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."

For Civilians, Finding A Therapist Skilled In PTSD Treatments Is A Tough Task

KFF Health News, May 22, 2019

Only a portion of the more than 423,000 mental health counselors, therapists, psychologists, and psychiatrists in the U.S. are trained in two key therapies recommended as part of PTSD care.

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

By Caroline Covington

AUSTIN, Texas—Lauren Walls has lived with panic attacks, nightmares and flashbacks for years. The 26-year-old San Antonio teacher sought help from a variety of mental health professionals—including spending five years and at least $20,000 with one therapist who used a Christian-faith-based approach, viewing her condition as part of a spiritual weakness that could be conquered—but her symptoms worsened. She hit a breaking point two years ago, when she contemplated suicide.

In her search for help, Walls encountered a psychiatrist who diagnosed her with post-traumatic stress disorder. As a result, she sought out a therapist who specialized in trauma treatment, and that's when she finally experienced relief.

"It was just like a world of difference," Walls said.

Seeing herself as someone with PTSD was odd at first, Walls recalled. She isn't a military veteran and thought PTSD was a diagnosis reserved for service members. But her psychologist, Lindsay Bira, explained that she likely developed the mental disorder from years of childhood abuse, neglect and poverty.

PTSD has long been associated with members of the military who have gone through combat, and with first responders who may face trauma in their work. It's also associated with survivors of sexual assault, car accidents and natural disasters. Researchers have also found that it can develop in adults who've experienced chronic childhood trauma—from physical, emotional or sexual abuse by caregivers, to neglect or other violations of safety.

Walls was fortunate to find a therapist trained to treat PTSD. Outside of military and veterans' health facilities, finding knowledgeable help is often difficult.

Only a portion of the more than 423,000 mental health counselors, therapists, psychologists and psychiatrists in the U.S. are trained in two key therapies, called Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) therapy. These are treatments recommended as part of a patient's care by the American Psychiatric Association and the Department of Veterans Affairs, which has studied treatments for PTSD since it affects many service members.

There is no definitive tally of people trained in these therapies, and neither the American Psychiatric Association nor the American Psychological Association tracks this data. A 2014 study by the Rand Corp. found that only about a third of psychotherapists had the training. The VA says over 6,000 of its therapists have, although rosters for the CPT and PE organizations list just a few hundred total practitioners.

Nonetheless, the VA's National Center for PTSD wants to expand access to these treatments, and regional groups, including those in Texas, are following its lead. Texas has a need for more PTSD providers: It ranks No. 2 nationwide for its number of human-trafficking victims; it's the leading state for refugee resettlement; it has the most unaccompanied child migrants of any state; and Texas is second only to California in the number of military service members—all factors that raise the risk of PTSD.

UT Health San Antonio, a University of Texas medical school and hospital, teaches community mental health providers how to provide the two PTSD therapies through its Strong Star Training Initiative. Funded by the Texas Veterans + Family Alliance grant program and the Bob Woodruff Foundation, it has trained 500 providers since it started in 2017. Most training takes place in San Antonio, and many of the mental health professionals who participate are Texas-based, though they also come from Florida, Illinois and other states.

In February, about 20 therapists gathered in a conference room at the medical school for instruction. Calleen Friedel, a San Antonio-based marriage and family therapist, was one of them. She said she is seeing more people with PTSD and often feels inept at helping them.

"I would just do what I know and do my own reading," Friedel said. "And what I was taught in graduate school, which was, like, over 20 years ago."

The group learned about one of the mainstream therapies, Prolonged Exposure therapy, which gradually exposes patients to trauma memories to help reduce PTSD symptoms. Strong Star also teaches Cognitive Processing Therapy, which involves helping the patients learn to reframe their thoughts about the trauma. But both therapies—often referred to as "evidence-based treatments"—have been slow to gain traction among psychotherapists because they're closely scripted and differ from the common therapeutic approach to mental health issues.

Edna Foa, who created PE, said in a 2013 journal article that many psychotherapists believe delving into a patient's inner life and history is central to their work. By contrast, highly structured evidence-based treatments—with their pre- and post-session evaluations and their focus on symptom relief—can seem "narrow and boring," she wrote.

Indeed, some people living with PTSD have complained that the treatments don't work for everyone. But Foa and others argue the focused approach targets the brain's mechanisms that cause PTSD symptoms, and symptom relief is what many living with PTSD want.

Edwina Martin, a psychologist in Bonham, Texas, said treatments like the ones she's learning at Strong Star weren't mainstream when she finished school more than 10 years ago. She now is employed at a VA health center after working for a decade in prisons, and she said she wants these in her "tool bag."

The push to expand the workforce coincides with a growing understanding of trauma's effects. The National Council for Behavioral Health, a nonprofit organization of mental health care providers, calls trauma a "near universal experience" for people with mental and behavioral health issues.

Because so many patients think that PTSD is mostly a military problem, Bira said, they encounter a roadblock to recovery.

"I get that all the time," Bira said. "The beginning stages in treatment that I find with civilians are really about educating [them] about what PTSD is and who can develop it."

A Medical Sanctuary For Migrant Farmworkers

KFF Health News, May 21, 2019

Patients are never asked about their immigration status, and the staffs have set up protocols in case the offices are raided by immigration authorities.

This article was published May 21, 2019, by Kaiser Health News.

By John M. Glionna

FRESNO, Calif.—On the 15-mile drive between his two Central Valley medical clinics, Dr. J. Luis Bautista often passes armies of farmworkers stooped over in the fields, picking onions, melons and tomatoes.

Most of the 30,000 annual office visits to his small staff of doctors and nurses in downtown Fresno and the nearby rural town of Sanger are by these farmworkers. Many of them are undocumented.

