagree with President Donald Trump about how to lower drug prices.

Some of Trump's efforts to reduce Americans' drug costs took a beating Thursday. They were criticized — by members of his own party — for putting too much power in the hands of government.

Despite urging from White House and federal health officials to support the legislation, 13 of the committee's 15 Republicans voted to remove its controversial proposal to prevent drug prices from rising faster than inflation under Medicare. Their attempt failed, barely.

Medicaid already uses this strategy, requiring drugmakers to pay the government a rebate if the prices it pays outpace inflation, and Medicaid tends to pay lower prices on drugs than Medicare. The HHS inspector general has said Medicare could collect billions of dollars from the drug industry if it did the same. But many Republicans strongly oppose any government interference in private markets or price setting.

Sen. Patrick Toomey (R-Pa.), who introduced the amendment to remove the proposal, said it wasn't necessary because seniors would be protected from paying too much by another proposal in the bill to cap out-of-pocket expenses.

"It's my view that we should not use this sledgehammer of a universal price control, imported from Medicaid, to deal with that relatively narrow problem and to disrupt a program that's working very well," Toomey said, mentioning Medicare's popularity.

Grassley said the inflation caps would help relieve taxpayers from covering Medicare's skyrocketing drug costs.

And having played a key role in 2003 creating Medicare's prescription drug program, called Medicare Part D, he took issue with the idea that his latest bill would harm the program: "I wrote it, so you ought to know that I want to protect it," Grassley said.

Most of the Republicans also backed an amendment to block a proposal being considered by the Trump administration to tie drug prices here to those paid in other developed nations, which narrowly failed. While Grassley said he, too, opposes the administration's proposal, he did not want the issue to hold up his own bill and so voted against the amendment.

Grassley also said he is not comfortable with empowering federal health officials to negotiate drug prices, as Wyden said he would like to see considered. But Grassley noted that the issue isn't going away: Trump campaigned on the idea, which White House officials have been discussing with House Democratic leaders as part of a plan expected to be released in September.

But that may not be enough, Grassley suggested: "I don't think that you're going to get 60 votes in the United States Senate."

Critics in Congress are using some of the same misleading arguments as drugmakers.

Smelling trouble, pharmaceutical executives met with Trump at the White House on Wednesday evening to voice their opposition to the Grassley-Wyden bill.

In a statement after their meeting, PhRMA, the industry's lobbying group, called it "the wrong approach to lowering drug prices" and said it "imposes harmful price controls in Medicare Part D."

PhRMA claimed the bill would "siphon more than $150 billion from researching and developing new medicines." (Experts say most innovation now happens at academic institutions, not pharmaceutical companies.) It said the Medicare Payment Advisory Commission, a panel that advises Congress, had found "it will only benefit 2% of Medicare patients starting in 2022." (A Bloomberg Law reporter said a commission official told her it had not analyzed the bill.) The lobbying group asserted the bill would "result in money going to the federal treasury instead of seniors." (The money collected by the new rebates would go into the Supplemental Medical Insurance trust fund, which pays for health services for Medicare beneficiaries.)

The flaws in PhRMA's claims did not stop critics from echoing some of them. Sen. Robert Menendez (D-N.J.), whose state is home to several drugmakers, said the bill's savings should go to patients and not into "some fund" where patients would not see it. (He nonetheless voted to advance the bill.)

And Republicans decried the bill's "price controls" — even as Grassley and Wyden explained that the inflation caps would do nothing to the list prices set by drugmakers, only slow price increases once they were on the market.

In one exchange, Sen. John Cornyn (R-Texas) questioned Phillip Swagel, the director of the Congressional Budget Office, about who would pay more under the legislation's inflation caps. "If you cut the subsidy," he said, referring to what the government pays drugmakers, "doesn't somebody else's cost have to go up?"

"In this case, the out-of-pocket spending would go down. The premiums would go down. The federal spending would go down," Swagel replied. "The drug manufacturer, they would see lower price increases than they might have seen without this provision."

"So they would have to eat that cost?" Cornyn asked.

"We would see them, as you put it, eating some of that cost, and they might change their overall pricing as well," Swagel said.

Saying there was "sufficient uncertainty" about how the caps would work, Cornyn then asked to be added as a co-sponsor of the amendment opposing that change.

Democrats, who unanimously voted to advance the bill, may still kill it.

Wyden opened with an unusual declaration as he discussed the legislation he and Grassley had spent months crafting: If Republican leaders do not allow votes on amendments that would protect preexisting conditions and empower federal health officials to negotiate drug prices, Democrats will oppose moving forward on it.

