Hospitals Accused of Paying Doctors Large Kickbacks in Quest for Patients

KFF Health News, May 31, 2019

Hospitals are eager to get particular specialists on staff because they bring in business that can be highly profitable. But those efforts, if they involve unusually high salaries or other enticements, can violate federal anti-kickback laws.

This story was first published on Friday, May 31, in Kaiser Health News and in Daily Beast.

By Jordan Rau  

For a hospital that had once labored to break even, Wheeling Hospital displayed abnormally deep pockets when recruiting doctors.

To lure Dr. Adam Tune, an anesthesiologist from nearby Pittsburgh who specialized in pain management, the Catholic hospital built a clinic for him to run on its campus in Wheeling, W.Va. It paid Tune as much as $1.2 million a year — well above the salaries of 90% of pain management physicians across the nation, the federal government charged in a lawsuit filed this spring.

In addition, Wheeling paid an obstetrician-gynecologist a salary as high as $1.3 million a year, so much that her department bled money, according to a related lawsuit by a whistleblowing executive. The hospital paid a cardiothoracic surgeon $770,000 and let him take 12 weeks off each year even though his cardiac team also routinely ran in the red, that lawsuit said.

Despite the losses from these stratospheric salaries and perks, the recruitment efforts had a golden lining for Wheeling, the government asserts. Specialists in fields like labor and delivery, pain management and cardiology reliably referred patients for tests, procedures and other services Wheeling offered, earning the hospital millions of dollars, the lawsuit said.

The problem, according to the government, is that the efforts run counter to federal self-referral bans and anti-kickback laws that are designed to prevent financial considerations from warping physicians' clinical decisions. The Stark law prohibits a physician from referring patients for services in which the doctor has a financial interest. The federal anti-kickback statute bars hospitals from paying doctors for referrals. Together, these rules are intended to remove financial incentives that can lead doctors to order up extraneous tests and treatments that increase costs to Medicare and other insurers and expose patients to unnecessary risks.

Wheeling Hospital is contesting the lawsuits. It said in a countersuit against the whistleblower that its generous salaries were not kickbacks but the only way it could provide specialized care to local residents who otherwise would have to travel to other cities for services such as labor and delivery that are best provided near home.

The hospital and its specialists declined requests for interviews. In a statement, Gregg Warren, a hospital spokesman, wrote, "We are confident that, if this case goes to a trial, there will be no evidence of wrongdoing — only proof that Wheeling Hospital offers the Northern Panhandle Community access to superior care, world class physicians and services."

Elsewhere, whistleblowers and investigators have alleged that other hospitals, in their quests to fill beds and expand, disguise these arrangements by overpaying doctors or offering other financial incentives such as free office space. More brazenly, others set doctor salaries based on the business they generate, federal lawsuits have asserted.

"If we're going to solve the healthcare pricing problem, these kinds of practices are going to have to go away," said Dr. Vikas Saini, president of the Lown Institute, a Massachusetts nonprofit that advocates for affordable care.

'It's Almost A Game'

Hospitals live and die by physician referrals. Doctors generate business each time they order a hospital procedure or test, decide that a patient needs to be admitted overnight or send patients to see a specialist at the hospital. An internal medicine doctor generates $2.7 million in average revenues — 10 times his salary — for the hospital with which he is affiliated, while an average cardiovascular surgeon generates $3.7 million in hospital revenues, nearly nine times her salary, according to a survey released this year by Merritt Hawkins, a physician recruiting firm.

Last August, William Beaumont Hospital, part of Michigan's largest health system and located outside Detroit, paid $85 million to settle government allegations that it gave physicians free or discounted offices and subsidized the cost of assistants in exchange for patient referrals.

A month later in Montana, Kalispell Regional Healthcare System paid $24 million to resolve a lawsuit alleging that it overcompensated 63 specialists in exchange for referrals, paying some as full-time employees when they worked far less. Both nonprofit hospital systems did not admit wrongdoing in their settlements but signed corporate integrity agreements with the federal government requiring strict oversight.

"It's almost a game of 'We're going to stretch the limits and see if we get caught, and if we get caught we won't be prosecuted and we'll pay a settlement,'" said Tom Ealey, a professor of business administration at Alma College in Michigan who studies healthcare fraud.

Dubious payment arrangements are a byproduct of a major shift in the hospital industry. Hospitals have gone on buying sprees of physician practices and added doctors directly to their payrolls. As of January 2018, hospitals employed 44% of physicians and owned 31% of practices, according to a report the consulting group Avalere prepared for the Physician Advocacy Institute, a group led by state medical association executives. Many of those acquisitions occurred this decade: In July 2012, hospitals employed 26% of doctors and owned 14% of physician practices.

"If you acquire some key physician practices, it really shifts their referrals to the mother ship," said Martin Gaynor, a health policy professor at Carnegie Mellon University in Pittsburgh. Nonprofit hospitals are just as assertive as profit-oriented companies in seeking to expand their reach. "Any firm — it doesn't matter what the firm is — once they get dominant market power, they don't want to give it up," he said.

But these hires and acquisitions have increased opportunities for hospitals to collide with federal laws mandating that hospitals pay doctors fair market value for their services without regard to how much additional business they bring through referrals.

"The law is very broad, and the exceptions are very narrow," said Kate Stern, an Atlanta lawyer who represents hospitals.

'A Man We Need to Keep Happy'

Lavish salaries for physicians with high potentials for referrals was the key to the business plan to turn Wheeling Hospital, a 247-bed facility near the Ohio River, into a profit machine, according to a lawsuit brought by Louis Longo, a former executive vice president at the hospital, and a companion suit from the U.S. Department of Justice.

Between 1998 and 2005, Wheeling Hospital lost $55 million, prompting the local Catholic diocese to hire a private management company from Pittsburgh, according to the suits. In 2007, the company's managing director, Ronald Violi, a former children's hospital executive, took over as Wheeling's chief executive officer.

The hospital remained church-owned, but Violi adopted an aggressively market-oriented approach. He began hiring physicians — both as employees and independent contractors — "to capture for the hospital those physicians' referrals and the resulting revenues, thereby increasing Wheeling Hospital's market share," the government alleged. Along with greater market share came the ability to bargain for higher payments from insurers, according to Longo's suit.

The government complaint said at least 36 physicians had employment contracts tied to the business they brought to the hospital. Hospital executives closely tracked how much each doctor earned for the hospital, and executives catered to those whose referrals were most lucrative.

In 2008, the hospital's chief financial officer wrote in an internal memorandum that cardiovascular surgeon Dr. Ahmad Rahbar "is a man we need to keep happy" because the previous year "he generated over $11 million in revenues for us," according to the government's lawsuit.

Dr. Chandra Swamy, an obstetrician-gynecologist the hospital hired in 2009, was another physician whose referrals Wheeling coveted. By 2012, Wheeling was paying her $1.2 million, four times the national median for her peers, according to Longo's suit.

An internal memorandum by the hospitals' chief operating officer quoted in Longo's lawsuit said that the labor and delivery practice where Swamy worked was the biggest money loser among the specialty divisions and that her salary made it "almost impossible for this practice to show a bottom line profit." But the memo went on to conclude that Wheeling should "continue to absorb the practice loss" because it "would not want to endanger the significant downstream revenue that she produces" for the hospital: nearly $4.6 million a year, according to the lawsuit.