The 64-year-old physician has personal insight into the struggles of these laborers: He was once one of them. As a boy, he picked fruit alongside his parents and nine siblings in Ventura County. The family made $4,000 a year back then, a little over $30,000 in today's dollars—rarely enough to spare for doctor's visits.

These days, Bautista sees that many farmworkers still lack the transportation, money or time off from work to treat injuries, let alone seek preventive medical care. Plus, there is the heightened fear that by seeking medical treatment they might be exposed to federal immigration authorities.

"I pledged in medical school to help these people in the farm fields," said Bautista. "I knew how it felt not to have anything, not to have the money to go to a doctor."

Now he treats them whether or not they have money—or legal documents. "We never say no to patients," he said.

President Donald Trump's campaign pledge to deport an estimated 11 million immigrants who have entered the U.S. illegally has fostered fear among farmworkers nationwide. Terrified they'll be caught in an immigration dragnet, farm laborers across the San Joaquin Valley without U.S. citizenship or official documents avoid driving to see a doctor or visit an emergency room.

Although California law strictly limits the state's cooperation with U.S. immigration enforcement, some jurisdictions outside the Central Valley have decided to participate in federal efforts to detain undocumented workers. Many here fear that local officials will soon join them, Bautista said.

Farmworkers also worry that personal information housed in doctors' offices could find its way into the hands of federal authorities. And some fear that if they enroll in programs for low-income residents, they'll later be denied permanent residence, the so-called green card, or U.S. citizenship.

The Trump administration has proposed a federal rule change that would make it harder for legal immigrants to get green cards if they have received certain public assistance benefits, including food stamps, housing subsidies and Medicaid—the government-funded health care program for people with low incomes.

"Many people don't know what the government will do," Bautista said. "They tell me that one reason they don't go to the doctor is over fear they'll be reported."

Bautista's two clinics provide a haven for immigrants burdened by these concerns. Patients are never asked about their immigration status, and the staffs have set up protocols in case the offices are raided by immigration authorities.

"I feel secure with him," said Julia Rojas, a 45-year-old undocumented mother of five who has picked oranges in Fresno County for two decades. "He's one of us."

Bautista accepts as payment whatever his patients can offer: onions, handmade key chains, eggs, even live chickens.

Dan Baradat, a Fresno personal injury lawyer who has handled cases involving migrant workers, said Bautista's clinics are indispensable to the Central Valley's poorer residents. "They're stand-up people who provide care to people who could not otherwise afford it," he said.

[caption id="attachment_310148" align="aligncenter" width="1024"] Bautista, a former farmworker, runs two clinics in California's Central Valley providing care—often free of charge—for migrants who don't have money and are deeply worried about the federal government's hard-line stance on immigration. (John M. Glionna for KHN)[/caption]

Bautista's clinics are among a network of federally supported community clinics that provide care for nearly 1 million migratory and seasonal agricultural workers and their families around the U.S. But few providers have a better connection to the community they serve than Bautista, who in 2013 founded a nonprofit that raises money to assist low-income farm families with food and clothing, and provides scholarships to send their children to college.

Born in Fresno, Bautista was deported with his parents when he was just 3 months old. He lived in Mazatlán, Mexico, until he returned to the U.S. at age 12.

In 1979, at age 24, he was picking lemons when his mother came running out to the fields with the letter announcing he'd been admitted to medical school. She'd always been big on education for her 10 children.

Bautista attended the Medical College of Wisconsin in Milwaukee and did his residency in internal medicine at the University of Nevada-Reno.

Today, Bautista's two sons are also doctors, as is his son-in-law, who was a farmworker before attending medical school and has joined the clinic. They all know that fear of deportation is affecting farmworkers' health.

Dr. Ed Zuroweste, founding medical director of the nationwide Migrant Clinicians Network, said a recent survey of providers within the organization underlined these fears.

"What we're seeing on the front lines is that farmworkers and their families are not coming in for regular appointments as frequently as they had before," he said.

Bautista said many undocumented farmworkers rely on home remedies to treat ailments such as diabetes and high blood pressure, often until it's too late for effective medical treatment. "By the time I see many diabetic patients, their feet are already necrotic and we have to amputate," Bautista said. "It's terrible to see."

Jose Jimenez, a former farmworker, said his father, who is not in this country legally, was too afraid to drive to Bautista's office, even after developing signs of melanoma on his face. His dad's fears were heightened last year following the death of an undocumented couple, the parents of six children, whose van overturned while they were fleeing federal immigration officers in nearby Delano.

"He was even afraid to drive to the supermarket," said Jimenez, 30. "He knew that if he was picked up, he'd be deported. For a close-knit family like ours, that would mean losing everything." But Jimenez finally persuaded his father to visit Bautista.

Bautista's clinics are on guard against U.S. immigration officials, known in this community as la migra.

Law enforcement officials requesting records are asked for a warrant, and staff members are on the lookout for intruders. "By the time any ICE officers got inside the office," Bautista said, "we'd have people hiding in the restrooms."

Julia Rojas said her fears of deportation almost killed her. Years ago, before she began seeing Bautista, she chose to ignore the piercing pain in her lower abdomen. In the U.S. without papers and afraid to drive, she spent nearly a day drinking mint leaves in hot water—a remedy her mother used for stomach pain back in Mexico.

Unable to stand the spasms, she finally went to the nearest emergency room, where doctors removed her gall bladder. "Among undocumented workers in the fields, we have a dark little joke," Rojas said. "You can survive out here. Just don't get sick."

U.S. Supreme Court

Supreme Court Declines To Hear Military Medical Malpractice Case

KFF Health News, May 21, 2019

Justices won’t alter the rule that prevents active-duty military members from suing the government for negligence. The challenge came from the family of Navy nurse Lt. Rebekah 'Moani' Daniel, who died in 2014 after bleeding to death following childbirth.

