Medicare Advantage Overbills Taxpayers By Billions A Year As Feds Struggle To Stop It

KFF Health News, July 16, 2019

Officials have known for years that some Medicare Advantage plans overcharge for treating serious medical conditions they cannot prove their patients have.

This article was first published on Tuesday, July 16, 2019 in Kaiser Health News.

By Fred Schulte and Lauren Weber

Health insurers that treat millions of seniors have overcharged Medicare by nearly $30 billion the past three years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.

Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have.

Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed, or backed off, efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat over 22 million seniors, more than 1 in 3 people on Medicare.

Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 — just a tenth of what it estimates the plans overcharge the government in a given year.

At the same time, the Department of Health and Human Services Inspector General's Office has launched a separate nationwide round of Medicare Advantage audits.

As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.

America's Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it "fatally flawed."

Insurer Cigna Corp. warned in a May financial filing: "If adopted in its current form, [the audits] could have a detrimental impact" on all Medicare Advantage plans and "affect the ability of plans to deliver high quality care."

But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, said officials must move past powerful lobbying efforts to hold health insurers accountable and demand refunds for "inappropriate" billings.

"There's a lot of things that could cause Medicare to go broke. This would be one of the contributing factors," she said. "Ten billion dollars a year is real money."

Catching Overbilling With A Wider Net

 

In the overpayment dispute, health plans want CMS to scale back — if not kill off — an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they've received.

For over a decade, audits have been little more than an irritant to insurers because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients they paid the companies to treat, CMS has simply required a rebate for those patients for just the year audited — relatively small sums for plans with thousands of members.

The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan's full membership — a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations — except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.

"The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers," CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.

Penalties In Limbo

 

In a written response to questions posed by Kaiser Health News, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 — and expects to collect $650 million in extrapolated penalties as a result.

Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million, far less than it cost to conduct them, federal records show.

Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.

This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.

This spring, CMS announced it would extend until the end of August the audit proposal's public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.

Healthcare industry consultant Jessica Smith said CMS might be taking additional time to make sure the audit protocol can pass muster. "Once they have their ducks in a row, CMS will come back hard at the health plans. There is so much money tied to this."

But Sean Creighton, a former senior CMS official who now advises the industry for healthcare consultant Avalere Health, said payment error rates have been dropping because many health plans "are trying as hard as they can to become compliant."

Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had treated for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.

Essence also faces a pending whistleblower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients' medical conditions. Essence has called the allegations "wholly without merit" and "baseless."

Essence started as a St. Louis physician group, then grew into a broader holding company backed by prominent Silicon Valley venture capitalist John Doerr with his brother, St. Louis doctor and software designer Thomas Doerr, in 2007. Neither would comment on the allegations.

How We Got Here

 

CMS uses a billing formula called a "risk score" to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.

Congress approved risk scoring in 2003 to ensure health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores — and their revenues.

In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an "honor system," the agency launched "Risk Adjustment Data Validation," or RADV, audits. The idea was to cut down on undeserved payments that cost CMS nearly $30 billion over the past three years.

The audits of 37 health plans revealed that on average auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.

Extra payments to plans that had claimed some of its diabetic patients had complications, such as eye or kidney problems, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.

But CMS kept the findings under wraps until the Center for Public Integrity, an investigative journalism group, sued the agency under the Freedom of Information Act to make them public.

Despite the alarming results, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS' authority to conduct them, and the threat of extrapolated repayments. Some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard, records released through the FOIA lawsuit show.

CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method — at least for now.

At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should CMS agree, it would write off more than half a billion dollars that could be recovered for the U.S. Treasury.

Fred Schulte: fschulte@kff.org, @fredschulte

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Even When HIV Prevention Drug Is Covered, Other Costs Block Treatment

KFF Health News, July 15, 2019

In addition to the ancillary charges, other roadblocks persist for people who need prescription pre-exposure prophylaxis.

This article was first published on Monday, July 15, 2019 in Kaiser Health News

By Michelle Andrews

Three years ago, Corey Walsh, who was in a relationship with a man who was HIV-positive, got a prescription for Truvada, a drug approved by the Food and Drug Administration to prevent infection with the virus that causes AIDS.

Walsh, then 23, was covered by his parents' health insurance policy, which picked up the cost of the drug. But the price tag for the quarterly lab tests and doctor visits he needed as part of the prevention regimen cost him roughly $400, more than he could afford.

"I went back to my physician and said, 'I can't take this anymore because all these ancillary services aren't covered,'" Walsh recalled. He ended up joining a clinical trial that covered all his costs.

Walsh's experience with high out-of-pocket costs, whether for medication or related services, is common, advocates say. Last month, the U.S. Preventive Services Task Force recommended that clinicians offer prescription pre-exposure prophylaxis, or PrEP, to people at high risk of contracting HIV. The decision by the independent group of experts means that starting in 2021 most health plans are required to cover drugs that are recommended to prevent HIV, and patients can't be charged anything out-of-pocket for the medication.

But the recommendation doesn't apply to the other clinical and lab services people need if they're on PrEP, according to task force officials.

In addition to the ancillary charges, other roadblocks persist for people who need PrEP from getting it.

"Eliminating cost sharing will undoubtedly expand access to individuals for whom affordability has been a significant barrier," said Amy Killelea, senior director of health systems integration at NASTAD, an organization representing public health officials nationwide. "However, scaling up access to PrEP to individuals who need it most — including young, gay, black and Latino men — will require addressing other major systemic and structural challenges, such as stigma and provider awareness and willingness to prescribe PrEP to their patients."

President Donald Trump has emphasized the need for more efforts to fight the HIV epidemic. In his State of the Union address in February, the president vowed to eliminate HIV transmission by 2030.

Currently, Truvada for PrEP, made by Gilead, is the only drug approved to prevent HIV. The once-a-day pill is at least 90% effective in some high-risk groups, including men who have sex with men as well as heterosexual men and women who have sex with HIV-positive partners, and 70% effective in people who inject illicit drugs.

Gilead estimated that 200,000 people now receive Truvada. The Centers for Disease Control and Prevention estimated that in 2015 there were 1.1 million people in the United States who could benefit from PrEP.

With a monthly price tag approaching $2,000, many private health plans have put the drug in a specialty drug tier with high copayments or coinsurance. Those payments will disappear when the task force recommendations take effect in 2021.

Truvada is generally covered in state Medicaid programs, as is the required clinical and lab work. But in the southern part of the country, where many states have not expanded Medicaid under the Affordable Care Act and HIV infection rates are high, there may be less access to the medication and other services.

Gilead offers a medication assistance program for uninsured people and a copay assistance program for those with private coverage that can fill gaps.

Gilead has submitted another HIV drug, Descovy, for FDA approval for PrEP, and a generic version of Truvada is expected next year.

It's unclear how these options might affect people's access to and ability to afford PrEP.