In some cases it was the specialists who demanded lopsided pay packages. When Wheeling, eager to get a piece of the booming field of pain management, decided to recruit Tune, the anesthesiologist responded that he wanted an "alternative/undefined model" of compensation that could earn him $1 million a year, according to Longo's lawsuit.

Instead of making Tune an employee, Longo alleges, Wheeling leased clinic space to a company created by Tune and paid him $3,000 a day — more than $700,000 a year. In its initial contract, Wheeling also let Tune keep 70% of his practice's net income, according to the government's complaint.

Two years later, when the hospital's chief lawyer raised legal concerns, Wheeling revised the contract, dropping the profit-sharing provision but boosting Tune's daily stipend to $6,100. The government complaint said this was designed to make up for the lost incentives and thus remained illegally based on how much business Tune generated for Wheeling. Indeed, Tune and his clinic earned roughly the same amount of money as they had received before the new compensation package, the complaint indicated.

Longo said his resistance to such deals rankled both Violi and physicians. He was fired in 2015 because, he alleged, of his objections to various contracts the hospital struck with physicians. The hospital countersued in March, saying Longo had breached his fiduciary duties because he never reported any financial irregularities when he worked there. Wheeling said that after Longo was fired, he threatened to file his lawsuit unless he received a settlement. Longo has asked that the case be dismissed and said in court papers he told Violi about his concerns on "multiple occasions."

As a whistleblower, Longo is entitled to receive a portion of any money the government collects in its complaint. Longo's lawyer said he would not comment for this story.

In financial terms, Wheeling's tactics succeeded. According to the government's suit, over the first five years under Violi, Wheeling earned profits of nearly $90 million. Violi's management firm, R&V Associates, also prospered: Wheeling more than doubled the firm's annual compensation from $1.5 million in 2007 to $3.5 million in 2018. Violi and his lawyer did not respond to requests for comment.

"The hospital has benefited tremendously from Ron's keen business acumen," Monsignor Kevin Quirk, the hospital board chairman, said last week in announcing Violi's retirement.

Wheeling's quality of care has not excelled commensurately, however, according to Hospital Compare, Medicare's consumer website. Patients with heart failure or pneumonia are more likely to die than at most hospitals. In April, Medicare awarded Wheeling Hospital its lowest rating, one star, for overall quality.

Jordan Rau: jrau@kff.org, @JordanRau

Elderly

A Doctor Speaks Out About Ageism In Medicine

KFF Health News, May 30, 2019

Imagine if the phases of later life were mapped and expertise in aging were valued, not discounted.

This article was published May 30, 2019, by Kaiser Health News.

By Judith Graham

Society gives short shrift to older age. This distinct phase of life doesn't get the same attention that's devoted to childhood. And the special characteristics of people in their 60s, 70s, 80s and beyond are poorly understood.

Medicine reflects this narrow-mindedness. In medical school, physicians learn that people in the prime of life are "normal" and scant time is spent studying aging. In practice, doctors too often fail to appreciate older adults' unique needs or to tailor treatments appropriately.

Imagine a better way. Older adults would be seen as "different than," not "less than." The phases of later life would be mapped and expertise in aging would be valued, not discounted.

With the growth of the elder population, it's time for this to happen, argues Dr. Louise Aronson, a geriatrician and professor of medicine at the University of California-San Francisco, in her new book, "Elderhood."

It's an in-depth, unusually frank exploration of biases that distort society's view of old age and that shape dysfunctional health policies and medical practices.

In an interview, edited for clarity and length, Aronson elaborated on these themes.

Q: How do you define "elderhood"?

Elderhood is the third major phase of life, which follows childhood and adulthood and lasts for 20 to 40 years, depending on how long we live.

Medicine pretends that this part of life isn't really different from young adulthood or middle age. But it is. And that needs a lot more recognition than it currently gets.

Q: Does elderhood have distinct stages?

It's not like the stages of child development—being a baby, a toddler, school-age, a teenager—which occur in a predictable sequence at about the same age for almost everybody.

People age differently—in different ways and at different rates. Sometimes people skip stages. Or they move from an earlier stage to a later stage but then move back again.

Let's say someone in their 70s with cancer gets really aggressive treatment for a year. Before, this person was vital and robust. Now, he's gaunt and frail. But say the treatment works and this man starts eating healthily, exercising and getting lots of help from a supportive social network. In another year, he may feel and look much better, as if time had rolled backwards.

Q: What might the stages of elderhood look like for a healthy older person?

In their 60s and 70s, people's joints may start to give them trouble. Their skin changes. Their hearing and eyesight deteriorate. They begin to lose muscle mass. Your brain still works, but your processing speed is slower.

In your 80s and above, you start to develop more stiffness. You're more likely to fall or have trouble with continence or sleeping or cognition—the so-called geriatric syndromes. You begin to change how you do what you do to compensate.

Because bodies alter with aging, your response to treatment changes. Take a common disease like diabetes. The risks of tight blood sugar control become higher and the benefits become lower as people move into this "old old" stage. But many doctors aren't aware of the evidence or don't follow it.

Q: You've launched an elderhood clinic at UCSF. What do you do there?

I see anyone over age 60 in every stage of health. Last week, my youngest patient was 62 and my oldest was 102.

I've been focusing on what I call the five P's. First, the whole person—not the disease—is my foremost concern.

Prevention comes next. Evidence shows that you can increase the strength and decrease the frailty of people through age 100. The more unfit you are, the greater the benefits from even a small amount of exercise. And yet, doctors don't routinely prescribe exercise. I do that.

It's really clear that purpose, the third P, makes a huge difference in health and wellness. So, I ask people, "What are your goals and values? What makes you happy? What is it you are doing that you like best or you wish you were doing that you're not doing anymore?" And then I try to help them make that happen.

Many people haven't established priorities, the fourth P. Recently, I saw a man in his 70s who's had HIV/AIDS for a long time and who assumed he would die decades ago. He had never planned for growing older or done advance care planning. It terrified him. But now he's thinking about what it means to be an old man and what his priorities are, something he's finally willing to let me help him with.

Perspective is the fifth P. When I work on this with people, I ask, "Let's figure out a way for you to keep doing the things that are important to you. Do you need new skills? Do you need to change your environment? Do you need to do a bit of both?"

Perspective is about how people see themselves in older age. Are you willing to adapt and compensate for some of the ways you've changed? This isn't easy by any means, but I think most people can get there if we give them the right support.

Q: You're very forthright in the book about ageism in medicine. How common is that?

Do you know the famous anecdote about the 97-year-old man with the painful left knee? He goes to a doctor who takes a history and does an exam. There's no sign of trauma, and the doctor says, "Hey, the knee is 97 years old. What do you expect?" And the patient says, "But my right knee is 97 and it doesn't hurt a bit."

That's ageism: dismissing an older person's concerns simply because the person is old. It happens all the time.

On the research side, traditionally, older adults have been excluded from clinical trials, although that's changing. In medical education, only a tiny part of the curriculum is devoted to older adults, although in hospitals and outpatient clinics they account for a very significant share of patients.

The consequence is that most physicians have little or no specific training in the anatomy, physiology, pharmacology and special conditions and circumstances of old age—though we know that old people are the ones most likely to be harmed by hospital care and medications.

Q: What does ageism look like on the ground?