In short, he threatened his own bill.

"We're certainly not going to sit quietly by while protections for preexisting conditions are wiped out," Wyden said. "We're not going to sit by while opportunities for seniors to use their bargaining power in Medicare are frittered away."

Democrats slammed Republicans during the 2018 midterm election for not doing enough to protect those with preexisting conditions, especially since Republican attorneys general have sued to void the entire Affordable Care Act. It looks like Democrats are warming up that argument for 2020.

During one tense exchange Thursday, Sen. Bob Casey (D-Pa.) fired back at Cornyn for claiming Republicans have a plan to protect patients should the ACA be thrown out.

"How the hell can you say that you support protections when you have all the power and a bill did not pass that would support the Affordable Care Act?" Casey said. "You've had eight years of bellyaching about it, and you haven't done a damn thing about it."

As the hearing went on, Democrats praised the bipartisan legislation at hand but listed other proposals they would like to see, including the revival of the Trump administration's now-defunct rebate rule. That would have forced the pharmacy benefit managers who negotiate drug prices for government health plans to refund some of those discounts to customers. (Grassley, for his part, asked Wyden to work with him on incorporating the proposal into their legislation.)

Still, Grassley referred to the opposition among his own Republican colleagues as his "most vexing problem." At one point, when Sen. John Thune (R-S.D.) gently suggested that stripping out the inflation caps would leave them with "a big, bipartisan margin on this bill coming out of here," Grassley didn't miss a beat.

"It could get us a unanimous vote in this committee, but it would also leave the taxpayers with $50 billion more cost," he said before calling on the next senator.

A primary care provider works to improve physicians' 'computer-side manner.'

This story was first published on Wednesday, July 24, 2019 in Kaiser Health News.

By Carmen Heredia Rodriguez July 24, 2019

As Wei Wei Lee sat with her doctor to discuss starting a family, she felt a "distance" between them. The physician was busy on the computer and focused on the screen.

"It just didn't feel very personal," Lee said. "I didn't feel heard."

It seemed as though keeping a record of the conversation was more important to the doctor than making a connection with Lee.

It wasn't the experience she wanted, but she could relate: Lee is Dr. Wei Wei Lee, a primary care physician with the University of Chicago Medicine.

When she first started using electronic health records (EHRs) in the exam room, Lee struggled too. She would apologize to patients for not giving them her full attention. And Lee spent valuable patient time trying to toggle between tasks on the computer, she said.

Today, Lee studies the influence of electronic health records on the doctor-patient relationship. She's interested in improving physicians' "computer-side manner."

Electronic health records can help reduce medical errors, but when not used well they can strain the doctor-patient relationship.

But medical providers — and patients — can learn skills to keep communication flowing even when there's a screen in the room, Lee said.

KHN spoke with Lee about her survey of patients at the University of Chicago Medicine. Lee found that the vast majority of them were satisfied with doctors using computers in the exam room. But some people felt the focus of their appointments had shifted away from them. And the medical provider's body language sometimes made communication more difficult:

In the past, the patient could be the center of attention through that visit. Now, the physician is really dividing their attention between putting in orders and working in the computer without paying full attention to the patient. So, eye contact, having a back to the patient, awkward silences while the doctor is looking up something in the computer — all these can cause challenging communication issues for patients.

Those "awkward silences" can have consequences, Lee said.

Most patients want to go to the doctor to feel that they're heard and really be able to talk to the doctor about what's bothering them. When the computer is not used well, often it can make that patient less likely to go back to that physician if they felt like there was a disconnect in the way that they communicated. Other things that can happen are medical errors. If the doctor is more distracted during that visit, they may put in wrong orders for medications or not record a part of the history that is pertinent.

Lee and colleagues developed strategies to help physicians better relate to their patients while also working with a computer. There's now a curriculum to teach clinicians how to use EHRs in a "patient-centered" way.

A lot of it has to do with behaviors and skills that are not rocket science. For example, starting off the visit completely technology-free. Greeting your patient. Honoring that golden minute. Establishing rapport and conversation in that first minute can really go a long way. And then another thing that's been found to be very helpful is screen-sharing.

So what does effective screen-sharing look like? Instead of placing the computer between the patient and doctor, the physician can move his or her chair next to the patient so they are sitting side by side, Lee suggested. Then, the computer is positioned in front of both of them — to form a triangle.And if a computer is still getting in the way of conversation, Lee says patients shouldn't hesitate to speak up. Her team developed a comic using a simple ABC mnemonic to teach people those skills. Ask To See The Screen. Become Involved. Call For Attention.

