Docs Call California's Probe of Opioid Deaths a 'Witch Hunt'

KFF Health News, January 23, 2019

State regulators have formally accused at least 23 doctors of negligent prescribing. More accusations are expected.

This article first appeared January 23, 2019 on Kaiser Health News.

By Cheryl Clark

The Medical Board of California has launched investigations into doctors who prescribed opioids to patients who, perhaps months or years later, fatally overdosed.

The effort, dubbed “the Death Certificate Project,” has sparked a conflict with physicians in California and beyond, in part because the doctors being investigated did not necessarily write the prescriptions leading to a death. The project is one of a kind nationally, although a much more limited program is operated by North Carolina’s board.

So far, the board has launched investigations into the practices of about 450 physicians and referred the names of 72 nurse practitioners, physician assistants and osteopathic physicians to their respective licensing boards.

To date, the regulators have formally accused at least 23 doctors of negligent prescribing, and more accusations are expected. Some of the accusations, like one 63-page document filed against Dr. Frank Gilman, a San Diego internist, detail hundreds of prescriptions for one patient over four years, most of them by him. Gilman did not respond to a request for comment.

Using terms such as "witch hunt" and "inquisition," many doctors said the project is leading them or their peers to refuse patients’ requests for painkiller prescriptions — no matter how well documented the need — out of fear their practices will come under disciplinary review.

The project, first reported by MedPage Today, has struck a nerve among medical associations. Dr. Barbara McAneny, the American Medical Association president and an Albuquerque, N.M., oncologist whose cancer patients sometimes need treatment for acute pain, called the project "terrifying." She said "it will only discourage doctors from taking care of patients with pain."

The influential California Health Care Foundation also has pushed back against the project, saying it could harm patients. (California Healthline is an editorially independent publication of the California Health Care Foundation.)

Unusually aggressive for the board, the program is a reaction to the by now well-known phenomenon of physicians overprescribing opioids. Nationally, a host of policy changes and educational efforts have driven down the rate of opioid prescriptions in recent years.

The goal of California’s program, quietly launched four years ago, is not necessarily to link a doctor's specific prescription to a specific patient’s death — although many of the cases do — but to find doctors whose patterns of prescribing are so dangerous they may lead to patients' ultimately fatal addictions.

Sometimes a doctor was earmarked for investigation even though the cause of death included multiple drugs prescribed by many physicians, or suicide by overdose, board documents indicate.

Kimberly Kirchmeyer, executive director of the Medical Board of California, defended the project. She said the effort has found patterns of "gross negligence," incompetence and excessive prescribing.

"I understand their frustrations," she said of the complaining doctors, "but we do have to continue our role with consumer protection."

She noted that part of the point of the project is to educate doctors and, through probation requirements, change the behavior of those who prescribe excessively.

"That's education that could potentially save patients in the future," said Kirchmeyer, whose agency licenses some 141,000 doctors.

Some consumer groups consider the board’s bold effort to find overprescribing doctors not aggressive enough.

"It's long overdue," said Carmen Balber, executive director of the nonprofit Consumer Watchdog. The board should investigate opioid-related deaths that occurred more recently, she said: "They need to get their act together and speed things up."

The agency thus far has looked at deaths only in 2012 and 2013 in which opioids were confirmed as a cause or contributing cause. It matched the names of the dead with the prescription drugs they filled, which are listed in the state’s prescription database. The database also shows the names of the doctors who prescribed to them. Physician experts reviewed those doctors’ prescribing history and selected those who appeared to prescribe drugs heavily.

Some doctors said they were especially angered that the letters they received concerned prescriptions they wrote as long as nine years ago.

McAneny, of the AMA, noted that prescribing practices now deemed unacceptable came out of public policies years ago that "compelled doctors to treat pain more aggressively for the comfort of our patients." Also, payers have measured quality of care by whether their patients answered surveys about whether their pain was well-controlled.

"We’re [already] doing a lot of education to undo the damage" from those policies, she said.

Similarly, Dr. David Aizuss, a Los Angeles ophthalmologist who is president of the California Medical Association, said state and federal guidelines that took effect in 2014 and 2016 impose much more stringent prescribing precautions than “what was going on six or seven years ago.”

Many insurance plans and pharmacies in recent years have restricted dosages and durations of certain painkillers a physician may prescribe at one time.