Recently, a distressed geriatrician colleague told me a story about grand rounds at a major medical center where the case of a very complex older patient brought in from a nursing home was presented. [Grand rounds are meetings where doctors discuss interesting or difficult cases.]

When it was time for comments, one of the leaders of the medical service stood up and said, "I have a solution to this case. We just need to have nursing homes be 100 miles away from our hospitals." And the crowd laughed.

Basically, he was saying: We don't want to see old people; they're a waste of our time and money. If someone had said this about women or people of color or LGBTQ people, there would have been outrage. In this case, there was none. It makes you want to cry.

Q: What can people do if they encounter this from a doctor?

If you put someone on the defensive, you won't get anywhere.

You have to say in the gentlest, friendliest way possible, "I picked you for my physician because I know you're a wonderful doctor. But I have to admit, I'm pretty disappointed by what you just said, because it felt to me that you were discounting me. I'd really like a different approach."

Doctors are human beings, and we live in a super ageist society. They may have unconscious biases, but they may not be malicious. So, give them some time to think about what you said. If after some time they don't respond, you should definitely change doctors.

Q: Do you see signs of positive change?

Absolutely. There's a much larger social conversation around aging than there was five years ago. And that is making its way to the health system.

Surgeons are thinking more and more about evaluating and preparing older adults before surgery and the different kind of care they need after. Anesthesiologists are thinking more about delirium, which has short-term and long-term impact on older adults' brains. And neurologists are thinking more about the experience of illness as well as the pathophysiology and imaging of it.

Then you have the age-friendly health system movement, which is unquestionably a step in the right direction. And a whole host of startups that could make various types of care more convenient and that could, if they succeed, end up benefiting older people.

UCSF Medical Center Backs Off Plan To Deepen Ties With Dignity Health

KFF Health News, May 29, 2019

The proposal sharply split faculty and the medical staff at UCSF, who aired their differences in heated public forums. Supporters of a closer alliance with Dignity said it would add capacity to a public health care system that is strapped for bed space.

This story was published May 29, 2019, by Kaiser Health News.

By Jenny Gold, Kaiser Health News

SAN FRANCISCO—UCSF Medical Center officials said Tuesday they no longer would pursue a formal affiliation with Dignity Health, a large Catholic health care system that restricts care on the basis of religious doctrine.

The decision follows months of heated protest from hundreds of University of California-San Francisco faculty and staffers, who argued that such an arrangement would compromise patient care and threaten the famously progressive health system's reputation as a provider of unbiased and evidence-based care.

In a letter to staff announcing the decision to end negotiations, UCSF Chancellor Sam Hawgood and UCSF Health President and CEO Mark Laret cited "strong concerns about a significantly expanded UCSF relationship with a health care system that has certain limits on women's reproductive services, LGBTQ care, and end-of-life options."

Dignity hospitals are bound by ethical and religious directives from the United States Conference of Catholic Bishops. Among other prohibitions, Dignity hospitals ban abortions unless the mother's life is at risk, in vitro fertilization and physician-assisted death. Twenty-four of Dignity's 39 hospitals prohibit contraception services and gender-confirming care for transgender people, such as hormone therapy and surgical procedures.

Under the proposed affiliation, UCSF would have remained independent and continued to provide such services, but UCSF physicians would have had to abide by Dignity's care restrictions while practicing at Dignity hospitals.

The proposal sharply split faculty and the medical staff at UCSF, who aired their differences in heated public forums. Supporters of a closer alliance with Dignity said it would add capacity to a public health care system that is strapped for bed space and turns away more than 800 patients a year. They also noted that Dignity is California's largest private provider for patients with Medi-Cal, the state-federal insurance program for the poor.

Dignity, meanwhile, would have benefited from an inflow of patients at hospitals that often operate under capacity.

The two systems already have a relationship among several departments, including neurology, adolescent psychology and pediatric burn care. The new proposal would have deepened the affiliation at Dignity's four Bay Area hospitals.

UCSF said the decision to end negotiations was made over the past several days, following internal meetings with Dignity officials and members of the UC Board of Regents, whose approval was required. In a written statement, a Dignity Health spokesperson said system officials "understand the concerns raised by UCSF faculty and others" and "agree that we cannot move forward."

In April, Laret told a meeting of the UC Regents that UCSF had no "good Plan B" for adding capacity and that disengaging from the partnership would be "catastrophic for the health care delivery system in San Francisco." On Tuesday, UCSF released an FAQ saying the medical center would continue to look for new ways to work with Dignity, including in the areas of adolescent and adult psychiatry, surgical services, primary care and cancer care.

The proposal for formal affiliation had drawn vocal opposition from California's lieutenant governor, some major UCSF donors and dozens of organizations advocating for reproductive rights and the gay and transgender communities.

"I'm really happy they made this decision," said Dr. Daniel Grossman, a professor of obstetrics and gynecology who helped write a letter of opposition that was signed by more than 1,500 faculty members, residents, students and alumni. "Particularly in this moment when the rights of women and LGBT folks are under attack, this [affiliation] was just not the right decision, and I'm glad they recognized that. It's important that California remain a haven state for these services."

But Grossman said he remains concerned about UCSF's ongoing collaboration with Dignity, and the possibility it still could expand.

"We need to be vigilant and really hold them accountable moving forward," he said.

What Closing Missouri's Last Abortion Clinic Will Mean For Neighboring States

KFF Health News, May 29, 2019

Missouri would be the only state in the country to not have an operating abortion clinic, though five other states reportedly have only one abortion clinic.

This story was published May 29, 2019, by Kaiser Health News.

By Lauren Weber

ST. LOUIS—As the last abortion clinic in Missouri warned that it will have to stop providing the procedure as soon as Friday, abortion providers in surrounding states said they are anticipating an uptick of even more Missouri patients.

At Hope Clinic in Granite City, Ill., just 10 minutes from downtown St. Louis, Deputy Director Alison Dreith said Tuesday her clinic was preparing for more patients as news about Missouri spread.

"We're really scrambling today about the need for increased staff and how fast can we hire and train," Dreith said.

And at a Trust Women clinic in Wichita, Kan., that already has to fly in doctors, the staff didn't know what it would mean for their overloaded patient schedule.

"God forbid we see that people can't get services in Missouri," said Julie Burkhart, Trust Women founder and CEO. "What is that going to mean on our limited physician days?"

If St. Louis' Planned Parenthood clinic is unable to offer abortions, the group said, Missouri would be the only state in the country to not have an operating abortion clinic. Five other states—Kentucky, Mississippi, North Dakota, South Dakota and West Virginia—reportedly have only one abortion clinic. And 90% of U.S. counties didn't have an abortion clinic as of 2014, according to the Guttmacher Institute, a reproductive rights research and advocacy group.

For some, this echoes back to the days before abortion was legalized nationwide in 1973 with the Supreme Court's Roe v. Wade decision, when patients who could afford to travel would go to more liberal states like California or New York where abortion was legal.

But providers in Kansas and Illinois say this influx from Missouri isn't new. About half of their clients already come from the Show Me State. To the south, in neighboring Arkansas, where a 72-hour waiting period will go into effect in July, the vast majority of its patients still live within the state.

Over the past 10 years, four Missouri abortion clinics have closed because of increased regulations, including a mandatory 72-hour waiting period after receiving counseling on abortion, thus requiring two trips to a facility; requirements that physicians have hospital admitting privileges within 15 minutes of their clinics; and a rule requiring two-parent notification for minors and one-parent notarized consent. All those limits left one clinic in downtown St. Louis to serve the whole state.