This article was published May 20, 2019, by Kaiser Health News.

By JoNel Aleccia, Kaiser Health News

The family of a young Navy nurse who died after military doctors allegedly failed to halt massive bleeding following childbirth won't get a hearing in the nation's highest court.

The Supreme Court on Monday denied a petition that sought to change what's known as the Feres doctrine, a long-standing rule that bars active-duty military members from suing the federal government for injuries, including medical malpractice.

The justices declined to discuss the case of Navy Lt. Rebekah "Moani" Daniel, who was 33 in 2014 when she died following a massive postpartum hemorrhage at the Naval Hospital Bremerton, within hours of the birth of her daughter, Victoria.

In court documents, Justice Ruth Bader Ginsburg said she would have granted the petition. Justice Clarence Thomas dissented from the decision, arguing that it was up to the court to reconsider the rule in the absence of a decision by Congress. He noted that the court in recent rulings "twisted traditional tort principles" to allow certain veterans to seek damages for negligence.

"Such unfortunate repercussions—denial of relief to military personnel and distortions of other areas of law to compensate—will continue to ripple through our jurisprudence as long as the Court refuses to reconsider Feres," he wrote.

Through a lawyer, the nurse's widower, Walter Daniel, and her daughter, Victoria, now 4, argued that the court should amend the 1950 ruling to allow service members to sue for medical malpractice the same way civilians can.

"Sadly, the justice system remains closed to our family, our colleagues and the families who commit their lives to military service," Daniel, 39, said in a statement Monday. "Victoria and I won’t have the opportunity to learn what led to Moani's death, and to ensure others don't experience the same tragedy."

Andrew Hoyal, Daniel's lawyer, said he was "clearly disappointed" at the decision but heartened at the responses from Thomas and Ginsburg.

"We knew from the beginning that this would be a long journey with even longer odds," he said.

Rebekah Daniel died on March 9, 2014, at the Washington state facility. In a 2015 wrongful death lawsuit, her husband claimed that she died from botched medical care that failed to halt hemorrhaging of nearly a third of the blood in her body.

Daniel, a former Coast Guard officer, disputed the findings of a Navy autopsy that concluded Rebekah Daniel died of "natural" causes possibly linked to a rare, hard-to-prove complication of childbirth.

But that lawsuit and subsequent appeals were dismissed not based on the facts of the case but because of the Feres doctrine, which holds that active-duty members of the military can't sue under the Federal Tort Claims Act for harm that they incur "incident to service."

The ruling was last challenged in the high court more than 30 years ago when the justices voted 5-4 to uphold it. That decision drew a scathing dissent from Justice Antonin Scalia, who declared the rule should be scrapped. More recently, Justice Thomas also argued it should be amended.

Since then, however, the court has refused to accept two previous petitions that would have allowed reconsideration. The Daniel request beat the odds. Of the 7,000 to 8,000 cases submitted to the Supreme Court each term, only about 80 are accepted.

Congress has considered amending the Feres rule in the past but stopped short of action. In April, Rep. Jackie Speier (D-Calif.) introduced H.R. 2422, which would allow active-duty service members to sue the government for damages caused by medical malpractice. The bill has been referred to the House judiciary committee.

Daniel said he would continue to work with lawmakers and advocates to change the rule.

"Our case and our fight is over—but it continues for other service members. Moani's story has generated a groundswell of momentum to correct the injustice of Feres, and now this issue is going all the way to Capitol Hill," the statement said.

Why Missouri's The Last Holdout On A Statewide Rx Monitoring Program

KFF Health News, May 20, 2019

Because of ongoing fears about privacy violations tangled up with gun control, the bill never got a full vote in the Missouri Senate.

This article was first published on Monday, May 20, 2019 in Kaiser Health News.

By Lauren Weber

Missouri retained its lonely title as the only state without a statewide prescription drug monitoring program — for the seventh year in a row — after the legislative session ended Friday.

Patient advocates, politicians, experts and members of the medical community had hoped this would finally be the year Missouri would create a statewide electronic database designed to help spot the abuse of prescription drugs. After all, Republican Gov. Mike Parson had pushed for it and, more important, its longtime opponent was no longer in office to block it.

But, because of ongoing fears about privacy violations tangled up with gun control, the bill never got a full Senate vote. And finance site WalletHub last week ranked Missouri third worst in the country for its drug use based on a review of arrests, overdose rates, opioid prescriptions and other measures.

Katie Reichard, a lobbyist with Missouri Primary Care Association who has been working in and around the Missouri legislature for almost 15 years and previously pushed for the issue, said this proposal has bedeviled the state capital as none other while the opioid crisis continues to rage nationwide.

"I've never seen anything take seven years to get anywhere, and especially something that's going to be put into place to save lives."

Missouri's cities, neighboring states and the federal government have been forced to create a patchwork of incomplete workarounds. Those include a voluntary program tracking patients' prescriptions run by St. Louis County that receives federal funding and a statewide monitoring system put into place by former Republican Gov. Eric Greitens that tracks physicians' prescriptions.

And yet, the state cannot seem to legislate a complete fix. "It's frustrating to watch the rest of the country get this done and watch Missouri be the last one," said Dr. Sam Page, the St. Louis County prescription drug monitoring program architect and current St. Louis County Executive.

To be sure, the databases don't eliminate the ability of drug abusers to acquire prescription opioids. But the federal Centers for Disease Control and Prevention has called such statewide patient monitoring databases "among the most promising state-level interventions" to improve opioid prescribing and protect at-risk patients.