I think speaking up and calling for that attention is a way to continue to build that relationship with their doctor because it may be a behavior that the physicians aren't aware of. There may be times when they're talking about a sensitive topic or issues that have come up that they want the physician's undivided attention. In those moments, I think it's OK to say, "Is it OK if we just talk without the computer for a few minutes?"

I think that goes a long way to also just signaling to the physician that there is something that the patient really finds important.

Carmen Heredia Rodriguez: CarmenH@kff.org, @ByCHRodriguez

For the North Carolina Cherokee, self-governance has meant adopting an integrated care model that not only improves patients' health, but also is tailor-made for the needs of the tribe.

This article was first published on Monday, July 22, 2019 in Kaiser Health News.

By Katja Ridderbusch

CHEROKEE, N.C. — Light pours through large windows and glass ceilings of the Cherokee Indian Hospital onto a fireplace, a waterfall and murals. Rattlesnake Mountain, which the Cherokee elders say holds ancient healing powers, is visible from most angles. The hospital's motto — "Ni hi tsa tse li" or "It belongs to you" — is written in Cherokee syllabary on the wall at the main entrance.

"It doesn't look like a hospital, and it doesn't feel like a hospital," Kristy Nations said on a recent visit to pick up medications at the pharmacy. "It actually feels good to be here."

Profits from the tribe's casino have helped the 12,000 members of the Eastern Band of Cherokee Indians opt out of the troubled U.S. government-run Indian Health Service. They are part of an expanding experiment in decentralization, in which about 20% of federally recognized tribes in Oklahoma, California, Arizona and elsewhere have been granted permission to take full control of their health care.

For the North Carolina Cherokee, self-governance has meant adopting an integrated care model designed by Alaska Natives to deliver care that not only improves patients' health, but also is tailor-made for the needs of the tribe. It has meant the opening of a 20-bed state-of-the-art facility in 2015 and the construction of an 18-bed mental health clinic scheduled to open in October 2020.

The hospital is a "medical home for our people," said Casey Cooper, the hospital's CEO who is a member of the tribe.

Half of the Indian Health Service budget is now managed by Indian tribes to various degrees. But while full control has worked out well for tribes with resources like the Eastern Cherokee, they are one of just a few bright spots in an otherwise dire medical landscape. It remains to be seen how widely this model can be applied.

"Not all tribal communities have access to the economic opportunities that we have," Cooper said. "Some tribes are in these desolate, remote locations where there are no natural resources or economic development opportunities. I get that."

Self-Governing To Change The Narrative
 

The U.S is legally obligated to offer health services to all members of the 573 federally recognized tribes. Yet the federal Indian Health Service, which currently provides direct care to about 2.2 million out of the nation's estimated 3.7 million American Indians and Alaska Natives, is chronically underfunded. The current IHS budget is about $5.4 billion, yet the National Indian Health Board estimates the total level of need to be nearly $37 billion.

American Indians are more than twice as likely to get diabetes and six times as likely to get tuberculosis than the average U.S. population. Mental illness, and especially substance abuse, runs high in Indian Country. Native Americans are more likely to commit suicide than any other ethnic or racial group.

Health disparities are particularly harsh in the Northern Plains region. In the Dakotas, average life expectancy among American Indians is 20 years less than among white Americans.

"You do not have to cross an ocean to find Third World health conditions," said Dr. Donald Warne, a professor of public health at the University of North Dakota and an Oglala Lakota tribesman. "You can find them right here, in the heartland of the United States."

One particularly grim example is the Rosebud Indian Reservation in South Dakota. In 2015, the Centers for Medicare & Medicaid Services found safety violations at the local IHS hospital so severe that they shut down the emergency room for six months. During this time, at least five patients died en route to other hospitals located sometimes 100 or more miles away. Since then, the situation has only slightly improved.

"The Indian Health Service respects tribal sovereignty and is committed to tribal self-governance," said IHS spokesman Joshua Barnett. "IHS recognizes that tribal leaders and members are in the best position to understand the health care needs and priorities of their communities."

Self-governance also allows tribes to be eligible for Medicare, Medicaid, private-sector health insurance, partnerships with larger health systems and even federal grants that are designed for underserved communities — all which can be limited for the IHS.

"Generally speaking, tribally operated health care systems tend to run more efficiently, more effectively and with higher quality of care than IHS-managed systems," said Warne.