The crackdown on doctors has created fear, said Dr. Robert Wailes, a pain medicine specialist in Encinitas and chair of the California Medical Association’s Board of Trustees.

"What we're finding is that more and more primary care doctors are afraid to prescribe and more of those patients are showing up on our doorsteps," he said.

Officially, the CMA stops short of saying the medical board should stop the project, perhaps to avoid any perception that the association condones overprescribing. But it has asked the board to hire an independent reviewer to assess the criteria the board is using to decide which physicians to investigate, and whether physicians in certain specialties or regions of the state are being targeted more than others.

Dr. Ako Jacintho, a San Francisco addiction medicine specialist, was notified by the board that he was in trouble over a year ago. A patient for whom he had prescribed methadone fatally overdosed in 2012. The letter said "a complaint" had been filed against him, and asked him to respond to the allegations or, if he delayed, face a citation or fine of $1,000 per day. (The medical board can file its own complaints against a doctor.)

The letter said the patient had died of "acute combined methadone and diphenhydramine intoxication." Jacintho had refilled the patient's prescription for methadone the day before but said a 10-milligram pill was not a toxic dose. And he said he never prescribed diphenhydramine, the antihistamine sold as Benadryl.

"The only way he would have died was if he had not taken it as directed, or had mixed it with a medication that was not prescribed," Jacintho said.

As of Dec. 21, Jacintho was still waiting to hear if he would face a formal accusation.

Last year, the board rewrote those letters in a less accusatory tone — describing the "review" as routine — although it still threatens doctors with $1,000 fines. In a much smaller subset of cases, it finds problems that result in formal accusations that can result in discipline, such as public reprimands or restrictions on a physician's ability to practice.

Despite its designation as a "Death Certificate Project," the California effort has not focused only on doctors whose patients died. In an unknown number of overdose cases, the board has sent letters to living patients asking them to authorize their doctors to relinquish their medical records to the board, adding that those documents would otherwise be subpoenaed.

Dr. Paul Speckart, a San Diego internist, said three of his patients last year received board letters that seemed to question his quality of care when all he did was try to relieve their well-documented pain. The board has not filed any accusations against him.

"You can't even begin to understand how disrupting and upsetting this is," Speckart said. "It's not just a threat on your license; it's a threat that you've not been a good physician."

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Can States Fix the Disaster of U.S. Healthcare?

KFF Health News, January 22, 2019

The legalization of gay marriage began in a few states and quickly became national policy. Marijuana legalization seems to be headed in the same direction. Could reforming healthcare follow the same trajectory?

This article first appeared January 22, 2019 on Kaiser Health News.

By Elisabeth Rosenthal

Last week, California’s new governor, Gavin Newsom, promised to pursue a smörgåsbord of changes to his state's healthcare system: state negotiation of drug prices, a requirement that every Californian have health insurance, more assistance to help middle-class Californians afford it and healthcare for undocumented immigrants up to age 26.

The proposals fell short of the sweeping government-run single-payer plan Newsom had supported during his campaign — a system in which the state government would pay all the bills and effectively control the rates paid for services. (Many California politicians before him had flirted with such an idea, before backing off when it was estimated that it could cost $400 billion a year.) But in firing off this opening salvo, Newsom has challenged the notion that states can't meaningfully tackle healthcare on their own. And he's not alone.

A day later, Gov. Jay Inslee of Washington proposed that his state offer a public plan, with rates tied to those of Medicare, to compete with private offerings.

New Mexico is considering a plan that would allow any resident to buy in to the state's Medicaid program. And this month, Mayor Bill de Blasio of New York announced a plan to expand healthcare access to uninsured, low-income residents of the city, including undocumented immigrants.

For over a decade, we've been waiting for Washington to solve our healthcare woes, with endless political wrangling and mixed results. Around 70 percent of Americans have said that healthcare is "in a state of crisis" or has "major problems." Now, with Washington in total dysfunction, state and local politicians are taking up the baton.

The legalization of gay marriage began in a few states and quickly became national policy. Marijuana legalization seems to be headed in the same direction. Could reforming healthcare follow the same trajectory?

States have always cared about healthcare costs, but mostly insofar as they related to Medicaid, since that comes from state budgets. "The interesting new frontier is how states can use state power to change the health care system," said Joshua Sharfstein, a vice dean at Johns Hopkins Bloomberg School of Public Health and a former secretary of the Maryland Department of Health and Mental Hygiene. He added that the new proposals "open the conversation about using the power of the state to leverage lower prices in healthcare generally."