It's an embarrassment Missouri can't figure out its own statewide system, often referred to as a PDMP, according to St. Joseph pharmacist JulieMarie Nickelson. "No one in the pharmacy or medical world really understands it," she said.

Privacy, Guns And Opposition

While a PDMP bill has been introduced every year in the Missouri legislature since 2005, it was initially championed by the minority Democratic Party, which meant it didn't have much of a shot at passing until 2012.

Then New Hampshire approved a statewide program in 2012, leaving Missouri as the sole holdout. That pressure, combined with an uptick in awareness of drug abuse, led to a swell of bipartisan agreement.

A statewide PDMP bill passed the Missouri House handily that year, then met its biggest adversary: Republican state Sen. Robert Schaaf, whose district stretched from Kansas City to St. Joseph along Missouri's western border.

Since then, Schaaf — who is also a family physician — filibustered or insisted on kill clauses that would never pass the House, citing his concerns over privacy and personal liberty issues along with his belief it was an ineffective tool. Year after year, his efforts would defeat PDMP bills.

Schaaf has said the risk of a database of patient information being hacked — and the government having access to the information — far outweighed the potential benefits. He also tapped into underlying fears of privacy violations, driven in part by a 2013 scandal over the Missouri Highway Patrol turning over a database of concealed weapons permit holders to a federal agent.

"I've always been opposed to taking private citizens' information and putting it on a government database to which many, many people have access," he told Kaiser Health News. "My understanding is there is no computer information to which the NSA is not privy. How long is it going to be 'til this is used to pare down the number of people with concealed weapons or weapons at all?"

By stoking privacy fears and connecting them to gun rights, Schaaf also helped tap into grassroots far-right opposition that lives on to this day. A YouTube video tweeted by this year's anti-PDMP supporters details how the St. Louis County monitoring system could be used in "passing your personal information on to the federal government, which could use it to infringe on your right to bear arms."

To date, the only reported hack has been of Virginia's PDMP database, though it is unclear if the hackers were able to access medical records.

Over the years, Missouri's PDMP advocates, led by Republican Rep. Holly Rehder, unsuccessfully tried to assuage such concerns by offering amendments to delete records older than three years and ensure medical information could not be tied to buying a gun. And while Schaaf did an about-face in 2017 and agreed to stop filibustering the proposal, he effectively killed it with his only stipulation: that all physicians be required to use it. That measure, which took away the inherent voluntary aspect of the PDMP, failed in the House.

"If they're going to take our liberty away for something that's never been proven to work, doctors have to use it," Schaaf told Kaiser Health News.

The former head of the St. Louis County Health Department, Faisal Khan, who in 2017 helped start the voluntary county-based PDMP program that now covers other portions of the state, claims the opposition goes deeper than what he called "totally unfounded" privacy concerns.

"They view St. Louis County and St. Louis City and St. Louis, in general, as this liberal Democratic bastion that they don't want anything to do with," he said. "It's the usual nonsense that we're seeing around the country at the moment, and it's stymying progress in the parts of the state where we need it the most."

But this year, Schaaf had hit his term limit of eight years in office and did not return to the Missouri Senate. Finally becoming like every other state seemed within reach — until a group of six Republican state senators formed a new conservative caucus and filibustered yet again over the issue, citing the same privacy issues and civil liberties.

"The conservative caucus has carried his torch on," Reichard said.

A Series Of Workarounds

Now, because the legislature has refused to move on the issue, cities, states and the federal government must continue to rely on the stopgaps they created to help address the opioid problem ravaging Missouri.

Today, 72 jurisdictions have opted into St. Louis County's voluntary prescription drug monitoring system so pharmacists and doctors could check a patient's other prescriptions. It now covers 84% of the state's population.

Even St. Joseph, one of the areas hardest hit by the opioid epidemic and where Schaaf lives, joined last year.

For Nickelson, a pharmacist at Rogers Pharmacy in the city of about 76,000 people, the voluntary database means she no longer has to spend upward of 30 minutes on the phone tracking down whether a patient had prescriptions for drugs elsewhere.

"It's really helpful to us as it makes it so we can make sure that patients aren't taking medications that interact and can increase risk for an overdose," she said. "We just want to make sure our patients are safe, and we want to make sure medication that's not necessary doesn't get into the community."

Since her city's voluntary PDMP has been in effect, she estimates she sees a handful fewer people each week who were doctor-shopping, a particular risk considering the pharmacy is less than 5 miles from the Kansas border.

Missouri was a premier destination for pill-shopping, Page said, but that's changed.

"Our PDMP is first-class, as any in the country," Page said. "We have gaps, but those will continue to fill in. If the state continues to not move forward with this, then St. Louis County will continue to do the right thing."

And while St. Louis County built its voluntary database in part with $200,000 from the U.S. Department of Justice, interstate sharing of the data with neighboring Illinois, Kansas and Oklahoma didn't happen until February. Eight states border Missouri and more states are expected to collaborate with St. Louis County's system this year. But data-sharing can occur only among states that have managed to bend or rewrite their regulations to accommodate the one state in the nation without a statewide program.

Tennessee even created and passed legislation to allow it to communicate with the St. Louis County program while Missouri was still haggling over its PDMP bill, according to Spring Schmidt, acting head of the St. Louis County Department of Public Health.

The system that Greitens created when governor, along with Express Scripts, to monitor physicians' prescriptions for unusual patterns led to 50 referrals to the Missouri Healing Arts Board — the disciplinary board for medical practitioners in Missouri — for prescribing issues since March 2018, according to Missouri's head of Health and Senior Services, Dr. Randall Williams.

Ideally, Williams said, he would love to combine a statewide version of the voluntary PDMP system with Greitens' physician-monitoring one, but he's waiting on the legislation.