Now Planned Parenthood, which operates that final abortion clinic, said Tuesday it will be forced to end its abortion services altogether by Friday if the state suspends its license. The closure is not related to new anti-abortion laws that Missouri Gov. Mike Parson, a Republican, signed last week to ban most abortions after eight weeks of pregnancy. The new laws don't take effect until August.

Already the number of patients in Missouri seeking an abortion at the clinic from April 2018 until this April had dropped by 50% compared with the same period the previous year. Planned Parenthood spokesman Jesse Lawder attributes two-thirds of the decrease to the clinic's refusal to do pelvic exams for abortions performed through medication—recently required by the state—thus forcing all such abortions to be performed out of state.

For Dreith, while she expects the Missouri numbers to continue to grow at her Illinois clinic across the Mississippi River, it's not the only state sending patients her way.

"Patients were literally coming to us from the last remaining clinics in Kentucky … so that they wouldn't get past 24 weeks," Dreith said. "We don't want these patients in surrounding states traveling [to] New York [or] California like they once had to."

That's how it was prior to the Roe v. Wade ruling, according to Mary Ziegler, a professor at the Florida State University College of Law who is writing her third book on the history of the legal battle around abortion access. She anticipates the pattern of privilege will repeat itself.

"You would still expect women with resources to be able to travel as far as they needed," she said. "And you would expect women without resources to not be able to travel. … The more the court retreats from protecting abortion rights, the more stark those differences will become."

For Dreith, the historical comparison to the pre-Roe era rings true, albeit with improved medical practices.

There are safer, easier and more effective ways to perform abortions now than the "horror stories that we saw pre-Roe," said Dreith. "But I think the travel will be one of the huge throwbacks and the scariest part will be the criminalization."

States such as Missouri could feel pressure to start arresting women who perform their own abortions with pills at home or travel out of state, Ziegler said. But, she said, "punishing women isn't something that's thought to be very popular."

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Lawmakers Push To Stop Surprise ER Billing

KFF Health News, May 29, 2019

Health policy experts say the problem demands federal action rather than an inconsistent patchwork of state laws.

This story was published May 29, 2019, by Kaiser Health News.

By Ana B. Ibarra, Kaiser Health News

California has some of the nation's strongest protections against surprise medical bills. But many Californians still get slammed with huge out-of-network charges.

State lawmakers are now trying to close gaps in the law with a bill that would limit how much hospitals outside of a patient's insurance network can charge for emergency care.

"We thought the practice of balance billing had been addressed," said state Assemblyman David Chiu (D-San Francisco), author of the bill. "Turns out there are major holes in the law potentially impacting millions of Californians with different types of insurance."

"Balance billing," better known as surprise billing, occurs when a patient receives care from a doctor or hospital—or another provider—outside of her insurance plan's network, and then the doctor or hospital bills the patient for the amount insurance didn't cover. These bills can soar into the tens of thousands of dollars.

Chiu's proposal would prohibit out-of-network hospitals from sending surprise bills to privately insured emergency patients. Instead, hospitals would have to work directly with health plans on billing, leaving the patients responsible only for their in-network copayments, coinsurance and deductibles. Hospitals are fighting the proposal, calling it a form of rate-setting.

"If we are able to move this forward in California, it could be a model and standard for what happens around the country," Chiu said of his measure, which the state Assembly is expected to consider this week.

Surprise billing is a scourge for patients around the country.

Last year, a Kaiser Family Foundation poll found that two-thirds of Americans are "very worried" or "somewhat worried" about being able to afford a surprise bill for themselves or a family member. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

Health policy experts say the problem demands federal action rather than an inconsistent patchwork of state laws. And President Donald Trump has called on Congress to pass legislation this year to put a stop to surprise medical bills.

"In one swipe, the federal government can offer a universal approach in protecting consumers," said Kevin Lucia, a research professor with Georgetown University's Health Policy Institute.

Lawmakers in both the U.S. Senate and House have introduced bills to end surprise billing. But passing federal legislation promises to be an uphill battle because two influential lobbying groups—health insurers and health providers—have been unable to agree on a solution.

Frustrated by waiting for federal lawmakers to act, states have been trying to solve this issue. As of December 2018, 25 states offered some protection against surprise billing, and the protections in nine of those states were considered "comprehensive," according to the Commonwealth Fund. California, New York, Florida, Illinois and Connecticut are among the nine.

New state laws also have been adopted since, including in Nevada, which will limit how much out-of-network providers, including hospitals, can charge patients for emergency care, starting next year.

In California, a 2009 state Supreme Court ruling protects some patients against surprise billing for emergency care, and a state law that took effect in 2017 protects some who receive non-emergency care.

But millions remain vulnerable, largely because California's protections don't cover all insurance plans. The California Supreme Court ruling applies to people with plans regulated by the state Department of Managed Health Care. That leaves out the roughly 1 million Californians with plans regulated by the state Department of Insurance and the nearly 6 million people with federally regulated plans, most of whom have employer-sponsored insurance.

The state law governing non-emergency care also doesn't apply to the millions of residents with health plans regulated by the federal government.

Chiu's bill attempts to close those loopholes by targeting hospitals and their billing practices. With this strategy, a patient's health plan—and the agency that regulates it—would not matter, explained Anthony Wright, executive director of Health Access California, a Sacramento-based advocacy group that is sponsoring the legislation.

The proposal "extends protections to a broader set of Californians," Wright said.

The California Hospital Association opposes the measure, which would limit the amount hospitals could charge insurance plans to a certain rate for each service, varying by region.

The association believes that would equate to the state setting prices, which could discourage health plans from entering contracts with hospitals, said Jan Emerson-Shea, a spokeswoman for the association.

"We fully support the provision of the bill that protects patients. It is the rate-setting piece that is our concern," she said.

Chiu said his bill was prompted by the peculiar billing practices at Zuckerberg San Francisco General Hospital spotlighted by Vox in January.

Unlike most large hospitals, San Francisco General does not contract with private insurers. Vox found that the hospital considered patients with private insurance out-of-network, and was slapping many of them with whopping bills.

Stefania Kappes-Rocha was one of them.

On April 30, 2018, Kappes-Rocha, 23, landed in San Francisco General's emergency room with a fever and intense pain in her lower right back caused by a kidney infection. A student at Hult International Business School at the time, she had a private plan through the college.

"I didn't know it at the time, but that was the problem—that I did have insurance," Kappes-Rocha said.

She was sent home a day later with ibuprofen. About two months later, she was billed $27,767.70.

"I couldn't move because of the pain," she said. The last thing on her mind was that she'd be on the hook for the entire cost of her hospital visit.

Her insurance eventually agreed to pay about $24,000 of her bill.

"I fought back, I pressured them every week," she said. "But some people don't know they should do that."

Skewered by media reports, the hospital announced in April that it would no longer balance-bill privately insured patients.

Oklahoma's 'Precedent-Setting' Suit Puts Opioid Drugmakers On Trial

KFF Health News, May 28, 2019

A major settlement just two days before the trial leaves a sole defendant in the case brought by Oklahoma's top law enforcement official.

This story was published May 28, 2019, by Kaiser Health News.