"Often it takes more than one generic for the price of a drug to drop," said Jennifer Kates, a senior vice president at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

The new preventive coverage requirement may lead to private insurers or Medicaid programs trying to limit access by imposing prior authorization requirements, some advocates worry. Insurers might, for example, require doctors to show that the patient is HIV-negative and meets the risk criteria before approving the prescription. That can have serious repercussions.

"Anytime there's a delay at the pharmacy or on the provider's end, patients will give up," said John Peller, president and CEO of the AIDS Foundation of Chicago.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

DOJ Lawyers Try New Tricks To Undo Obamacare. Will It Work?

KFF Health News, July 12, 2019

Legal experts say it's unusual for an administration to shift its own legal opinions during a case. The Trump DOJ has done it three times.

This story was first published on Friday, July 12, 2019 in Kaiser Health News.

By Julie Appleby

Once again, the fate of the Affordable Care Act is before the courts. The health law has traveled all the way to the Supreme Court (twice!) and is highly likely to make another visit.

On that path, the law made a stop Tuesday before a three-judge panel of the 5th Circuit Court of Appeals in New Orleans. Both sides presented arguments, interrupted, at times, by sharp questions from two of the judges.

For those just tuning in, the Trump administration is not defending the nine-year-old ACA.

It instead has sided with the 18 "red" states that seek to have the law overturned.

In doing so, Department of Justice lawyers appeared to use strategies and take positions that sounded somewhat unconventional to a layperson. But are they?

KHN checked with some legal experts for their take.

For starters, this is the third time the administration has changed its position. Does this often happen?

No. It's unusual for an administration to shift its own legal opinions during the case, say experts.

When the lawsuit was filed, the administration said only the parts of the law tied to a requirement that most Americans carry insurance, the so-called individual mandate, should be tossed. (That's a pretty big part, which includes protections for people with preexisting conditions.)

The red-state plaintiffs, conversely, argued that the entire law should go, pointing to Congress' 2017 vote to zero out the individual mandate's tax penalty. The Supreme Court's 2012 decision to preserve the ACA hinged on that penalty.

But, last December, a United States district court judge in Texas sided with the states, saying the whole law should be tossed, which would affect provisions as diverse as the preexisting condition protections, Medicaid expansion and calorie counts on restaurant menus.

That's when the Trump administration shifted its position to agree that, indeed, the whole thing had to go.

And that's rare.

"You don't usually say, 'Oh, never mind,'" said Tom Miller, resident fellow at the conservative American Enterprise Institute. "It's unusual to do that flip."

But that's not the last flip. Another change came up in legal papers filed shortly before the Tuesday hearing and in oral arguments.

DOJ attorney August Flentje told the appeals court that, well, maybe only those provisions of the law that directly affect the plaintiffs — the 18 states — should be struck.

"It's complicated," he admitted, calling to mind a similar statement made in 2017 by President Donald Trump amid the repeal debate in Congress: "Nobody knew that healthcare could be so complicated."

Even as this legal challenge works its way through the courts, the ACA remains the law of the land. The evolving legal positions, however, are fodder for professors.

"I'm teaching a class this fall and this gives me more material," said Miller. "But if I had to consistently try to argue a position at the DOJ, I would go crazy."

So, the government wants to skewer some provisions of the law, but not others — and have those changes apply only in some states. How would that work?  

Questions about that argument came from 5th Circuit Judge Jennifer Walker Elrod, appointed by President George W. Bush in 2007.

The government wants to have it apply "in certain states and strike it down in certain states?" Elrod asked. "The government believes that's a possibility?"

Unasked but implicit: How would some states enforce the law and not others?

Flentje said "a lot of that would have to get sorted out" but not until after all the appeals in the case are exhausted.

Behind the argument may well be an ongoing dispute in the legal community about whether lower-court judges should make decisions that have nationwide implications, said John Malcolm, director of the conservative Heritage Foundation's Edwin Meese III Center for Legal and Judicial Studies. Still, it would be difficult, he said, for the ACA to be declared unconstitutional in some states, but remain in effect elsewhere.

Beyond that legal question, such a position has financial and policy implications for consumers and state regulators.

"It would create a very untenable situation for the rest of the states," said Mila Kofman, executive director of the DC Health Benefit Exchange Authority, where individuals and small businesses buy health insurance.

Some of the very sickest people in the states where the rules were dropped would likely move to states keeping the preexisting condition protections so they could maintain their insurance, she said. That could drive up costs in those areas.

Arguments Tuesday revolved around whether parts of the law were "severable" from other parts. Did it seem the government wants it both ways — to toss the entire law, but also keep parts of it?

Elrod again queried Flentje.

The government wants the health insurance provisions to go, but "you would leave in the calorie guide?" Elrod asked, referring to the ACA's requirement that chain restaurants display calorie counts of menu items.

Flentje said the government's "argument on scope is totally separate from argument on severability."

She pressed him for clarification: "So, are you saying it's entirely inseverable, or arguing that some parts can be kept?"

The government's position remains that "the entire act is not severable," he replied, adding, however that the judgment could be "narrowed a bit to provisions that injure and impact the plaintiffs."

He suggested some of those details would still have to be worked out.

"They've gone from saying a couple of provisions have to go to the whole thing has to go, to now there are some things we might not have to get rid of," said Miller. "But they've never defined how far back down the ladder to go."

A ruling by the appeals court isn't expected for weeks or months, and some questions may well return to the district court.

Julie Appleby: jappleby@kff.org, @Julie_Appleby

How To Get A Cheaper Prescription Before Leaving The Doctor's Office

KFF Health News, July 10, 2019

A growing number of health systems and insurers providing real-time drug pricing information to physicians so they can help patients avoid 'sticker shock' at the pharmacy.

This article was first published on Wednesday, July 10, 2019 in Kaiser Health News.

By Phil Galewitz

When Mary Kay Gilbert saw her doctor in May for a skin infection on her leg, she wasn't surprised to receive a prescription for an antibiotic cream.

But Gilbert, 54, a nurse and health consultant, was shocked when her physician clicked on the desktop computer and told Gilbert the medicine would cost $30 on her Blue Cross and Blue Shield plan.

"I was like, 'Wow — that's pretty cool that you know that information,'" she recalled telling the doctor in Edina, Minn.

Allina Health, a large Minnesota hospital network to which Gilbert's doctor belongs, is one of a growing number of health systems and insurers providing real-time drug pricing information to physicians so they can help patients avoid "sticker shock" at the pharmacy.

The pricing tool, which is embedded in physicians' electronic health record and prescribing system, shows how much patients will pay out-of-pocket based on their insurance and the pharmacy. It allows the doctor to find a cheaper alternative when possible and start the process of getting authorization for a drug, if the insurer requires that.

The soaring cost of drugs has been front and center in the growing national debate about revamping U.S. healthcare.

Consumers abandon hundreds of thousands of prescriptions each year at the pharmacy, often because of high prices, jeopardizing their health and often leading to higher costs down the road, studies show.

Experts say the tool can help consumers — who are facing increasing copayments and higher deductibles — learn about cheaper options in the doctor's office.