Reichard can't help but wonder why the state won't join the rest of the nation in passing it.

"I'm not saying do what everyone else is doing," she said. "But if 49 other legislatures are saying 'This is important, we need to save lives,' I don't understand why Missouri can't find a way to compromise and do what's best for its citizens."

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Escalating Workplace Violence Rocks Hospitals

KFF Health News, May 20, 2019

Many healthcare workers say the physical and verbal abuse come primarily from patients, some of whom are disoriented because of illness or from medication.

This article was first published on Monday, May 20, 2019 in Kaiser Health News.

By Marlene Harris-Taylor, Ideastream

Across the country, many doctors, nurses and other healthcare workers have remained silent about what is being called an epidemic of violence against them.

The violent outbursts come from patients and patients' families. And for years, it has been considered part of the job.

When you visit the Cleveland Clinic emergency department — whether as a patient, family member or friend — a large sign directs you toward a metal detector.

An officer inspects all bags and then instructs you to walk through the metal detector. In some cases, a metal wand is used — even on patients who come in on stretchers. Cleveland Clinic officials say they confiscate thousands of weapons like knives, pepper spray and guns each year. The metal detectors were installed in response to what CEO Tom Mihaljevic calls an epidemic.

"There is a very fundamental problem in U.S. healthcare that very few people speak about," he said, "and that's the violence against healthcare workers. Daily — literally, daily — we are exposed to violent outbursts, in particular in emergency rooms."

Many healthcare workers say the physical and verbal abuse come primarily from patients, some of whom are disoriented because of illness or from medication. Sometimes nurses and doctors are abused by family members who are on edge because their loved one is so ill.

Cleveland Clinic has introduced other safety measures — such as wireless panic buttons incorporated into ID badges and more safety cameras and plainclothes officers in ERs.

But these incidents aren't limited to emergency rooms.

Allysha Shin works as a registered nurse in neuroscience intensive care at the University of Southern California's Keck Hospital in Los Angeles. One of the most violent incidents she has experienced happened when she was caring for a patient who was bleeding inside her brain.

The woman had already lashed out at other staff, so she had been tied to the bed, Shin said. She broke free of the restraints and then kicked and punched Shin in the chest — before throwing a punch at her face.

"There was this one point where she swung, and she had just glanced off the side of my chin. If I hadn't dodged that punch, she could have knocked me out," Shin said. "And she very well could have killed me."

The encounter left Shin shaken and anxious when she returned to work days later. She still has flashbacks.

She used to be afraid to speak about these types of attacks, she said, because of what she calls a culture of accepting violence in most hospitals. "It is expected that you are going to get beat up from time to time," Shin said.

According to the Occupational Safety and Health Administration, incidents of serious workplace violence are four times more common in healthcare than in private industry. And a poll conducted by the American College of Emergency Physicians in August found nearly half of emergency physician respondents reported having been physically assaulted. More than 60% of them said the assault occurred within the previous year.

Groups representing doctors and nurses say that, while the voluntary safety improvements that some hospitals have enacted are a good first step, more needs to be done.

There is still a code of silence in healthcare, said Michelle Mahon, a representative of the labor group National Nurses United. "What happens if they do report it?" she said. "In some cases, unfortunately, they are treated as if they are the ones who don't know how to do their job. Or that it's their fault that this happened."

"There's a lot of focus on de-escalation techniques," Mahon added. "Those are helpful tools, but oftentimes they are used to blame workers."

In California, the nurses' labor union pushed for a law giving OSHA more authority to monitor hospital safety. The group is now backing a national effort to do the same thing. "The standard that we are recommending federally holds the employer responsible," Mahon said. "It mandates reporting of incidents and transparency."

The Workplace Violence Prevention for Healthcare and Social Service Workers Act, introduced last fall in Congress, would require hospitals to implement plans to prevent violence. And any hospital could face fines for not reporting incidents to OSHA, Mahon said.

The goal of the legislation — and of the union — is to hold administrators more accountable for acts of violence in their hospitals.

This story is part of a partnership that includes Ideastream, NPR and Kaiser Health News.

'Sham' Sharing Ministries Test Faith Of Patients And Insurance Regulators

KFF Health News, May 17, 2019

Insurance regulators in Washington and other states are taking a hard look at healthcare sharing ministry — faith-based co-ops in which members agree to pay one another's medical bills.

This article was first published on Friday, May 17, 2019 in Kaiser Health News.

By JoNel Aleccia

Sheri Lewis, 59, of Seattle, needed a hip transplant. Bradley Fuller, 63, of nearby Kirkland, needed chemotherapy and radiation when the pain in his jaw turned out to be throat cancer. And Kim Bruzas, 55, of Waitsburg, hundreds of miles away, needed emergency care to stop sudden —and severe — rectal bleeding.

Each of these Washington state residents required medical treatment during the past few years, and each thought they had purchased health insurance through an online site.

But when it was time to pay the bills, they learned that the products they bought through Aliera Healthcare Inc. weren't insurance at all — and that the cost of their care wasn't covered.

Lewis and the others had enrolled in what Aliera officials claimed was a healthcare sharing ministry (HCSM) — faith-based co-ops in which members agree to pay one another's medical bills.

But Washington insurance officials this week said the firm doesn't meet the definition of a sharing ministry and described Aliera's products as a "sham" aimed at misleading consumers. Other states, including Texas and New Hampshire, are poised to take similar action.

Insurance Commissioner Mike Kreidler on Monday ordered Aliera, which operates Trinity Healthshare Inc., both of Delaware, to halt operations in Washington, alleging the firm was selling health insurance illegally and engaging in deceptive business practices.

Aliera falsely represented itself as a sharing ministry, which would be exempt from insurance regulations, an investigation found. Though he wouldn't name them, Kreidler said he's investigating two additional firms over similar concerns.