By Jackie Fortier, StateImpact Oklahoma

All eyes will be on Oklahoma this week when the first case in a flood of litigation against opioid drug manufacturers begins Tuesday.

Oklahoma Attorney General Mike Hunter's suit alleges Johnson & Johnson, the nation's largest drugmaker, helped ignite a public health crisis that has killed thousands of state residents.

With just two days to go before the trial, one of the remaining defendants, Teva Pharmaceutical Industries of Jerusalem, announced an $85 million settlement with the state on Sunday. The money will be used for litigation costs and an undisclosed amount will be allocated "to abate the opioid crisis in Oklahoma," according to a press release from Hunter's office.

In its own statement, Teva said the settlement does not establish any wrongdoing on the part of the company, adding Teva "has not contributed to the abuse of opioids in Oklahoma in any way."

That leaves Johnson & Johnson as the sole defendant.

Court filings accuse the company of overstating the benefits of opioids and understating their risks in marketing campaigns that duped doctors into prescribing the drugs for ailments not approved by regulators.

The bench trial—with a judge and no jury—is poised to be the first of its kind to play out in court.

Nora Freeman Engstrom, a professor at Stanford Law school, said lawyers in the other cases and the general public are eager to see what proof Hunter's office offers the court.

"We'll all be seeing what evidence is available, what evidence isn't available and just how convincing that evidence is," she said.

Most states and more than 1,600 local and tribal governments are suing drugmakers and distributors. They are trying to recoup billions of dollars spent on addressing the fallout tied to opioid addiction.

Initially, Hunter's lawsuit included Purdue Pharma, the maker of OxyContin. In March, Purdue Pharma settled with the state for $270 million. Soon after, Hunter dropped all but one of the civil claims, including fraud, against the remaining defendants. Teva settled for $85 million in May, leaving Johnson & Johnson as the only opioid manufacturer willing to go to trial with the state.

But he still thinks the case is strong.

"We have looked at literally millions of documents, taken hundreds of depositions, and we are even more convinced that these companies are the proximate cause for the epidemic in our state and in our country," Hunter said.

Precedent-Setting Case
 

The companies involved have a broad concern about what their liability might be, said University of Kentucky law professor Richard Ausness.

"This case will set a precedent," he said. "If Oklahoma loses, of course they'll appeal if they lose, but the defendants may have to reconsider their strategy."

With hundreds of similar cases pending—especially a mammoth case pending in Ohio—Oklahoma's strategy will be closely watched.

"And of course lurking in the background is the multi-state litigation in Cleveland, where there will ultimately be a settlement in all likelihood, but the size of the settlement and the terms of the settlement may be influenced by Oklahoma," Ausness said.

'There's Nothing Wrong with Producing Opioids"

The legal case is complicated. Unlike tobacco, where states won a landmark settlement, Ausness pointed out that opioids serve a medical purpose.

"There's nothing wrong with producing opioids. It's regulated and approved by the Federal Drug Administration, the sale is overseen by the Drug Enforcement Administration, so there's a great deal of regulation in the production and distribution and sale of opioid products," Ausness said. "They are useful products, so this is not a situation where the product is defective in some way."

It's an argument that has found some traction in court. Recently, a North Dakota judge dismissed all of that state's claims against Purdue, a big court win for the company. In a written ruling that the state says it will appeal, Judge James Hill questioned the idea of blaming a company that makes a legal product for opioid-related deaths. "Purdue cannot control how doctors prescribe its products and it certainly cannot control how individual patients use and respond to its products," the judge wrote, "regardless of any warning or instruction Purdue may give."

Now the Oklahoma case rests entirely on a claim of public nuisance, which refers to actions that harm members of the public, including injury to public health.

"It's sexy you know, 'public nuisance' makes it sound like the defendants are really bad," Ausness said.

If the state's claim prevails, Big Pharma could be forced to spend billions of dollars in Oklahoma helping ease the epidemic. "It doesn't diminish the amount of damages we believe we'll be able to justify to the judge," Hunter said, estimating a final payout could run into the "billions of dollars."

Hunter's decision to go it alone and not join with a larger consolidated case could mean a quicker resolution for the state, Ausness said.

"Particularly when we're talking about [attorneys general], who are politicians, who want to be able to tell the people, 'Gee this is what I've done for you.' They are not interested in waiting two or three years [for a settlement], they want it now," he said. "Of course, the risk of that is you may lose."

Looking For Treatment
 

Oklahoma has the second-highest uninsured rate in the nation and little money for public health. The state is trying to win money from the drug companies to pay for treatment for people like Greg, who is afraid he'll lose his job if we use his last name.

Greg and his wife, Judy, said they haven't been able to find the integrated treatment that Greg needs for both his opioid addiction and his bipolar disorder. It's either one or the other.

"They don't give you … a treatment plan for both," Judy said. "They just say 'Here, you can talk to this person.' They don't recognize that it's like self-medicating."

The couple live in Guthrie, Okla., about an hour north of the courthouse where the opioid trial will take place. Greg said he has been addicted to opioids for 11 years. People with prescriptions sell him their pills—sometimes Greg binges and takes 400 milligrams of morphine at once, a huge dose.

Of the $270 million Purdue settlement, $200 million is earmarked for an addiction research and treatment center in Tulsa, though no details have been released. An undisclosed amount of the $85 million Teva settlement will also go to abating the crisis. Judy said she hopes the treatment center will eventually help Greg.

"I wish he would stop using [opioids], but I love him. I'll always be here," she said.

This story is part of a partnership that includes StateImpact Oklahoma, NPR and Kaiser Health News, a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

A Final Comfort: 'Palliative Transport' Brings Dying Children Home

KFF Health News, May 28, 2019

The practice, which appears to be spreading, lets families move critically ill children from the hospital intensive care unit to their home or hospice, with the expectation they will die within minutes to days after removing life support.

This story was published May 28, 2019, by Kaiser Health News.

By Melissa Bailey, Kaiser Health

Anne Brescia sat beside her only child, Anthony, as he lay unconscious in a hospital bed at age 16. Just a few months before, he was competing in a swim meet; now cancer was destroying his brain. Brescia couldn't save her son. But she was determined to bring him home.

Anthony Gabriel Brescia-Connell was not conscious for his voyage from Boston Children's Hospital to his home in Medford, Mass., where he died on March 3, 2011, surrounded by his family and beloved stuffed animals. He may not have heard the parting blessings before a doctor turned off his portable ventilator and let him die naturally.

But having the choice to take Anthony home, away from the beeping hospital monitors, "meant the world to me," his mother said.

Anthony's journey was made possible through swift and unconventional efforts by the hospital staff, including a critical care transport team accustomed to rushing kids to the hospital to save their lives, not taking them home to die.

The experience galvanized Harriett Nelson, a nurse on that team who helped arrange the trip. It inspired her to conduct pioneering research on and advocate for "pediatric palliative transport"—a rare but growing practice that aims to give families choice, control and comfort at the end of life.

Palliative transport lets families move critically ill children from the hospital intensive care unit to their home or hospice, with the expectation they will die within minutes to days after removing life support.

It means "having parents go through the hardest thing they'll ever know—in the way they want to do it," Nelson said. Boston Children's has sent 19 children to home or hospice through palliative transport since 2007, she said.