Still, doctors have been slow to adopt the technology, sometimes because of concerns about getting bogged down in long discussions about drug costs. Humana, for example, introduced its drug pricing tool to its network doctors in 2015. Today, fewer than 10% are using it, company officials said.

But the tool has serious limitations too. Because price negotiations among insurers, drugmakers and middlemen are often highly competitive and secretive, the tools often don't have data for everyone. For example, Allina's works for only about half its patients. That's because not all pharmacy benefit managers share their data on health plan enrollee costs, and those that do often provide only a fraction of their information.

"It's a chicken-and-egg thing where doctors don't use it because they don't have the data for all their patients, and health plans don't promote it to physicians because doctors don't have the technology in place," said Anthony Schueth, a health information technology consultant in Jacksonville, Fla. "It can be a powerful tool when it works, but at the moment the drivers are not there across the board for widespread adoption."

At a hearing last month, Sen. Martha McSally (R-Ariz.) pressed a top Trump administration health official about why many patients lack access to information on prescription drug prices at their doctor's office.

"This is America. Why can't we have this tool available tool now?" she asked. "The data is out there; the information is out there. What is it going to take to make this happen?"

The technology got a boost last month when the Centers for Medicare & Medicaid Services mandated that all Medicare drug plans embed such a tool in their doctors' electronic prescribing system starting in 2021.

The details of what consumers spend out-of-pocket for drugs is provided by pharmacy benefit managers, or PBMs. They are the middlemen that negotiate with drugmakers on the prices insurers will pay for the medications and which ones the insurers will cover. So a tool's usefulness is undermined when key PBMs are not included in the listings.

For example, a drug pricing tool sold by Arlington, Va.-based Surescripts, which is owned partly by the PBMs CVS Caremark and Express Scripts, includes data from those companies, but not OptumRx, a PBM owned by insurance titan UnitedHealth. And the OptumRX drug pricing tool includes Optum data but not that of Express Scripts and CVS.

Demetrios Kouzoukas, who heads the Medicare program for CMS, said he hopes the program's new drug mandate will spark the industry to provide doctors and patients access to a pricing tool, regardless of their insurance.

"What we are hoping and expecting is that there will be a standard that's developed by the industry … so that the tool is available in all the electronic health records, for all the doctors and all patients, and spreads even beyond Medicare," he told McSally at the hearing.

Given the competitive nature of the industry, cooperation does not seem to be on the horizon, some industry officials say.

"I don't see any chance that there will be a centralized system that will connect all of the plans/PBMs with all of the EHR systems currently in use anytime soon," said Thomas Borzilleri, CEO of InteliSys Health, a health technology company based in San Diego.

However, the National Council for Prescription Drug Programs, a nonprofit group that helps set guidelines for the pharmacy industry, has been working on standards for a drug pricing tool. John Klimek, a senior vice president, predicts that by next year doctors across the country will be able to use the same drug pricing tool to look up all their patients' drug costs, regardless of the insurer.

Even without such a standard in place, doctors and hospitals have an incentive to use the tool beyond offering a cost-saving service to their patients: It can save providers money, too.

For example, Allina, which owns or operates about a dozen hospitals and dozens of clinics in Minnesota and Wisconsin, gets a set fee from some insurers to care for all of a patient's health needs. So the doctors and health system benefit when they can reduce costs and improve patients' adherence to taking their medication, said Dr. David Ingham, a family doctor also from Edina, one of 600 primary care doctors at Allina using the tool.

"When we prescribe a more expensive medication, we share less revenue from the insurance contract," he said.

For example, he noted that the tool helped him prescribe inhalers to asthma patients.

"I pulled up one medication I normally use, and it said it would be $240 out-of-pocket, but it suggested an alternative for $20 that was pharmacologically equivalent. I sheepishly asked the patient which we should choose," he said.

Dr. Norman Rosen, a family physician in Orange, Calif., who is employed by Providence St. Joseph Health System, is one of 800 doctors at the hospital testing the Blue Shield of California drug pricing tool this year. Based on the first few months of use, the tool is expected to save patients a total of more than $100,000 in out-of-pocket costs this year, according to the companies.

Without the tool, Rosen said, it would be impossible for him to quickly know what drugs are covered by which insurers and what the copays are. He said he already has saved some patients several thousand dollars a year by changing their blood pressure and diabetes medications.

"It doesn't take a lot of time, and this can be an important intervention because one of the fears we have is a patient not taking their medication because it's too expensive," Rosen said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Medi-Cal Enrollment Among Immigrant Kids Stalls, Then Falls. Is Fear To Blame?

KFF Health News, July 9, 2019

This drop mirrors statewide and national trends for all children enrolled in Medicaid and the Children's Health Insurance Program.

This article was first published on Tuesday, July 9, 2019 in Kaiser Health News.

By Ana B. Ibarra

As California prepares to expand Medicaid coverage to young adults living in the state illegally, the number of undocumented immigrant children in the program is slowly declining, new state data show.

Unauthorized immigrant children have been eligible for Medi-Cal, the state's Medicaid program for low-income residents, since May 2016, and their enrollment peaked nearly a year later at 134,374, according to data from the state Department of Healthcare Services.

Since then, enrollment has stayed mostly flat or fallen. Last February, the latest month for which data are available, 127,845 undocumented immigrant children through age 18 were enrolled in Medi-Cal, down about 5% from the April 2017 peak.

This drop mirrors statewide and national trends for all children enrolled in Medicaid and the Children's Health Insurance Program, a separate public program that some states use to cover low-income children.

From December 2017 to December 2018, overall child enrollment in both programs dropped 2.2% nationally and 3% in California, according to a recent report from Georgetown University's Health Policy Institute.

Some experts attribute the enrollment drop among all children to a strong economy because more people have jobs — and access to employer-sponsored health insurance. But Medicaid researchers say there are likely other factors at play for immigrant children.

The decline in their enrollment is more likely due to a shift in migration patterns and rising fear among their families in response to anti-immigrant rhetoric and federal crackdowns on unauthorized immigrants, said Edwin Park, a health policy research professor at Georgetown University.

"It's likely the overall hostile environment for immigrant families is playing a critical role in enrollment," Park said. "You should have seen a continued ramp-up" in sign-ups because the program is still relatively new. California along with Illinois, Massachusetts, New York, Oregon and Washington, plus the District of Columbia, provide public health coverage for undocumented immigrant children.

Last year, California allocated $365.2 million to cover these children. Even though Medicaid is a joint state-federal program, California must pay for the expanded benefits for unauthorized immigrants itself.

Starting next year, as part of the 2019-20 state budget signed last month by Gov. Gavin Newsom, the state will expand Medi-Cal coverage to young adult unauthorized immigrants ages 19 through 25. Officials estimate 90,000 young adults will join in the first year.

President Donald Trump criticized California's move and threatened to "stop it."

"The Democrats want to treat the illegals with healthcare and with other things, better than they treat the citizens of our country," Trump said on July 1.

The state Department of Healthcare Services, which administers Medi-Cal, said undocumented immigrant children might be leaving the program because they age out of eligibility when they turn 19 or move out of state.