"They don't have the direct affiliation with a particular religious group, a church, a pastor," Kreidler said. 

In a statement, Aliera officials disputed Kreidler's conclusions. The company has 90 days to request a hearing.

"Aliera has never misled consumer and sales agents about its health plans," the statement said. "For example, our website, marketing materials and other communications clearly state that Trinity's health sharing products are not insurance. Most importantly, they have never been represented as insurance."

The Washington order followed complaints from nearly two dozen people, including Lewis, a dance teacher who was told her planned hip surgery wouldn't be covered.

Across the U.S., several state insurance regulators report similar concerns.

Texas insurance officials have scheduled a hearing to consider a similar order against Aliera, which has 100,000 members nationwide and reported revenue of $180 million in 2018, documents showed.

New Hampshire insurance officials on Tuesday warned consumers about Aliera, saying they were concerned about "potential fraudulent or criminal activity." Officials in at least five other states told Kaiser Health News they are reviewing firms operating as "illegitimate" healthcare sharing ministries.

Aliera is operated by Shelley Steele of Marietta, Ga., and her husband, Timothy Moses, who was convicted in 2006 of federal securities fraud and perjury. He was sentenced to 6½ years in prison and ordered to repay more than $1 million to victims.

Nationwide, nearly 1 million people are enrolled in more than 100 sharing ministries in at least 29 states, according to the Alliance of Healthcare Sharing Ministries. But that's just an estimate, said James Lansberry, executive vice president of Samaritan Ministries International of Peoria, Ill. No comprehensive data is available.

"We try to track what's going on out there," Lansberry said. "Anyone claiming to be a healthcare sharing ministry could spill over onto our reputation."

Samaritan is among what have been the three top players in the sharing ministries field. The oldest, founded in 1993, is the Medi-Share program of Melbourne, Fla., operated by Christian Care Ministry. The third is Christian Healthcare Ministries of Barberton, Ohio. All are explicitly religious and emphasize faith as the basis for members to share medical burdens.

Those groups originally were certified by the Centers for Medicare & Medicaid Services and required to meet specific criteria. Consumers who enrolled were shielded from the Affordable Care Act's individual mandate that required they show proof of insurance or pay a fine.

But CMS no longer certifies HCSMs and, since Congress zeroed out the mandate's penalty in 2017, a new crop of companies, including Aliera, has sprung up. That worries some of the traditional ministries.

"HCSMs must operate with integrity, transparency, full compliance with the law, and enforcement of the law," officials with Medi-Share, which has 415,000 members nationwide, said in a statement. "Anything outside of that violates the true spirit of the HCSM community."

Washington investigators found that Aliera's marketing materials rarely mention religious or ethical motivations, and they don't meet government requirements.

Many of these entities mimic the marketing, structure and language of ACA-compliant health insurance plans — but offer none of the protections, said JoAnn Volk and Justin Giovannelli, researchers at the Georgetown University Center on Health Insurance Reforms, who wrote about the issue last summer.

"The way they advertise and the services they are providing, it sounds a heck of a lot like health insurance," Giovannelli said. "They're letting folks believe they have a product that has a promise to pay."

That's exactly what Lewis thought.

"It looked like Aliera was health insurance to me," she said.

When Aliera denied her surgery, she had to resort to a GoFundMe site organized by friends to raise nearly $13,000 and then travel to Tijuana, Mexico, to get a hip transplant she could afford.

Fuller, who was diagnosed with throat cancer, said he was stuck with $81,000 in bills for his first month of treatment.

"They started checking my insurance and it didn't cover nothing," said the retired commercial electrician.

Fuller, his voice still raspy after radiation, said he had insurance through his union for years, but when the premiums spiked, he went online to find something else.

The person he talked to from Aliera said he could get insurance, no problem, Fuller said. The premium would be $350 a month, rather than the $1,300 fee for a gold plan on the state insurance exchange. "And that was with dental, too," he added.

Low premiums also attracted Bruzas, who left her well-paid government job in Tacoma, and the insurance it provided, after her husband died in 2015. She moved to a small town in southeastern Washington to care for her parents and went online to find health insurance.

"I just sat down and Googled 'Obamacare,'" she said. "I got a call back from a lady who said she could help me find coverage." Bruzas was charged $219 for the first month.

Four days later, she was in the local emergency room with massive rectal bleeding. As she was discharged, hospital officials said they had "never heard of Aliera Healthcare," she said.

The $10,000 bill was not covered. Bruzas, who works part time at a hardware store, filed for charity care and the debt was reduced to $6,500. She is paying it off slowly, $50 each month.

The Washington patients recalled mentions of "sharing" and vague references to spirituality. But none realized they were signing up for a religious cost-sharing ministry, they said.

"I would have hung up the phone if she would have said, 'We're a group, and we'll review your records and pray for you,'" Bruzas said.

Aliera officials said they make the nature of their products clear.

"Aliera disagrees that Trinity's inclusive and specific statement of beliefs misleads consumers or violates the applicable regulations governing healthcare sharing ministries," the statement said.

It's not clear how states can curb the new sharing ministries. If Aliera ignores his order, Kreidler said, he'll seek a court injunction to force the groups to cease operations. But several states contacted by KHN said that because the ministries are not health insurance, state insurance officials don't review or regulate them.

Some users of sharing ministries say the lower-priced products should be available for consumers who understand and accept the risks involved.

But consumers need to pay close attention to details when they sign up for any health plans, said Colorado Insurance Commissioner Michael Conway, who is investigating sharing ministries operating in his state.

"Ask if it's actually insurance," he advised. "Ask if there's a guarantee of coverage. Get into the policy documents. Read the contract they're agreeing to."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Editor's note: This story has been updated to include a link from Aliera.