Money Makes A Difference
 

The Cherokee Indian Hospital is lucky to be supported by a tribe that's economically thriving due to gambling revenues, according to Cooper. The Qualla Boundary is home to Harrah's Cherokee Casino Resort. It's a unique situation, said Indian health expert Warne, as most reservation casinos don't make huge profits.

The hospital's annual budget has grown from $20 million to over $80 million within the past 17 years. The largest sources are third-party reimbursements, mostly from Medicaid and Medicare, at $27.4 million, followed by IHS contributions and tribal funding.

In 2012, the hospital decided to implement a new, patient-centered approach called the Nuka System of Care, created by the Southcentral Foundation, a nonprofit health provider owned and led by Alaska Natives. A Cherokee delegation visited a Nuka program to see how it could be tailored to their culture and health needs.

"An integrated approach is more consistent with traditional healing," Warne said. Since "we don't separate our physical, mental, spiritual and emotional health the way we do in modern specialized health care."

At Cherokee Indian Hospital, patients are assigned a team, which typically includes a primary care physician or a family nurse practitioner as well as a nutritionist, a pharmacist and a behavioral health specialist.

Rebuilding their health care prompted the need for the new hospital. Gambling revenue covered most of the costs for the $82 million facility. "The old building was outdated and inefficient," said Cooper, "a constant reminder of the paternalistically provided Indian Health Service."

The new hospital's main concourse — called Riverwalk — tells stories from Cherokee legend through graphics of a winding river, fish and turtles inlaid in the terrazzo floor. Signs are written in English and Cherokee. A literal translation of the emergency room sign is "Get better in a hurry," and the dental suite is "the place that gives you a big smile."

Patients can receive dialysis, acupuncture, massage therapy and chiropractic care. The ambulance bay, surgical suite and in-patient unit are located out of patients' view to reduce anxiety and stress.

"The building really is one big strategic tool," Cooper said.

Nations, the patient visiting recently, remembers the old days when she and her family, many of them dealing with diabetes and some on dialysis, used to wait for hours in the former hospital, a dark space dubbed "the bunker."

The 46-year-old said that she'd typically see different providers every visit. "And every time I would have to tell my story over and over and over." Now, she feels somewhat accountable to her care team — and more motivated to make and keep appointments.

"Back then, if my provider had wanted me to see a nutritionist, for example, I would have probably said, 'Whatever,' and forgotten about it," she said.

"We're trying to build a relationship with our patients," said Richard Bunio, the Cherokee Indian Hospital's clinical director who is Canadian and married to a tribe member. He noted that Native Americans generally have suffered a lot of historical trauma, leading to deeply rooted mistrust of mainstream medicine.

By quality measures, including the widely used Healthcare Effectiveness Data and Information Set, the hospital has recently performed in the top quartile for blood pressure control, blood sugar control and several cancer screenings. Also, Cooper added that in the past four years the diabetes rate in the community has leveled.

Could It Work Everywhere?
 

It is uncertain if self-governance would work for tribes such as the Rosebud Sioux or the Oglala Lakota on the Pine Ridge Indian Reservation, where geographic isolation, poverty and a lack of resources make new health care investments difficult.

"It's a huge challenge, but it's possible," said Warne, adding that philanthropy or partnerships with an academic health system might help finance such projects.

Not too long ago, tribal officials from South Dakota visited the Cherokee Indian Hospital. Despite their geographic and socioeconomic challenges, Cooper said, he believes self-determination is essential for their future. "Self-determination works. Self-determination is the right thing. And self-determination is the catalyst to restoring the health of our communities."

Yet many of the South Dakota tribal leaders remain skeptical. They are concerned that self-determination would let the federal government off the hook from its responsibility to provide health services.

Therefore, the Rosebud Sioux took a different route. Instead of just parting ways with the IHS, they sued the federal government for violating treaties. The case is pending in court.

WHO calls climate change 'the greatest health challenge of the 21st century,' and a dozen U.S. medical societies urge action to limit global warming.

This story was first published on Friday, July 19, 2019, and is part of a partnership that includes WBUR, NPR and Kaiser Health News.

By Martha Bebinger, WBUR

When Michael Howard arrived for a checkup with his lung specialist, he was worried about how his body would cope with the heat and humidity of a Boston summer.

"I lived in Florida for 14 years, and I moved back because the humidity was just too much," Howard told pulmonologist Dr. Mary Rice as he settled into an exam room chair at a Beth Israel Deaconess HealthCare clinic.