Randy Capps, director of research at the Washington, D.C.-based Migration Policy Institute, said a shift in immigration patterns into and out of California could also affect their enrollment.

The number of people coming into the country illegally is down, especially from Mexico, according to a Pew Research Center report released in June. That is notable in California, where Mexican nationals make up the majority of the state's undocumented immigrant population.

The report estimates there were 4.9 million unauthorized immigrants from Mexico in the U.S. in 2017, down from 6.9 million in 2007.

"All data suggest a downward trend on illegal immigration, especially of Mexican origin," Capps said.

In California, "with the recent economic boom, that may be accelerating because the cost of living is escalating astronomically," he said. "Housing is becoming prohibitively expensive for undocumented immigrants in large parts of the state."

Although there have been an increasing number of Central American migrants trying to enter the U.S. at the southern border this year, most are claiming asylum and are not considered undocumented immigrants.

As a result, most of those children wouldn't qualify for Medi-Cal under this program, explained Gabrielle Lessard, a staff attorney with the National Immigration Law Center.

But the rhetoric surrounding the Central American refugees has been heated, and Trump has made tough talk on immigration a centerpiece of his presidency.

Last month, Trump warned of "massive" deportation raids that would have targeted about 2,000 families — but they were postponed after he gave members of Congress time to make changes to asylum laws. He said the raids might begin this week.

His administration also has pursued policies targeting immigrants. For instance, last fall, the federal government introduced its "public charge" proposal, which would consider immigrants' use of public benefit programs including Medi-Cal, CalFresh and Section 8 housing vouchers as a reason to deny lawful permanent residency — or green card status.

That proposed rule has not taken effect, and it's not clear whether it will. If implemented, the policy would mostly affect legal immigrants, but it could also affect undocumented immigrants should they become eligible to seek legal status in the future.

In response, unauthorized immigrant families have been forgoing care, missing doctors' appointments and asking whether they should disenroll from Medicaid coverage, health centers across California and the country have reported.

Lessard suspects that unauthorized immigrants could be pulling their children out of Medi-Cal or simply not renewing their coverage.

"This community has been so terrorized by the administration that people are afraid to show up to their appointments at health centers," she said. "So the prospect of giving your information to the government, even though it's the state government, is really terrifying to a lot of people."

This KHN story first published on California Healthline, a service of the California Healthcare Foundation.

Ana B. Ibarra: aibarra@kff.org, @ab_ibarra

Federal Appeals Court Takes Up Case That Could Upend U.S. Health System

KFF Health News, July 9, 2019

The stakes couldn't be higher as oral arguments are set to be heard this afternoon in New Orleans.

This story was first published on Tuesday, July 9, 2019 in Kaiser Health News.

By Julie Rovner

The fate of the Affordable Care Act is again on the line Tuesday, as a federal appeals court in New Orleans takes up a case in which a lower court judge has already ruled the massive health law unconstitutional.

If the lower court ruling is ultimately upheld, the case, Texas v. United States, has the potential to shake the nation's entire healthcare system to its core.

Not only would such a decision immediately affect the estimated 20 million people who get their health coverage through programs created under the law, ending the ACA would also create chaos in other parts of the healthcare system that were directly or indirectly changed under the law's multitude of provisions, such as calorie counts on menus, a pathway for approval of generic copies of expensive biologic drugs and, perhaps most important politically, protections for people with preexisting conditions.

"Billions of dollars of private and public investment — impacting every corner of the American health system — have been made based on the existence of the ACA," said a friend-of-the-court brief filed by a bipartisan group of economists and other health policy experts to the 5th Circuit Court of Appeals. Upholding the lower court's ruling, the scholars added, "would upend all of those settled expectations and throw healthcare markets, and 1/5 of the economy, into chaos."

Here are five important things to know about the case:

It was prompted by the tax bill Republicans passed in 2017.

The big tax cut bill passed by the GOP Congress in December 2017 eliminated the penalty included in the ACA for failure to maintain health insurance coverage. The lawsuit was filed in February 2018 by a group of Republican attorneys general and two governors. They argued that since the Supreme Court had upheld the ACA in 2012 specifically because it was a valid exercise of Congress' taxing power, taking the tax away makes the entire rest of the law unconstitutional.

Last December, Judge Reed C. O'Connor agreed with the Republicans. "In some ways the question before the court involves the intent of both the 2010 and 2017 Congresses," O'Connor wrote in his decision. "The former enacted the ACA. The latter sawed off the last leg it stood on."

State and federal Democrats are defending the law.

Arguing that the rest of the law remains valid is a group of Democratic attorneys general, led by California's Xavier Becerra.

"Our argument is simple," said Becerra in a statement last Friday. "The health and wellbeing of nearly every American is at risk. Healthcare can mean the difference between life and death, financial stability and bankruptcy. Our families' wellbeing should not be treated as a political football."

The Democratic-led House of Representatives has also been granted "intervenor" status in the case.

The Trump administration has taken several positions on the lawsuit.

The defendant in the case is technically the Trump administration. Traditionally, an administration, even one that did not work to pass the law in question, defends existing law in court.

Not this time. And it is still unclear exactly what the administration's position is on the lawsuit. "They have changed their position several times," Sen. Chris Murphy (D-Conn.) told reporters on a conference call Monday.

When the administration first weighed in on the case, in June 2018, it said it believed that without the tax penalty only the provisions most closely connected to that penalty — including requiring insurers to sell policies to people with preexisting conditions — should be struck down. The rest of the law should stay, the Justice Department argued.

After O'Connor's ruling, however, the administration changed its mind. In March, a spokeswoman for the Justice Department said it had "determined that the district court's comprehensive opinion came to the correct conclusion and will support it on appeal."

Now it appears the administration is shifting its opinion again. In a filing with the court late last week, Justice Department attorneys argued that perhaps the health law should be invalidated only in the GOP states that are suing, rather than all states. It is unclear how that would work.

Legal scholars — including those who oppose the ACA — consider the case dubious.

In a brief filed with the appeals court, legal scholars from both sides of the fight over the ACA agreed that the lawsuit's underlying claim makes no sense.

In passing the tax bill that eliminated the ACA's tax penalty but nothing else, Congress "made the judgment that it wanted the insurance reforms and the rest of the ACA to remain even in the absence of an enforceable insurance mandate," wrote law professors Jonathan Adler, Nicholas Bagley, Abbe Gluck and Ilya Somin. Bagley and Gluck are supporters of the ACA; Adler and Somin have argued against it in earlier suits. "Congress itself — not a court — eliminated enforcement of the provision in question and left the rest of the statute standing. So congressional intent is clear."

It could end up in front of the Supreme Court right in the middle of the 2020 election.

Depending on what happens at the appeals court level, the health law could be back in front of the Supreme Court — which has upheld the health law on other grounds in 2012 and 2015 — and land there in the middle of next year's presidential campaign.

Democrats are already sharpening their rhetoric for that possibility.