Already states have proved to be a good crucible for experimentation. Massachusetts introduced "Romneycare," a system credited as the model for the Affordable Care Act, in 2006. It now has the lowest uninsured rate in the nation, under 4 percent. Maryland has successfully regulated hospital prices based on an "all payer" system.

It remains to be seen how far the West Coast governors can take their proposals. Businesses — pharmaceutical companies, hospitals, doctors' groups — are likely to fight every step of the way to protect their financial interests. These are powerful constituents, with lobbyists and cash to throw around.

The California Hospital Association came out in full support of Newsom's proposals to expand insurance (after all, this would be good for hospitals' bottom lines). It offered a slightly less enthusiastic endorsement for the drug negotiation program (which is less certain to help their budgets), calling it a "welcome" development. It's notable that his proposals didn’t directly take on hospital pricing, even though many of the state's medical centers are notoriously expensive.

Giving the state power to negotiate drug prices for the more than 13 million patients either covered by Medicaid or employed by the state is likely to yield better prices for some. But pharma is an agile adversary and may well respond by charging those with private insurance more. The governor's plan will eventually allow some employers to join in the negotiating bloc. But how that might happen remains unclear.

The proposal by Washington Gov. Inslee to tie payment under the public option plans to Medicare's rates drew "deep concern" from the Washington State Medical Association, which called those rates "artificially low, arbitrary and subject to the political whims of Washington, D.C."

On the bright side, if Newsom or Inslee succeeds in making healthcare more affordable and accessible for all with a new model, it will probably be replicated one by one in other states. That's why I'm hopeful.

In 2004, the Canadian Broadcasting Corp. conducted an exhaustive nationwide poll to select the greatest Canadian of all time. The top-10 list included Wayne Gretzky, Alexander Graham Bell and Pierre Trudeau. No. 1 is someone most Americans have never heard of: Tommy Douglas.

Douglas, a Baptist minister and left-wing politician, was premier of Saskatchewan from 1944 to 1961. Considered the father of Canada's health system, he arduously built up the components of universal healthcare in that province, even in the face of an infamous 23-day doctors' strike.

In 1962, the province implemented a single-payer program of universal, publicly funded health insurance. Within a decade, all of Canada had adopted it.

The United States will presumably, sooner or later, find a model for healthcare that suits its values and its needs. But 2019 may be a time to look to the states for ideas rather than to the nation's capital. Whichever state official pioneers such a system will certainly be regarded as a great American.

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. KHN's coverage in California is supported in part by Blue Shield of California Foundation.

Secretive 'Rebate Trap' Keeps Generic Drugs For Diabetes And Other Ills Out Of Reach

Secretive 'Rebate Trap' Keeps Generic Drugs For Diabetes And Other Ills Out Of Reach

KFF Health News, January 18, 2019

Drug companies routinely make hidden pacts with middlemen that effectively block patients from getting cheaper generic medicines.

This article first appeared January 18, 2019 on Kaiser Health News.

By Jay Hancock and Sydney Lupkin

Lisa Crook was lucky. She saved $800 last year after her insurance company started covering a new, less expensive insulin called Basaglar that was virtually identical to the brand she had used for years.

The list price for Lantus, a long-acting insulin made by Sanofi that she injected once a day, had nearly quadrupled over a decade.

With Basaglar, "I've never had my insulin cost drop so significantly," said Crook, a legal assistant in Dallas who has Type 1 diabetes.

But many people with diabetes can't get the deal Crook got. In a practice that policy experts say smothers competition and keeps prices high, drug companies routinely make hidden pacts with middlemen that effectively block patients from getting cheaper generic medicines.

Such agreements "make it difficult for generics to compete or know what they're competing against," said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University School of Medicine.

Here's how it works: Makers of established brands give volume-based rebates to insurers or intermediaries called pharmacy benefit managers. In return, those middlemen often leave competing generics off the menu of drugs they cover, called a formulary, or they jack up the price for patients. The result is that many can't get the cheaper drugs unless they shoulder a bigger copay or buy them with no help from insurance.

Brand-drug sellers "pay for position" on the formulary, said Michael Rea, CEO of Rx Savings Solutions, which helps health plans and employers manage pharma costs. "In this country, the most cost-effective drugs don't necessarily mean anyone will have access to them … [Companies with] the deepest pockets win."