These final journeys—also offered by Mayo Clinic, Children's Hospital of Philadelphia and Kentucky Children's Hospital—can involve elaborate planning, delicate transfers and even long helicopter rides. In some cases, families took a child far from home for a last-ditch effort to save their lives.

At Mayo Clinic in Rochester, Minn., palliative transport has helped culturally diverse families carry out end-of-life wishes for their dying children. In one case, a newborn girl rode 400 miles by ambulance to return to her Amish community, where she was extubated and died in her parents' arms, in the company of her 11 siblings. In another, an 8-month-old Native American girl traveled 600 miles by air and ground ambulance to her rural tribal reservation, where she could participate in end-of-life rituals that could not be done in the hospital.

These trips, which can cost thousands of dollars, are typically offered free to families, paid for by hospitals or charities. Most children are taken home, where they transition to receiving care from hospice staff. Some go instead to hospice facilities.

Dr. Megan Thorvilson, a pediatrician and palliative care specialist at Mayo Clinic, said palliative transport aims to address a gap between families' preference and reality. Most parents of terminally ill children would prefer that their child die at home, but most of these children die in the hospital, most commonly in the intensive care unit. Most pediatric ICU deaths happen in a controlled way, following the removal of life support, she noted. That means there may be time to move the child to an alternative location to honor a family's wishes.

Transporting children on life support is risky. At a palliative care conference, a nurse from Children's Hospital of Philadelphia described the difficulties staff faced in trying to fly a 10-year-old girl home to Michigan. After she was rolled on her side several times to be transferred between vehicles, the child died before the plane could take off.

And dying at home is not what every family wants.

"We do sometimes overly romanticize the death at home," Thorvilson acknowledged. Some parents would much rather have a child die in the hospital, with familiar nurses at the bedside for medical and emotional support. Some would rather keep this traumatic experience away from where they live.

Brescia, however, said she couldn't bear to return home without her son.

Brescia, a biologist who used to run an electron microscopy lab, wasn't sure if she and her husband, Brian Connell, would ever have kids. Fertility treatments didn't work. But on June 23, 1994, seven days before Brescia turned 44, she gave birth to a baby boy.

"Anthony is the love of my life," said Brescia, who is now 68. "The OB-GYN put him on my chest and I really thought that my heart was going to burst."

The mother-son bond was especially close: Brescia home-schooled her son for most of his life. Anthony grew to be 6 feet tall, full of curiosity. He loved identifying mushrooms, studied Arabic and oceanography, and aspired to go to MIT. He was an avid swimmer, competing on a team in Belmont, Mass.

One day in late 2010, while racing the backstroke, he became disoriented in the pool and was disqualified.

A neurologist prescribed rest. But over the next two weeks, Anthony grew only more tired and began to lose his balance. On Dec. 20, he was taken to Boston Children's Hospital and diagnosed with a brain tumor.

The disease "came out of nowhere," Brescia recalled. "He went from looking incredibly healthy and swimming like a healthy kid" to living at the hospital. At his bedside, she told him she'd bring him home to celebrate Christmas and eat stuffed shells.

His condition deteriorated very quickly. The tumor could not be surgically removed. Anthony pushed through radiation and chemotherapy with the hope of going home, but the treatments failed. By late February 2011, the tumor began pressing on his brain stem, and fluid was building up in his brain.

Anthony was unconscious, relying on a ventilator to breathe. Brescia connected with the hospital's palliative care team.

"I want to bring him home tomorrow," Brescia told the staff.

"I was scared to death he was going to have another incident," she recalled. "I didn't want them to do any more invasive procedures to reduce the pressure on his brain."

Staff from the ICU, palliative care and transport teams scrambled to honor her request. The critical care transport team arranged for the use of its ambulance, a mobile ICU the size of a small bus.

The night before the trip, Brescia said goodbye in the privacy of Anthony's hospital room.

"I don't want to lose you," she told him, holding his hands. "I'm going to let go. I want you to go where you need to be."

On March 3, 2011, Brescia and her husband boarded the bus along with Anthony, a chaplain, two doctors, Nelson and a nurse from the ICU. They rode 10 miles to the family's home, where Anthony was laid on a hospital bed in his living room, surrounded by his stuffed animals, on his favorite flannel sheets.

A pastor held a service for Anthony, and close family gathered to say goodbye. Then Brescia signaled for a doctor to disconnect the ventilator.

Anthony seemed to be at peace, Brescia said. After he died, she climbed into the bed with her son and held onto him for a while.

The death was still traumatic. But "it was really a gift to bring him home," she said. "It was a significant act of compassion and kindness and love on the part of the Children's staff."

After Brescia's experience, Nelson was inspired to offer the choice to more families. First, she interviewed Brescia and other parents about whether palliative transport had had a positive impact. All nine parents said it had. One family described holding a celebration when they brought their newborn baby home, even though he was about to die. They took family photos and used the nursery they had set up, establishing a brief sense of normalcy for four days before he died.

In her 14 years on Boston Children's critical transport team, Nelson has found that parents benefit from palliative transport for various reasons: At home, they're away from the noise of the hospital. They have control over who can visit. They feel more comfortable. And they don't feel rushed after their child dies.

Nelson created a protocol that allows the hospital to offer palliative transport in a more routine way. Now, when children come to any of the hospital's four ICUs, Nelson said, "we have the power to say, 'You have a choice when it comes to the end of life.'"

The practice appears to be spreading.

After Dr. Lindsay Ragsdale, director of the palliative care team at Kentucky Children's Hospital in Lexington, presented her protocol for palliative transport at a conference last year, staff from 20 hospitals asked her to share her checklist, she said.

Mayo's Thorvilson, who has worked closely on a half-dozen palliative transports, said it's possible these last-minute trips from ICU to home could be avoided by earlier referrals to hospice, which might get kids home sooner. But when children with complex illnesses get sick, she said, "sometimes it's hard to know whether this is just another bump in the road, or whether this is the natural end of the child's life."

"There's something really unique about a child dying," she said. "Everyone's heart breaks, and we want to be able to do all that we can to be able to support the family in the midst of the tragedy."

Eight years after Anthony's death, his bedroom remains untouched, his socks still folded in his top drawer, swimming trophies on the cabinet, slippers under his chair. Pictures of him adorn every room in the house—on the fridge, the kitchen table, the living room stereo.

Looking through photos one recent morning of her son fishing and blowing out birthday candles, Brescia struggled to hold back tears.

"I couldn't cure him," she said. "I failed to protect him from a tumor—that's how you feel. They did all they could. It wasn't enough. Bringing him home was the best I could do."

A Health Care Overhaul Could Kill 2 Million Jobs, And That's OK

KFF Health News, May 24, 2019

Shouldn't the primary goal of a health care system be delivering efficient care at a reasonable price, not rewarding shareholders or buttressing the economy?

This article was published May 24, 2019, by Kaiser Health News. It also ran as an opinion piece in The New York Times.

By Elisabeth Rosenthal

As calls for radical health reform grow louder, many on the right, in the center and in the health care industry are arguing that proposals like "Medicare for All" would cause economic ruin, decimating a sector that represents nearly 20% of our economy.

While exploring a presidential run, former Starbucks chief Howard Schultz called Medicare for All "not American," adding, "What industry are we going to abolish next—the coffee industry?" He said that it would "wipe out the insurance industry."