"President Trump and Republicans are playing a very dangerous game with people's lives," Senate Minority Leader Chuck Schumer told reporters on a conference call Monday.

Murphy said he is most concerned that if the lower court ruling is upheld and the health law struck down, Republicans "won't be able to come up with a plan" to put the healthcare system back together.

"Republicans tried to come up with a replacement plan for 10 years, and they couldn't do it," he said.

Julie Rovner: jrovner@kff.org, @jrovner

American Medical Students Less Likely To Choose To Become Primary Care Doctors

KFF Health News, July 3, 2019

This year, the percentage of primary care positions filled by fourth-year medical students was the lowest on record.

This article was first published on Wednesday, July 3, 2019 in Kaiser Health News.

By Victoria Knight

Despite hospital systems and health officials calling out the need for more primary care doctors, graduates of U.S. medical schools are becoming less likely to choose to specialize in one of those fields.

A record-high number of primary care positions was offered in the 2019 National Resident Matching Program — known to doctors as "the Match." It determines where a medical student will study in their chosen specialty after graduation. But this year, the percentage of primary care positions filled by fourth-year medical students was the lowest on record.

"I think part of it has to do with income," said Mona Signer, the CEO of the Match. "Primary care specialties are not the highest paying." She suggested that where a student gets a degree also influences the choice. "Many medical schools are part of academic medical centers where research and specialization is a priority," she said.

The three key primary care fields are internal medicine, family medicine and pediatrics. According to the 2019 Match report, 8,116 internal medicine positions were offered, the highest number on record and the most positions offered within any specialty, but only 41.5% were filled by seniors pursuing their M.D.s from U.S. medical schools. Similar trends were seen this year in family medicine and pediatrics.

In their final year of medical school, students apply and interview for residency programs in their chosen specialty. The Match, a nonprofit group, then assigns them a residency program based on how the applicant and the program ranked each other.

Since 2011, the percentage of U.S.-trained allopathic, or M.D., physicians who have matched into primary care positions has been on the decline, according to an analysis of historical Match data by Kaiser Health News.

But, over the same period, the percentage of U.S.-trained osteopathic and foreign-trained physicians matching into primary care roles has increased. 2019 marks the first year in which the percentage of osteopathic and foreign-trained doctors surpassed the percentage of U.S. trained medical doctors matching into primary care positions.

Medical colleges granting M.D. degrees graduate nearly three-quarters of U.S. students moving on to become doctors. The rest graduate from osteopathic schools, granting D.O. degrees. The five medical schools with the highest percentage of graduates who chose primary care are all osteopathic institutions, according to the latest U.S. News & World Report survey.

Beyond the standard medical curriculum, osteopathic students receive training in manipulative medicine, a hands-on technique focused on muscles and joints that can be used to diagnose and treat conditions. They are licensed by states and work side by side with M.D.s in physician practices and health systems.

Although the osteopathic graduates have been able to join the main residency match or go through a separate osteopathic match through this year, in 2020 the two matches will be combined.

Physicians who are trained at foreign medical schools, including both U.S. and non-U.S. citizens, also take unfilled primary care residency positions. In the 2019 match, 68.9% of foreign-trained physicians went into internal medicine, family medicine and pediatrics.

But, despite osteopathic graduates and foreign-trained medical doctors taking up these primary care spots, a looming primary care physician shortage is still expected.

The Association of American Medical Colleges predicts a shortage of between 21,100 and 55,200 primary care physicians by 2032. More doctors will be needed in the coming years to care for aging baby boomers, many of whom have multiple chronic conditions. The obesity rate is also increasing, which portends more people with chronic health problems.

Studies have shown that states with a higher ratio of primary care physicians have better health and lower rates of mortality. Patients who regularly see a primary care physician also have lower health costs than those without one.

But choosing a specialty other than primary care often means a higher paycheck.

According to a recently published survey of physicians conducted by Medscape, internal medicine doctors' salaries average $243,000 annually. That's a little over half of what the highest earners, orthopedic physicians, make with an average annual salary of $482,000. Family medicine and pediatrics earn even less than internal medicine, at $231,000 and $225,000 per year, respectively.

Dr. Eric Hsieh, the internal medicine residency program director at the University of Southern California's Keck School of Medicine, said another deterrent is the amount of time primary care doctors spend filling out patients' electronic medical records.

"I don't think people realize how involved electronic medical records are," said Hsieh. "You have to synthesize everything and coordinate all of the care. And something that I see with the residents in our program is that the time spent on electronic medical records rather than caring for patients frustrates them."

The Medscape survey confirms this. Internists appear to be more burdened with paperwork than other specialties, and 80% of internists report spending 10 or more hours a week on administrative tasks.

The result: Only 62% of internal medicine doctors said they would choose to go into their specialty again — the lowest percentage on record for all physician specialties surveyed.

Elsa Pearson, a health policy analyst at Boston University, said one way to keep and attract primary care doctors might be to shift some tasks to health care providers who aren't doctors, such as nurse practitioners or physician assistants.

"The primary care that they provide compared to a physician is just as effective," said Pearson. They wouldn't replace physicians but could help lift the burden and free up doctors for more complicated care issues.

Pearson said more medical scribes, individuals who take notes for doctors while they are seeing patients, could also help to ease the doctors' burden of electronic health record documentation.

Another solution is spreading the word about the loan forgiveness programs available to those who choose to pursue primary care, usually in an underserved area of the country, said Dr. Tyree Winters, the associate director of the pediatric residency program at Goryeb Children's Hospital in New Jersey.

"The trend has been more so thinking about the amount of debt that a student has, compared to potential income in primary care," said Winters. "But that's not considering things like medical debt forgiveness through state or federal programs, which really can help individuals who want to choose primary care."

KHN data correspondent Sydney Lupkin contributed to this report.

Victoria Knight: vknight@kff.org, @victoriaregisk

California Broadens Investigation Of Doctors For Issuing Questionable Vaccination Exemptions

KFF Health News, July 2, 2019

The Medical Board of California's investigations are unfolding amid the nation's worst measles outbreak in more than a quarter-century.

This article was first published on Tuesday, July 2, 2019 in Kaiser Health News.

By Barbara Feder Ostrov

The California agency that regulates doctors is investigating at least four physicians for issuing questionable medical exemptions to children whose parents did not  want them immunized.

The Medical Board of California's investigations are unfolding amid the nation's worst measles outbreak in more than a quarter-century, as California lawmakers consider controversial legislation to tighten the requirements for exempting children from the vaccinations required to attend schools and day care centers.

Last month, the Department of Consumer Affairs, which oversees the medical board, sued in state court to obtain medical records for patients of Sacramento-area pediatricians Dr. Kelly Sutton and Dr. Michael Fielding Allen.

In the past nine months, the board also has sought patients' records in connection with two Santa Rosa physicians under investigation for writing allegedly inappropriate exemptions.

The state acted on the Sutton and Allen cases following complaints to the medical board from Dr. Wendy Cerny, assistant chief of pediatrics at a Kaiser Permanente clinic in Roseville, court documents show. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanante.) Cerny contacted the board about Sutton in February 2017 and followed up with an email about Allen 15 months later, according to the documents.