Howard, 57, has chronic obstructive pulmonary disease (COPD), a progressive lung disease that can be exacerbated by heat and humidity. Even inside a comfortable, climate-controlled room, his oxygen levels worried Rice.

Howard reluctantly agreed to try using portable oxygen, resigned to wearing the clear plastic tubes looped over his ears and inserted into his nostrils. He assured Rice he has an air conditioner and will stay inside on extremely hot days. The doctor and patient agreed that Howard should take his walks in the evenings to be sure he gets enough exercise without overheating.

Then Howard turned to Rice with a question she didn't encounter in medical school: "Can I ask you: Last summer, why was it so hot?"

Rice, who studies air pollution, was ready.

"The overall trend of the hotter summers that we're seeing [is] due to climate change," Rice said.

For Rice, connecting climate-change consequences — heat waves, more pollen, longer allergy seasons — to her patients' health is becoming routine. She is among a small but growing number of doctors and nurses who discuss those connections with patients.

In June, the American Medical Association, American Academy of Pediatrics and American Heart Association were among a long list of medical and public health groups that issued a call to action asking the U.S. government, business and leaders to recognize climate change as a health emergency.

The World Health Organization calls climate change "the greatest health challenge of the 21st century," and a dozen U.S. medical societies urge action to limit global warming.

Some medical societies provide patients with information that explains the related health risks. But none have guidelines on how providers should talk to patients about climate change.

There is no concrete list of "do's" — as in wear a seat belt, use sunscreen and get exercise — or "don'ts" — as in don't smoke, don't drink too much and don't text while driving ― that doctors can talk about with patients.

Climate change is different, said Rice, because an individual patient can't prevent it. So Rice focuses on steps her patients can take to cope with the consequences of heat waves, such as more potent pollen and a longer allergy season.

That was Mary Heafy's main complaint. The 64-year-old has asthma that is worse during the allergy season. During her appointment with Rice, Heafy wanted to know why her eyes and nose were running and her chest feels tight for longer periods every year.

"It feels like once [the allergy season] starts in the springtime, it doesn't end until there's a killing frost," Heafy told Rice.

"Yes," Rice nodded, "because of global warming, the plants are flowering earlier in the spring. After hot summers, the trees are releasing more pollen the following season."  

So Heafy may need stronger medicines and more air filters, her doctor said, and may spend more days wearing a mask — although the effort of breathing through a mask is hard on her lungs as well.

As she and the doctor finalized a prescription plan, Heafy observed that "physicians talk about things like smoking, but I don't know that every physician talks about the environmental impact."

Why do so few doctors talk about the impact of the environment on health? Besides a lack of guidelines, doctors say, they don't have time during a 15- to 20-minute visit to broach something as complicated as climate change.

And the topic can be controversial: While a recent Pew Research Center poll found that 59% of Americans think climate change affects their local community "a great deal or some," only 31% say it affects them personally, and views vary widely by political party.

We contacted energy-industry trade groups to ask what role — if any — medical providers should have in the climate change conversation, but neither the American Petroleum Institute nor the American Fuel & Petrochemical Manufacturers returned calls or email requests for comment.

Some doctors say they worry about challenging a patient's beliefs on the sometimes fraught topic, according to Dr. Nitin Damle, a past president of the American College of Physicians.

"It's a difficult conversation to have," said Damle, who practices internal medicine in Wakefield, R.I.

Damle said he "takes the temperature" of patients, with some general questions about the environment or the weather, before deciding if he'll suggest that climate change is affecting their health.

Dr. Gaurab Basu, a primary care physician at Cambridge Health Alliance, said he's ready if patients want to talk about climate change, but he doesn't bring it up. He first must make sure patients feel safe in the exam room, he said, and raising a controversial political issue might erode that feeling.

"I have to be honest about the science and the threat that is there, and it is quite alarming," Basu said.

So alarming, Basu said, that he often refers patients to counseling. Psychiatrists concerned about the effects of climate change on mental health say there are no standards of care in their profession yet, but some common responses are emerging.

One environmental group isn't waiting for doctors and nurses to figure out how to talk to patients about climate change.

Molly Rauch, the public health policy director with Moms Clean Air Force, a project of the Environmental Defense Fund, urges the group's more than 1 million members to ask doctors and nurses for guidance. For example: When should parents keep children indoors because the outdoor air is too dirty?

"This isn't too scary for us to hear about," Rauch said. "We are hungry for information about this. We want to know."

Martha Bebinger, WBUR: marthab@wbur.org, @mbebinger