This so-called rebate trap joins a long history of efforts by makers of brand-name drugs to stifle generics, including protecting drugs with multiple layers of dubious patents, "pay for delay" deals to keep generics off the market and withholding key ingredients needed for generic production, critics say.

Because rebate contracts are secret, nobody knows the full extent of the practice nor how much it costs the health system in unrealized savings.

"The deals between the drug companies and the PBM middle players are guarded as fiercely as Fort Knox," said Robin Feldman, a law professor at the University of California, Hastings College of the Law, who studies pharma policy. "No one gets to see them."

But new research is turning up plenty of evidence of rebates distorting the market, such as numerous instances of effective, less expensive generics missing from formularies or patients burdened with higher out-of-pocket costs for generic drugs.

In unpublished research, Dusetzina found that only 17 percent of Medicare plans for seniors covered Basaglar, the biosimilar launched by Eli Lilly two years ago. Nearly all of them covered brand-name Lantus, sold by Sanofi, as of early last year.

Her research suggests rebates from Sanofi might have induced insurers to leave lower-priced Basaglar off their formularies, Dusetzina said.

Sanofi works with insurers and pharmacy benefit managers "to negotiate access for patients to our portfolio of products including Lantus," said company spokesman Jon Florio, declining to disclose specifics.

What's a pharmacy benefit manager? Watch our explainer.

Medicare plans covering Lantus but not Basaglar include numerous offerings from Anthem, the biggest for-profit, Blue Cross and Blue Shield insurer.

"After evaluating the total cost impact on consumers, taxpayers and the government, we chose to cover the brand drug, Lantus, over the biosimilar, Basaglar," said Anthem spokeswoman Lori McLaughlin.

Replacement versions of complex drugs often made from living cells are called biosimilars, not generics. Basaglar is considered clinically equivalent to Lantus but, because of a legal wrinkle, won't technically be considered a biosimilar by regulators until 2020.

Merck scrapped its own biosimilar version of Lantus last fall, despite receiving tentative approval by the Food and Drug Administration, after "assessing … the market environment," the company said.

Coverage of Lilly's Basaglar has grown, and the drug is now included in formularies used by slightly more than half the patients who have health insurance, said Eli Lilly spokesman Greg Kueterman.

In another forthcoming study, this one examining 2018 Medicare coverage, researchers at Johns Hopkins Bloomberg School of Public Health found that "almost every plan has at least one branded drug on the formulary that's in a better place than the generic," said Gerard Anderson, the professor leading the research.

(A grant from the Laura and John Arnold Foundation, which helps support Kaiser Health News, financed the Hopkins research.)

In 2015, only 19 percent of generic drugs covered by Medicare were in the preferred formulary tiers with the lowest out-of-pocket costs, found a study last year by consultants Avalere. In 2011, on the other hand, 71 percent of generics had been in the best tier, which helps determine what patients are prescribed.

The Association for Accessible Medicines, the generic drug lobby, paid for that study. Rebate-influenced barriers to generics are "increasingly problematic," said AAM CEO Chip Davis.

Disputes over formulary choices have hit the courts. Pfizer sued Johnson & Johnson in 2017, alleging that rebates induced insurers to prefer Remicade, an anti-inflammatory biologic, at the expense of Pfizer's lower-priced product.

Critics of rebate traps include top Trump administration officials, under pressure from a president who has promised to lower drug prices.

Because quick rebates from brands are often more attractive to PBMs and insurers than long-term savings from generics, "this is a real challenge in terms of biosimilars coming to market and gaining market share" Scott Gottlieb, head of the FDA, said in an interview.

Such objections add to a crescendo of grievances against hidden rebates. Consumers and advocates have complained for years that rebates cut costs for PBMs and insurers but do little for patients, who are often left paying their out-of-pocket share based on soaring list prices.

Crook's out-of-pocket costs for Lantus rose steadily over the years to about $900 annually, she said. After switching to Basaglar last year, her cost was less than $100.

Mark Gooley, who has Type 1 diabetes and lives in Florida, said he started ordering Lantus by mail from Canada after the U.S. list price rose fourfold in a little more than a decade.

"I have a very low opinion of companies like Sanofi," he said. "They could afford to sell it to me when it came out" at a much lower price, he said. "Inflation has not been 400 percent."

Because of rebates paid to PBMs, Sanofi's net price for Lantus has actually decreased over the past five years despite the list-price increases, said company spokesman Florio. "Unfortunately, these savings are not consistently passed through to patients," he said.