Cerny became concerned after seeing permanent medical exemptions for Kaiser Permanente pediatric patients written by Sutton and Allen that cited reasons including "a personal history of genetic defect," food and environmental allergies, "neurological vulnerability" and a family history of mental health disorders, according to the legal documents.

The doctors under investigation are not Kaiser Permanente doctors, but parents went to them for vaccination exemptions. In one case, Sutton issued a "lifelong medical exemption from all vaccines" to a boy before his family joined Kaiser Permanente, according to Cerny's complaint. When one of Cerny's colleagues refused to write similar exemptions for the boy's two younger siblings, the mother said she would go back to Sutton to get them, the complaint says.

"We feel this doctor and perhaps her colleagues … are making easy money on these exemptions that are not based on true medical need and are actually putting children and other people in the community at risk for contracting and spreading serious infectious diseases," Cerny wrote in her complaint about Sutton.

A physician appointed by the medical board to review exemptions issued by Sutton and Allen described them as "either of questionable validity or patently without medical basis."

Vaccine exemptions for medical reasons should be rare, according to the Centers for Disease Control and Prevention. They are typically reserved for children with severely compromised immune systems, like those being treated for cancer or those who are allergic to a vaccine component or have previously had a severe reaction to a vaccine.

A spokesman for the medical board declined to comment on the cases. The agency generally does not acknowledge investigations publicly unless a formal accusation is filed against a physician.

But the board's legal efforts to obtain patient records sheds rare light on how the agency handles such complaints.

It "tells me that there are doctors who are giving problematic exemptions and the Medical Board of California is taking this issue very seriously," said Dorit Reiss, a professor at University of California-Hastings College of the Law in San Francisco who researches vaccine law.

Sutton and Allen did not respond to phone calls and emails seeking comment.

Sutton, based in Fair Oaks, is known as a go-to doctor for medical vaccine exemptions. She offers a $97 "program" that purports to "help protect your child from the 'One Size Fits All' California vaccine mandate."

Cerny submitted copies of exemption letters by Sutton and Allen in the complaints she filed with the medical board, but the names of the patients were blacked out. The board wants the names of those children and their parents, and it asked the court to compel the Permanente Medical Group, a subsidiary of Kaiser Permanente, to hand over unredacted versions of the letters.

The board also wants Kaiser Permanente to hand over the patients' medical charts, which it believes will help determine whether the exemptions written by Sutton and Allen were indeed unmerited.

In June, Superior Court Judge Ethan Schulman ordered the Permanente Medical Group to disclose the names of the patients known to have received medical exemptions from Allen, as well as the names and addresses of their parents. He has not yet issued a ruling in the Sutton case.

Kaiser Permanente said it would comply with court orders.

"We take the health and safety of our members, patients and communities very seriously," said Dr. Stephen Parodi, associate executive director of the Permanente Medical Group, via email.

In a case similar to Sutton's and Allen's, a judge ordered the Permanente Medical Group in November to provide the names of patients and parents subpoenaed in a medical board investigation of Dr. Kenneth Stoller, a Santa Rosa physician who gave vaccine exemptions to children who were Kaiser Permanente patients, as well as to others in the Mammoth Unified School District.

Stoller, who is not affiliated with Kaiser Permanente, is also being investigated by the city attorney of San Francisco, where he used to practice. He didn't respond to a request for comment.

In April, Judge Schulman granted a petition from the state ordering Dr. Ron Kennedy to hand over the medical records of children to whom he had issued vaccination exemptions. Kennedy, a psychiatrist who runs an anti-aging clinic in Santa Rosa, has written numerous exemptions for kids, according to court records.

Kennedy's lawyer, Michael Machat, said his client has handed over the records as ordered.

"The medical board has adopted the practice of thinking it can invade people's privacy and search children's private medical records to see whether or not the doctors are following the law," Machat said. "Where does this stop?"

To date, the only doctor sanctioned for inappropriate medical vaccine exemptions is Southern California pediatrician Robert Sears, the well-known author of "The Vaccine Book."

In 2015, California banned all philosophical and religious exemptions for immunizations in the wake of a large measles outbreak that originated at Disneyland. It is one of four states to have done so, and its vaccination rate rose sharply for three years after the law was tightened. But vaccination rates have declined in the past two years, in part because many parents opposed to vaccines have found doctors willing to write questionable medical exemptions — sometimes for a fee.

California's vaccination policies are once again drawing national attention in the wake of the nation's recent measles outbreak, which totaled 1,095 cases as of June 27. In California, 55 cases were reported as of June 26.

A bill pending in the California legislature, SB-276, would impose more oversight on vaccine exemptions written by doctors. After it passed the state Senate in May, it was softened to appease Gov. Gavin Newsom but would still allow the state Department of Public Health to review some exemptions. It also would prevent doctors who are under investigation for writing unwarranted exemptions from issuing new ones.

Newsom has said he will sign the legislation if it lands on his desk.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Barbara Feder Ostrov: barbarao@kff.org, @barbfederostrov

 

AMA Abortion Lawsuit Puts Doctors In The Thick Of Debate

KFF Health News, July 1, 2019

AMA President Patrice Harris said the organization had to take a stand because new laws forced the small number of doctors who perform abortions to lie to patients.

This article was first published on Monday, July 1, 2019 in Kaiser Health News.

By Julie Rovner

The American Medical Association is suing North Dakota to block two abortion-related laws, the latest signal the doctors' group is shifting to a more aggressive stance as the Trump administration and state conservatives ratchet up efforts to eliminate legal abortion.

The group, which represents all types of physicians, has tended to stay on the sidelines of many controversial political issues, and until recently has done so concerning abortion and contraception. Instead, it has focused on legislation that affects the practice and finances of large swaths of its membership.

But, said AMA President Patrice Harris in an interview, the organization felt it had to take a stand because new laws forced the small number of doctors who perform abortions to lie to patients, putting "physicians in a place where we are required by law to commit an ethical violation."

One of the laws, set to take effect Aug. 1, requires physicians to tell patients that medication abortions — a procedure involving two drugs taken at different times — can be reversed. The AMA said that is "a patently false and unproven claim unsupported by scientific evidence." North Dakota is one of several states to pass such a measure.

The AMA, along with the last remaining abortion clinic in the state, is also challenging an existing North Dakota law that requires doctors to tell pregnant women that an abortion terminates "the life of a whole, separate, unique, living human being." The AMA said that law "unconstitutionally forces physicians to act as the mouthpiece of the state."

It's the second time this year the AMA has taken legal action on an abortion-related issue. In March, the group filed a lawsuit in Oregon in response to the Trump administration's new rules for the federal family planning program. Those rules would, among other things, ban doctors and other health professionals from referring pregnant patients for abortions.

"The Administration is putting physicians in an untenable situation, prohibiting us from having open, frank conversations with our patients about all their healthcare options — a violation of patients' rights under the [AMA] Code of Medical Ethics," wrote then-AMA President Barbara McAneny.