A fellow at the libertarian Cato Institute wrote that it would "carpet bomb the industry." David Wichmann, the chief executive of UnitedHealth Group, warned that it "would surely have a severe impact on the economy and jobs."

It's true: Any significant reform would require major realignment of the health care sector, which is now the biggest employer in at least a dozen states. Most hospitals and specialists would probably lose money. Some, like the middlemen who negotiate drug prices, could be eliminated. That would mean job losses in the millions.

Though it will be economically painful, the point is to streamline for patients a Kafka-esque health care system that makes money for industry through irrational practices. After all, shouldn't the primary goal of a health care system be delivering efficient care at a reasonable price, not rewarding shareholders or buttressing the economy?

In 2012, Harvard economists Katherine Baicker and Amitabh Chandra warned against "treating the health care system like a (wildly inefficient) jobs program." They were rightly worried that the health care system was the primary engine of recovery from the Great Recession. And yet the revelation that the health care sector added more jobs last year than any other in the economy was greeted by many as good news.

It's not surprising that those involved in the business of medicine have joined forces in a lobbying and media campaign, the Partnership for America's Health Care Future, to ward off transformational reform, particularly Medicare for All. But fed-up voters seem ready to upend an industry that saps their finances, wastes their time and doesn't deliver particularly good care. Few people would mourn the end of $35 million annual compensation packages for insurance executives or the downsizing of companies that have raised insulin prices to 10 times what they are in Canada—though they might miss hospitals' valet parking and private rooms.

Well over half of Americans already say they have a favorable view of Medicare for All. Though approval falls off when confronted with details such as higher taxes, it is clear that the electorate is searching for something big. Change could come in many guises: for example, some form of Medicare expansion, government negotiations on drug prices or enhancing the power of the Affordable Care Act. The more fundamental the reform, the more severe the economic effect.

The first casualties of a Medicare for All plan, said Dr. Kevin Schulman, a physician-economist at Stanford, would be the "intermediaries that add to cost, not quality." For example, the armies of administrators, coders, billers and claims negotiators who make good middle-class salaries and have often spent years in school learning these skills. There would be far less need for drug and device sales representatives who ply their trade office to office and hospital to hospital in a single-payer system, or one in which prices are set at a national level.

Some geographic areas would be hit particularly hard. A single hospital system is by far the biggest employer in many post-manufacturing cities like Pittsburgh and Cleveland. Hospitals and hospital corporations make up the top six employers in Boston and two of the top three in Nashville. Hartford is known as the insurance capital of the world. Where would New Jersey be if drugmakers took a big hit, or Minnesota if device makers vastly shrank their workforce? (That may be why some Democratic representatives and senators from these left-leaning states have been quiet or inconsistent on Medicare expansion.)

Stanford researchers estimate that 5,000 community hospitals would lose more than $151 billion under a Medicare for All plan; that would translate into the loss of 860,000 to 1.5 million jobs. A Navigant study found that a typical midsize, nonprofit hospital system would have a net revenue loss of 22%.

Robert Pollin, an economist at the Political Economy Research Institute of the University of Massachusetts-Amherst, is frustrated not just by the doomsday predictions but also by how proponents of Medicare for All tend to gloss over the jobs issue.

"Every proponent of Medicare for All—including myself—has to recognize that the biggest source of cost-saving is layoffs," he said. He has calculated that Medicare for All would result in job losses (mostly among administrators) "somewhere in the range of 2 million"—about half on the insurers' side and half employed in hospitals and doctors' offices to argue with the former. Supporters of Medicare for All, he said, have to think about a "just transition" and "what it might look like."

Of course, if more people get health insurance under an expanded Medicare, there will be a greater need for some workers—like nurse practitioners and physician assistants. And there is a large unmet labor need in caring for an aging population. The latter are mostly low-wage jobs, however, and neither compensates for the losses.

Pollin suggests that a transition to Medicare for All should be accompanied by a plan to give those made redundant up to three years of salary and help in retraining for another profession.

Despite the short-term suffering caused by any fundamental shift in our health care delivery system, reform would ultimately redirect resources in ways that are good for the economy, many experts say.

"I'm sympathetic to the impact that changes will have on specific markets and employment—we can measure that," Schulman said. "What we can't quantify is the effect that high health care costs have had on non-health care industries."

The expense of paying for employees' health care has depressed wages and entrepreneurship, he said. He described a textile manufacturer that moved more than 1,000 jobs out of the country because it couldn't afford to pay for insurance for its workers. Such decisions have become common in recent years.

"Yes, these are painful transitions," said Baicker, who is now the dean of the University of Chicago's Harris School of Public Policy. "But the answer is not to freeze the sectors where we are for all time. When agriculture improved and became more productive, no one said everyone had to stay farmers."

House Hagglers Zero In On Single-Payer And It All Comes Down To Two Little Words

KFF Health News, May 23, 2019

Whether 'single-payer' or 'Medicare-for-All,' proposals could play out in countless ways.

This article was published May 22, 2019, by Kaiser Health News.

By Shefali Luthra, Kaiser Health News

A powerful congressional committee holds a hearing on single-payer health care.

It sounds like the perfect place for lawmakers looking to score easy political points and cut new sound bites for one of the nation's biggest policy debates. Right?

Not if you're talking about Wednesday's hearing in the House Budget Committee. Members from both political parties questioned Congressional Budget Office officials in a quest for new ammunition in a health care fight that has already lit up the 2020 campaign trail.

Would single-payer severely weaken the economy, or drive doctors out of business? Would it result in better, more affordable care for all Americans, or even save lives?

And, consistently, they were thwarted by two deceptively simple words.

"It depends."

Deployed in various forms by three of Washington's top number crunchers, that caveat underscored a point the same office made three weeks ago: "single-payer," or "Medicare for All," could play out in countless ways. And before policymakers can prognosticate about what such a shift would do, they need to answer some more basic questions.

No matter what, said Mark Hadley, the CBO's deputy director, "Moving to a single-payer system would be a major undertaking."

Unanswered questions, he said, include what kinds of benefits would such a system cover, what would it pay doctors for those services, might nurse practitioners or physician assistants play a greater role under that system, what kind of cost sharing would be left intact and who might pay more in taxes under that system?

Just the term "single-payer"—a system in which health care is paid for by a single public authority—leaves those nuances murky.

This open-endedness is why the CBO hasn't put a price tag on what it might cost, which is its job. That point came up repeatedly Wednesday, with Republican committee members suggesting the office look at the progressive-backed Medicare for All bill spearheaded by Rep. Pramila Jayapal (D-Wash.), also a Budget Committee member.

Democrats didn't request an estimate on any single single-payer bill because "there are so many ways of doing this," said committee Chairman John Yarmuth (D-Ky.). "It would be an enormous matrix of a lot of different numbers on it."

It's unclear, Hadley emphasized, whether single-payer would cost more in health care spending than the current system does. Medicare pays far less on overhead and administration than does private insurance. But still, that's only one variable.

Even without those numbers—or much cooperation from their witnesses—members did their best to try out attack lines.

Republicans painted a picture in which doctors would face pay cuts and abandon the practice of medicine, Americans would languish on waitlists for lifesaving medical care, and Washington bureaucrats would decide what health care is covered.

"Americans would have no choice but to wait longer and pay more for lower-quality care," argued Rep. Jason Smith (R-Mo.)—despite Hadley's repeated response that, actually, wait times, cost and quality would all be products of choices Congress makes in designing any single-payer plan, and not inherent to the system itself.