As ER Wait Times Grow, More Patients Leave Against Medical Advice

KFF Health News, May 17, 2019

The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters.

This story was first published on Friday, May 17, 2019 in Kaiser Health News.

By Phillip Reese

Emergency room patients increasingly leave California hospitals against medical advice, and experts say crowded ERs are likely to blame.

About 352,000 California ER visits in 2017 ended when patients left after seeing a doctor but before their medical care was complete. That's up by 57%, or 128,000 incidents, from 2012, according to data from the Office of Statewide Health Planning and Development.

Another 322,000 would-be patients left the emergency room without seeing a doctor, up from 315,000 such episodes in 2012.

Several hospital administrators said overcrowding is a likely culprit for the trend. California emergency room trips grew by almost 20%, or 2.4 million, from 2012 to 2017.

Moreover, ER wait times also increased for many during that time period: In 2017, the median ER wait time for patients before admission as inpatients to California hospitals was 336 minutes — or more than 5½ hours. That is up 15 minutes from 2012, according to the federal Centers for Medicare & Medicaid Services. The median wait time for those discharged without admission to the hospital dropped 12 minutes over that period, but still clocked in at more than 2½ hours in 2017.

California wait times remain higher than the national average. In 2017, the median length of a stay in the ER before inpatient admission nationwide was 80 minutes shorter than the median stay in California. Four states — Maryland, New York, New Jersey and Delaware — had even longer median wait times.

The growth in patients leaving California ERs prematurely was faster than the growth in overall ER encounters. About 2.4% of ER trips in 2017 ended with patients leaving the ER against medical advice or abruptly discontinuing care after seeing a doctor, compared with 1.8% in 2012.

"Most patients are sick but not critically ill," said Dr. Steven Polevoi, medical director of the emergency department at UCSF Helen Diller Medical Center at Parnassus Heights. "Emergency care doesn't equal fast care all of the time."

When a patient leaves the ER after seeing a doctor but before the doctor clears them to leave, the Office of Statewide Health Planning and Development classifies that encounter as "leaving against medical advice or discontinued care." The definition includes encounters in which a doctor carefully explains the risks to the patient and has the patient sign a form, but also instances in which the patient simply discontinues care and bolts out the door.

Patients leaving the emergency room too soon "are deliberately putting themselves at more risk for morbidity and even mortality," Polevoi said — a point echoed by other physicians.

Dr. Veronica Vasquez-Montez, emergency room medical director at Good Samaritan Hospital in Los Angeles, said she sometimes finds herself having "tough conversations" with sick patients intent on leaving the ER, often citing pressing responsibilities.

"If you die from this," she tells them, "you are good to no one you are caring for."

One of her recent patients was at high risk for a major stroke but insisted he needed to leave the ER to take care of his pet.

"Guess what he came back for? A major stroke," said Vasquez-Montez, also a clinical assistant professor at the University of Southern California's Keck School of Medicine.

Compared with all ER patients, those leaving against medical advice were more likely to be men; people ages 20 to 39; and uninsured or on Medi-Cal, the government insurance program for the poor, state figures show. They were also more likely to complain primarily of non-specific symptoms such as chest pain or a cough.

Fresno, Shasta, Yuba, Kern, San Bernardino and Tulare counties had the highest proportion of ER encounters in 2017 that ended with patients leaving against medical advice or abruptly discontinuing care. Each of those counties recorded more than 4% of ER patients leaving too soon, state figures show.

From 2012 to 2017, the number of emergency room encounters in Fresno County increased by almost 95,000, or 37%. At Fresno's Community Regional Medical Center, about 9% of ER encounters ended with a patient leaving too soon, more than three times the statewide rate.

Community Regional Medical Center is one of the busiest hospitals in the state. It recently instituted a "Provider at Triage" program that puts caregivers in the lobby area with patients, said Dr. Jeffrey Thomas, the hospital's chief medical and quality officer. The hospital's internal data now show fewer than 2% of patients leaving against medical advice or abruptly discontinuing care.

"When patients bring themselves into the ED, they are seen in about 5 minutes by a qualified registered nurse and, on average, are seen by a provider within 30 minutes of arrival," Thomas said in a statement.

When a sick patient is about to leave the emergency room, doctors should determine why he or she wants to go, make sure the patient is capable of making a sound decision, involve friends and family, explain the course of treatment and, if nothing works, arrange for speedy follow-up care, said Dr. Jay Brenner, emergency department medical director at Upstate University Hospital-Community Campus in New York and co-author of several studies about patients leaving against medical advice.

"When someone requests to leave," Brenner said, "it needs to be a priority that ranks just below a cardiac arrest."

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

Walmart Charts New Course By Steering Workers To High-Quality Imaging Centers

KFF Health News, May 15, 2019

The retail giant is believed to be the first to prod workers to use imaging providers based on diagnostic accuracy — not price.

This article was first published on Wednesday, May 15, 2019 in Kaiser Health News.

By Phil Galewitz

Walmart Inc., the nation's largest private employer, is worried that too many of its workers are having health conditions misdiagnosed, leading to unnecessary surgery and wasted health spending.

The issue crystallized for Walmart officials when they discovered about half of the company's workers who went to the Mayo Clinic and other specialized hospitals for back surgery in the past few years turned out to not need those operations. They were either misdiagnosed by their doctor or needed only non-surgical treatment.

A key issue: Their diagnostic imaging, such as CT scans and MRIs, had high error rates, said Lisa Woods, senior director of benefits design for Walmart.