It's an unusually assertive stance for a group that has taken multiple positions on abortion-related issues over the years.

Mary Ziegler, a law professor at Florida State University who has written several books about abortion, said that the AMA's history on abortion is complicated. In general, she said, the AMA "didn't want to get into the [abortion] issue because of the political fallout and because historically there have been doctors in the AMA on both sides of the issue."

In recent years, the AMA has taken mostly a back seat on abortion issues, even ones that directly addressed physician autonomy, leaving the policy lead to specialty groups like the American College of Obstetricians and Gynecologists, which has consistently defended doctors' rights to practice medicine as they see fit when it comes to abortion issues.

Ziegler said it is not entirely clear why the AMA has suddenly become more outspoken on women's reproductive issues. One reason could be that the organization's membership is skewing younger and less conservative. Also, this year, for the first time, the AMA's top elected officials are all women.

In its earliest days, the AMA led the fight to outlaw abortion in the late 1800s, as doctors wanted to assert their professionalism and clear the field of "untrained" practitioners like midwives.

Abortion was not an issue for the group in the first half of the 20th century. The AMA became best known for successful fights to fend off a national health insurance system.

Leading up to Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide, the AMA softened its opposition. In 1970, the AMA board called for abortion decisions to be between "a woman and her doctor." But the organization declined to submit a friend-of-the-court brief to the high court during its consideration of Roe.

In 1997, the AMA, in a surprise move, endorsed a GOP-backed measure to ban what opponents called "partial-birth abortions," a little-used procedure that anti-abortion forces likened to infanticide. A year later, however, an audit of the AMA's leadership found its trustees had "blundered" in endorsing the bill and had contradicted long-standing AMA policy.

One reason the organization may be moving on the issue now could be the shifting parameters of the abortion debate itself. In 1997, the abortion procedure ban that the AMA endorsed "polled well and allowed abortion opponents to paint the other side as extremist," Ziegler said.

Exactly the opposite is true today, she said, as states pass abortion bans more sweeping than those seen at any time since Roe v. Wade. Yet most public opinion polls show a majority of Americans want abortion to remain legal in many or most cases.

"As abortion opponents take more extreme positions, the AMA is probably a little more comfortable intervening" Ziegler added.

Molly Duane, a lawyer from the Center for Reproductive Rights who is arguing the case for the AMA and North Dakota's sole remaining abortion clinic, said the laws being challenged are "something all doctors should be alarmed by. … This is an unprecedented act of invading the physician-patient relationship and forcing words into the mouths of physicians."

Julie Rovner: jrovner@kff.org, @jrovner

Have Cancer, Must Travel: Patients Left In Lurch After Hospital Closes

KFF Health News, July 1, 2019

As the rural town of Fort Scott, Kan., grapples with the closure of its hospital, cancer patients face new challenges as they try to continue their treatments in different locations.

This article was first published on Monday, July 1, 2019 in Kaiser Health News.

By Sarah Jane Tribble July 1, 2019

FORT SCOTT, Kan. — One Monday in February, 65-year-old Karen Endicott-Coyan gripped the wheel of her black 2014 Ford Taurus with both hands as she made the hour-long drive from her farm near Fort Scott to Chanute. With a rare form of multiple myeloma, she requires weekly chemotherapy injections to keep the cancer at bay.

She made the trip in pain, having skipped her morphine for the day to be able to drive safely. Since she sometimes "gets the pukes" after treatment, she had her neighbor and friend Shirley Palmer, 76, come along to drive her back.

Continuity of care is crucial for cancer patients in the midst of treatment, which often requires frequent repeated outpatient visits. So when Mercy Hospital Fort Scott, the rural hospital in Endicott-Coyan's hometown, was slated to close its doors at the end of 2018, hospital officials had arranged for its cancer clinic — called the "Unit of Hope" — to remain open.

Then "I got the email on Jan. 15," said Reta Baker, the hospital's CEO. It informed her that Cancer Center of Kansas, the contractor that operated and staffed the unit, had decided to shut it down too, just two weeks later.

"There are too many changes in that town" to keep the cancer center open, Yoosaf "Abe" Abraham, chief operating officer of the Cancer Center of Kansas, later told KHN. He added that patients would be "OK" because they could get treated at the center's offices in Chanute and Parsons.

From Fort Scott, those facilities are 50 and 63 miles away, respectively.

For Endicott-Coyan and dozens of other cancer patients, the distance meant new challenges getting lifesaving treatment. "You have a flat tire, and there is nothing out here," Endicott-Coyan said, waving her arm toward the open sky and the pastures dotted with black Angus and white-faced Hereford cattle on either side of the shoulderless, narrow highway she now must drive to get to her chemo appointment.

Nationwide, more than 100 rural hospitals have closed since 2010. In each case, a unique but familiar loss occurs. Residents, of course, lose healthcare services as wards are shut and doctors and nurses begin to move away.

But the ripple effect can be equally devastating. The economic vitality of a community takes a blow without the hospital's high-paying jobs and it becomes more difficult for other industries to attract workers who want to live in a town with a hospital. Whatever remains is at risk of withering without the support of the stabilizing institution.

The 7,800 residents of Fort Scott are reeling from the loss of their 132-year-old community hospital that was closed at the end of December by Mercy, a St. Louis-based nonprofit health system. Founded on the frontier in the 19th century and rebuilt into a 69-bed modern facility in 2002, the hospital had outlived its use, with largely empty inpatient beds, the parent company said. For the next year, Kaiser Health News and NPR will track how its citizens fare after the closure in the hopes of answering pressing national questions: Do citizens in small communities like Fort Scott need a traditional hospital for their health needs? If not a hospital, what then?

Traveling The Distance For Cancer Care

 

Reta Baker, the hospital's president who grew up on a farm south of Fort Scott, understood that the hospital's closure was unavoidable. She scrambled to make sure basic healthcare needs would be met. Mercy agreed to keep the building open and lights on until 2021. And Baker recruited a federally qualified health center to take over four outpatient clinics, including one inside the hospital; former employees were bought out and continue to operate a rehabilitation center; and the nonprofit Ascension Via Christi Hospital in Pittsburg reopened the emergency department in February.

As Fort Scott deals with the trauma of losing a beloved institution, deeper national questions underlie the struggle: Do small, rural communities need a traditional hospital at all? And if not, how will they get the healthcare they need?

But cancer care in rural areas, which requires specialists and the purchase and storage of a range of oncology drugs, presents unique challenges.

Rural cancer patients typically spend 66% more time traveling each way to treatment than those who live in more urban areas, according to a recent national survey by ASCO, the American Society of Clinical Oncology. Dr. Monica Bertagnolli, a cattle rancher's daughter who is now chair of ASCO's board, called this a "tremendous burden." Cancer care, she explained, is "not just one visit and you're done."

ASCO used federal data to find that while about 19% of Americans live in rural areas, only 7% of oncologists practice there.