Democrats showed their own division.

Rep. Seth Moulton (D-Mass.), who is also running for president, argued that the CBO framework supported the need, not for single-payer but for the government to offer a so-called public option—a government health plan that competes against private insurance. Many a Democratic candidate has already backed this approach on the campaign trail.

Other members, like Rep. Ro Khanna (D-Calif.), focused on more sweeping changes, such as those backed by Jayapal and, on the Senate side, Vermont independent Bernie Sanders. (Khanna is a co-chair on Sanders' presidential campaign.)

Khanna argued that single-payer health care would increase wages for the lower 50% of workers, since their employers would no longer have to subsidize health care and could instead pay higher salaries.

"It's possible to design that system, yes," Hadley said.

But that possibility depends on several other factors: for instance, how much employers pass those savings back to employees, and how any new taxes to finance the new health care system are structured.

Or, to put it another way: "It depends."

Wednesday's hearing marked the second House discussion of single-payer—but it won't be the last time the Budget Committee discusses it. In her remarks, Jayapal called for the committee to hear testimony on her specific Medicare for All bill at a later date.

Republicans, including the committee's ranking member, Steve Womack (R-Ark.), support this idea, which could help them tie more moderate Democrats to the single-payer issue.

If they do, members will once again have to confront an inconvenient fact: Actual health reform is complicated and won't reduce to easy sound bites.

"The effects of such a system," as Hadley put it, "could vary greatly depending on the details."

'Stonewall Generation' Confronts Old Age, Sickness—And Discrimination

KFF Health News, May 22, 2019

In a country where most elder care is left to family, many LGBTQ people are estranged from relatives and don't have that option. Turning to others for care makes them uniquely vulnerable.

This article was published May 22, 2019, by Kaiser Health News.

By JoNel Aleccia and Melissa Bailey

Two years ago, nursing professor Kim Acquaviva asked a group of home care nurses whether they thought she was going to hell for being a lesbian. It's OK if you do, Acquaviva said, but is the afterlife within your scope of practice?

After Acquaviva's talk, an older nurse announced she would change how she treats LGBTQ people under her care.

"I still think you're going to hell, but I'm going to stop telling patients that," the nurse told Acquaviva.

Acquaviva, a professor at the George Washington University School of Nursing in Washington, D.C., raised the example Tuesday at a panel hosted by Kaiser Health News on inclusive care for LGBTQ seniors. It was one of many examples of discrimination that these older adults may face as they seek medical care.

LGBTQ baby boomers, dubbed "the Stonewall Generation," came of age just as the 1969 New York uprising galvanized a push for gay rights. After living through an era of unprecedented social change, they're facing new challenges as they grow old.

"Fifty years after Stonewall, there's a new generation of LGBT elders who never thought they'd get an AARP card," said Nii-Quartelai-Quartey, AARP's senior adviser and national liaison on the issue who also participated in Tuesday's panel.

By 2030, there will be an estimated 7 million LGBT people in America over 50. About 4.7 million of them will need elder care and services, according to SAGE, an advocacy group.

In a country where most elder care is left to family, many LGBTQ people are estranged from relatives and don't have that option. Turning to others for care—in assisted living centers, nursing homes or hospice settings—makes them uniquely vulnerable.

"The fear of living in a situation where they can't advocate for their own care and safety is terrifying," said Hilary Meyer, chief enterprise and innovation officer for SAGE.

Three-quarters of LGBT people are worried about having adequate family or social supports, according to a nationally representative survey of AARP members released last year.

More than a third are concerned they'll have to hide their identity to find suitable housing as they age. And at least 60% are concerned about neglect, harassment and abuse, the survey showed.

Often, those fears are founded, according to results of a forthcoming survey of more than 850 hospice and palliative care providers about LGBT patients and family experiences.

"I think the information we've got is actually quite discouraging and quite concerning," said Gary Stein, a professor at the Wurzweiler School of Social Work at Yeshiva University who co-led the project.

Most providers surveyed said LGBT people received discriminatory care, he said. For transgender patients, two-thirds said that was true.

Caregivers reported hundreds of examples of disrespectful treatment, Stein said.

When LGBT couples would hold hands, staff "might roll their eyes, make faces at each other," he said. They often failed to consult the patients' partners, directing questions to biological family members instead.

In several instances, staff would "try to pray" to the patient or their family, Stein said.

Some LGBT patients were left in soiled diapers or rationed pain medication in a "punishing way" because of their sexual identity, he added.

"For transgender patients, there was lots of discomfort around what to call the person," Stein said. "A number of people said patients were called 'it' instead of a pronoun."

Twenty states have laws that specifically protect LGBT people against discrimination, but most don't, Stein noted. A recently enacted Trump administration "conscience rule" allows providers to decline to provide care that goes against their moral or spiritual beliefs. Advocates said the new rule could make it easier to discriminate against LGBTQ people.

Still, a growing number of senior housing and care sites are putting non-discrimination policies in place and training personnel to provide LGBTQ-inclusive care.

The SAGE staff has trained more than 50,000 people at more than 300 sites nationwide, Meyer said. They learn best practices for asking questions that don't perpetuate stigma.

"It's even something as simple as asking somebody, a woman, if her husband will be visiting," said Meyer, noting that the question forces the person to decide whether to announce her sexual identity. "Having to come out of the closet that way can be very challenging."

In a few high-profile instances, LGBTQ couples or individuals have sued providers for discrimination.

In 2016, Lambda Legal, a gay advocacy group, sued an Illinois senior residential facility for failing to protect Marsha Wetzel, 70, a disabled lesbian, from harassment and violence by other residents. The 7th Circuit Court of Appeals ruled that a landlord may be held liable under the Fair Housing Act for failing to protect a tenant from known, discriminatory harassment by other tenants.

Karen Loewy, Wetzel's attorney, would say only that "the matter has been resolved," and Wetzel is now living at a Chicago-area facility.

Last summer, in Missouri, a married lesbian couple, Mary Walsh, 73, and Bev Nance, 69, sued a senior-living facility that denied their housing application. The Friendship Village assisted living center cited a "cohabitation policy" that defines marriage as between one man and one woman as the reason.

A U.S. district judge dismissed the suit in January, saying that their claims of discrimination were "based on sexual orientation rather than sex alone." The distinction is important because neither federal nor state laws explicitly prohibit discrimination based on sexual orientation. The suit has been stayed pending Supreme Court decisions that could affect the outcome.

In the meantime, the couple has remained in their single-family home, where Walsh has developed health problems, said their lawyer, Julie Wilensky of the National Center for Lesbian Rights.

"They wanted to be planning in advance so that they would have stability when issues might come up in the future," Wilensky said.

Not every LGBTQ person will want to step forward in the way Wetzel, Walsh and Nance have, said Loewy.

"When you feel like you're being denied care … you may not want to be out there to wave the banner," she said.

Finding an LGBTQ-tolerant facility can be difficult. People are often bound by geography, and options are limited.

Still, LGBT people and their families can—and should—have candid conversations with potential caregivers before they make a choice, Loewy said.

One key question: Ask what kind of experience staff have working with LGBTQ people.

"If they say they haven't [treated any such patients], don't believe them," Loewy said. "You want to hear a real clear commitment to ensuring every resident of this facility is going to be treated with dignity."

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