So the company, whose health plans cover 1.1 million U.S. employees and dependents, has recommended since March that workers use one of 800 imaging centers identified as providing high-quality care. That list was developed for Walmart by Covera Health, a New York City-based health analytics company that uses data to help spot facilities likely to provide accurate imaging for a wide variety of conditions, from cancer to torn knee ligaments.

Although Walmart and other large employers in recent years have been steering workers to medical centers with proven track records for specific procedures such as transplants, the retail giant is believed to be the first to prod workers to use specific imaging providers based on diagnostic accuracy — not price, said employer health experts.

"A quality MRI or CT scan can improve the accuracy of diagnoses early in the care journey, helping create the correct treatment plan with the best opportunity for recovery," said Woods. "The goal is to give associates the best chance to get better, and that starts with the right diagnosis."

Walmart employees are not required to use those 800 centers, but if they don't use one that is available near them, they will have to pay additional cost sharing. Company officials advise workers that they could have more accurate results if they opt for the specified centers.

Studies show a 3% to 5% error rate each workday in a typical radiology practice, but some academic research has found mistakes on advanced images such as CT scans and MRIs can reach up to 30% of diagnoses. Although not every mistake affects patient care, with millions of CT scans and MRIs done each year in the United States, such mistakes can have a significant impact.

"There's no question that there are a lot of errors that occur," said Dr. Vijay Rao, chairwoman of radiology at the Thomas Jefferson University Hospital in Philadelphia.

Errors at imaging centers can happen for many reasons, including the radiologist not devoting enough time to reading each image, Rao said. The average radiologist typically has only seconds to read each image, she said. "It's just a lot of data that crosses your eye and there is human fatigue, interruptions, and errors are bound to happen," she added.

Other pitfalls: the technician not positioning the patient correctly in the imaging machine or a radiologist not having sufficient expertise or experience, Rao said.

Employers and insurers typically do little to help patients identify which radiology practices provide the most accurate results. Instead, employers have been focused on the cost of imaging tests. Some employers or insurers require plan members to use free-standing outpatient centers rather than those based in hospitals, which tend to be more expensive.

Woods said Walmart found that deficiencies and variation in imaging services affected employees nationwide. "Unfortunately, it is all over the country. It's everywhere," she said.

Walmart's new imaging strategy is aligned with its efforts over the past decade to direct employees to select hospitals for high-cost health procedures. Since 2013, Walmart has been sending workers and their dependents to select hospitals across the country where it believes they can get better results for spine surgery, heart surgery, joint replacement, weight loss surgery, transplants and certain cancers.

As part of its "Centers of Excellence" program, the Bentonville, Ark.-based retail giant picks up the tab for the surgeries and all related travel expenses for patients on the company's health insurance plan, including a caregiver.

Sampling Imaging Centers' Work

Covera has collected information on thousands of hospital-based and outpatient imaging facilities starting with its previous business work in the workers' compensation field.

"Our primary interest is understanding which radiologist or radiology practices are achieving the highest level of diagnostic accuracy for their patients," said Dan Elgort, Covera's chief data science officer.

Covera has independent radiologists evaluate a sampling of patient care data on imaging centers to determine facilities' error rates. It uses statistical modeling along with information on each center's equipment, physicians and use of industry-accepted patient protocols to determine the facilities' rates of accuracy.

Covera expects to have about 1,500 imaging centers in the program by year's end, said CEO Ron Vianu.

There are about 4,000 outpatient imaging centers in the United States, not counting thousands of hospital-based facilities, he estimated.

As a condition for participating in the program, each of the imaging centers has agreed to routinely send a sampling of their patients' images and reports to Covera.

Vianu said studies have shown that radiologists frequently offer different diagnoses based on the same image taken during an MRI or CT scan. Among explanations are that some radiologists are better at analyzing certain types of images — like those of the brain or bones — and sometimes radiologists read images from exams they have less experience with, he said.

Vianu noted that most consumers give little thought to where to get an MRI or CT scan, and usually go where their doctors send them, the closest facility or, increasingly, the one that offers the lowest price. "Most people think of diagnostic imaging as a commodity, and that's a mistake," he said.

Rao applauded the effort by Walmart and Covera to identify imaging facilities likely to provide the most accurate reports. "I am sure centers that are worried about their quality will not be happy, but most quality operations would welcome something like this," she said.

Few Guides For Consumers

Consumers have little way to distinguish the quality of care from one imaging center to the next. The American College of Radiology has an accreditation program but does not evaluate diagnostic quality.

"We would love to have more robust … measurements" than what is currently available, said Dr. Geraldine McGinty, chair of the college's board of chancellors.

Facilities typically conduct peer reviews of their radiologists' patient reports, but there is no public reporting of such results, she said.

Covera officials said they have worked with Walmart for nearly two years to demonstrate they could improve the quality of diagnostic care its employees receive. Part of the process has included reviewing a sample of Walmart employees' health records to see where changes in imaging services could have caught potential problems.

Covera said the centers in its network were chosen based on quality and price was not a factor.

In an effort to curtail unnecessary tests, Walmart, like many large employers and insurers, requires its insured members to get authorization before getting CT scans and MRIs.

"Walmart is on the leading edge of focusing on quality of diagnostic imaging," said Suzanne Delbanco, executive director of the Catalyst for Payment Reform, an employer-led healthcare think tank and advocacy group.

But Mark Stolper, executive vice president of Los Angeles-based RadNet, which owns 335 imaging centers nationally, questions how Covera has enough data to compare facilities. "This would be the first time," he said, "I have seen or heard of a company trying to narrow a network of imaging centers that is based on quality instead of price."

Woods said that even though the new imaging strategy is not based on financial concerns, it could pay dividends down the road.

"It's been demonstrated time and time again that high quality ends up being more economical in the long run because inappropriate care is avoided, and patients do better," she said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

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