People in rural America are more likely to die from cancer than those in the country's metropolitan counties, according to a Centers for Disease Control and Prevention report in 2017. It found 180 cancer deaths per 100,000 people a year in rural counties, compared with 158 deaths per 100,000 in populous metropolitan counties.

The discrepancy is partly because habits like smoking are more common among rural residents, but the risk of dying goes beyond that, said Jane Henley, a CDC epidemiologist and lead author of the report. "We know geography can affect your risk factors, but we don't expect it to affect mortality."

From an office inside a former Mercy outpatient clinic, Fort Scott's cancer support group, Care to Share, continues its efforts to meet some of the community's needs — which in some ways have increased since the Unit of Hope closed. It provides Ensure nutritional supplements, gas vouchers and emotional support to cancer patients.

Lavetta Simmons, one of the support group's founders, said she will have to raise more money to help people pay for gas so they can drive farther to treatments. Last year, in this impoverished corner of southeastern Kansas, Care to Share spent more than $17,000 providing gas money to area residents who had to travel to the Mercy hospital or farther away for care.

The group expects to spend more on gas this year, having spent nearly $6,000 during the first four months of 2019.

And the reserves of donated Ensure from Mercy are running out, so Simmons is reaching out to hospitals in nearby counties for help.

With Mercy Hospital Fort Scott closed, the likelihood of residents here dying from their cancer will grow, experts worry, because it's that much harder to access specialists and treatments.

Krista Postai, who took over the Fort Scott hospital's four primary care clinics, said it's not unusual for her staff to "see someone walk in [with] end-stage cancer that they put off because they didn't have money, they didn't have insurance, or it's just the way you are. … We wait too long here."

'If They Can't Cure Me, I'm Done'

 

Art Terry, 71, a farmer and Vietnam veteran, was one of them. Doctors discovered Terry's cancer after he broke a rib while bailing hay. When they found a mass below his armpit, it was already late-stage breast cancer that had metastasized to his bones.

With his twice-weekly chemotherapy treatment available in the "Unit of Hope," Terry spent hours there with his son and grandchildren telling stories and jokes as if they were in their own living room. The nurses began to feel like family, and Terry brought them fresh eggs from his farm.

"Dad couldn't have better or more personalized care anywhere," said his son, Dwight, bleary-eyed after a factory shift.

Terry knew it was difficult to find trustworthy cancer care. The shortage of cancer specialists in southeastern Kansas meant that many, including Mercy Hospital Fort Scott's patients, counted on traveling oncologists to visit their communities once or twice a week.

Wichita-based Cancer Center of Kansas has nearly two dozen locations statewide. It began leasing space in Fort Scott's hospital basement in the mid-2000s, the center's Abraham said. The hospital provided the staff while the Cancer Center of Kansas paid rent and sent roving oncologists to drop in and treat patients.

When Art Terry was diagnosed, his son tried to talk to him about seeking treatment at the bigger hospitals and academic centers in Joplin, Mo., or the Kansas City area. The elder Terry wasn't interested. "He's like, 'Nope,'" Dwight Terry recalled. "I'm going right there to Fort Scott. If they can't cure me, I'm done. I'm not driving.'"

In the end, as the elder Terry struggled to stay alive, Dwight Terry said he would have driven his father the hour to Chanute for treatment. Gas — already a mounting expense as they traveled the 20 miles from the farm near tiny Prescott, Kan., to Fort Scott — would be even more costly. And the journey would be taxing for his father, who traveled so little over the course of his life that he had visited Kansas City only twice in the past 25 years.

As it turned out, the family never had to make a choice. Art Terry's cancer advanced to his brain and killed him days before the hospital's cancer unit closed.

What Happens Next?

 

As Endicott-Coyan and her friend Palmer drove to Chanute for treatment, they passed the time chatting about how the hospital's closure is changing Fort Scott. "People started putting their houses up for sale," Palmer said.

Like many in Fort Scott, they had both spent their days at the Fort Scott hospital. Endicott-Coyan worked in administration for more than 23 years; Palmer volunteered with the auxiliary for six years.

The hospital grew with the community. But as the town's fortunes fell, it's perhaps no surprise that the hospital couldn't survive. But the intertwined history of Mercy and Fort Scott is also why its loss hit so many residents so hard.

Fort Scott began in 1842 when the U.S. government built a military fort to help with the nation's westward expansion. Historians say Fort Scott was a boomtown in the years just after the Civil War, with its recorded population rising to more than 10,000 as the town competed with Kansas City to become the largest railroad center west of the Mississippi. The hospital was an integral part of the community after Sisters of Mercy nuns opened a 10-bed hospital in 1886 with a mission to serve the needy and poor. Baker, Mercy Hospital Fort Scott's president, said the cancer center was an extension of that mission.

The Unit of Hope began operating out of the newest hospital building's basement, which was "pretty cramped," Baker said. As cancer treatments improved, it grew so rapidly that Mercy executives moved it to a spacious first-floor location that had previously been the business offices.

"Our whole purpose when we designed it was for it to be a place where somebody who was coming to have something unpleasant done could actually feel pampered and be in a nice environment," Baker said.

The center, with its muted natural grays and browns, had windows overlooking the front parking lot and forested land beyond. Every patient could look out the windows or watch their personal television terminal, and each treatment chair had plenty of space for family members to pull up chairs.

When Endicott-Coyan and Palmer arrived at the Cancer Center of Kansas clinic in Chanute in February, things looked starkly different. Patients entered a small room through a rusted back door. Three brown infusion chairs sat on either side of the entry door and two television monitors were mounted high on the walls. A nurse checked Endicott-Coyan's blood pressure and ushered her back to a private room to get a shot in her stomach. She was ready to leave about 15 minutes later.

The center's Abraham said the Chanute facility is "good for patients for the time being" and not a "Taj Mahal" like Mercy's Fort Scott hospital building, which he said was too expensive to maintain. Cancer Center of Kansas plans to open a clinic at a hospital in Girard, which is about 30 miles from Fort Scott, he said.

Some oncology doctors would say driving is not necessary. Indeed, a few healthcare systems across the country, such as Sanford Health in South Dakota and Thomas Jefferson University Hospitals in Pennsylvania, are administering some chemotherapy in patients' homes. Oncologist Adam Binder, who practices at Thomas Jefferson in Philadelphia, said "over 50% of chemotherapy would be safe to administer in the home setting if the right infrastructure existed."

But the infrastructure — that is, the nurses who would travel to treat patients and a reimbursement model to pay for such care within our complex healthcare system — is not yet in place.

Back in the car, Palmer took the wheel and Endicott-Coyan began planning for future cancer treatments in the void left by Mercy Hospital Fort Scott's closure. "I put a note on Facebook today and said, 'OK, I have drivers for the rest of February; I need drivers for March!'"

This is the first installment in KHN's year-long series, No Mercy, which follows how the closure of one beloved rural hospital disrupts a community's healthcare, economy and equilibrium.

Sarah Jane Tribble: sjtribble@kff.org, @SJTribble

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