PBMs say they respond to the terms drug companies offer and negotiate to save billions for government, insurers and employers. "Simply put, the easiest way to lower costs would be for drug companies to lower their prices," the Pharmaceutical Care Management Association, the PBM lobby, said in an emailed statement.

For its part, PhRMA, the branded-drug association, has said it wants to scrap the rebate system and have PBMs paid for services provided.

Congress has done little to fix the rebate problem despite widespread criticism, but senior legislators in both chambers have pledged to address high drug prices this year.

Last summer, the Department of Health and Human Services proposed changing "safe harbor" protections that shield pharma rebates from being viewed as illegal kickbacks. But the proposal, under review at the Office of Management and Budget since July, has never been publicly aired, leaving the industry to wonder how substantial it is and if it will ever take effect.

Furloughed Feds' Health Coverage Intact, But Shutdown Still Complicates Things

Furloughed Feds' Health Coverage Intact, But Shutdown Still Complicates Things

KFF Health News, January 18, 2019

Although the estimated 800,000 government workers affected by the shutdown won't lose their health insurance, an unknown number are in limbo.

This article first appeared January 18, 2019 on Kaiser Health News.

By Julie Appleby

Joseph Daskalakis' son was born New Year's Eve, a little over a week into the current government shutdown, and about 10 weeks before he was expected.

Little Oliver ended up in a specialized neonatal intensive care unit, the only one that could care for him near their home in Lakeville, Minn.

But air traffic controller Daskalakis, 33, has an additional worry: The hospital where the newborn is being treated is not part of his current insurer's network and the partial government shutdown prevents him from filing the paperwork necessary to switch insurers, as he would otherwise be allowed to do. He could be on the hook for a hefty bill — while not receiving pay. Daskalakis is just one example of federal employees for whom being unable to make changes to their health plans really matters.

Although the estimated 800,000 government workers affected by the shutdown won't lose their health insurance, an unknown number are in limbo, like Daskalakis, unable to change insurers because of unforeseen circumstances; add family members such as spouses, newborns or adopted children to an existing health plan; or deal with other issues that might arise.

"With 800,000 employees out there, I imagine that this is not a one-off event," said Dan Blair, who served as both acting director and deputy director of the federal Office of Personnel Management (OPM) during the early 2000s and is now senior counselor at the Bipartisan Policy Center. "The longer this goes on, the more we will see these types of occurrences."

While Oliver is getting stronger every day — he's now out of the ICU, according to Daskalakis' local air traffic union representative — it's unclear how the situation will affect his family's finances.

That's because out-of-network charges are generally far higher than being in-network, and NICU care is enormously expensive no matter what. Those bills could add up, especially as his current insurance has an out-of-pocket maximum of $12,000 annually. Because Oliver was born before the new year, the family could face that amount for 2018 — and 2019.

Daskalakis isn't getting paid, either.

"I don't know when I'll be able to change my insurance, or when I'll get paid again," Daskalakis wrote Sen. Tina Smith (D-Minn.), who shared his letter on Facebook and before the Senate last week.

Other families are also worried about paperwork delays, and the financial and medical effects a prolonged shutdown could cause.

Dania Palanker, a health policy researcher at Georgetown's Center on Health Insurance Reforms, studies what happens when families face insurance difficulties. Now she's also living it.

After arranging to reduce her work hours because of health problems, Palanker knew her family would not qualify for coverage through her university job. No problem, she thought, as she began the process in December to enroll her family into coverage offered by her husband's job with the federal government.

"We could not get the paperwork in time to apply for special enrollment through the government and get it processed before the shutdown," Palanker said.

Georgetown allowed her to boost her work hours this month to keep the family insured through January, but Georgetown's share of her coverage will end in February.

Her treatments are expensive, so she is likely to hit or exceed her annual $2,000 deductible in January — then start over with another annual deductible once the family secures new coverage.

"I'm postponing treatment in hopes that it is just a month and I'm back on the federal plan in February, but I can't postpone indefinitely, as my condition will get worse," said Palanker, who has an autoimmune disease that causes nerve damage.

Overseeing federal health benefits programs is within the purview of the OPM, whose data hub is operational, according to a spokeswoman. But getting information to that data hub to make the kind of changes Daskalakis, Palanker and others need depends on the individual agencies that employ government workers.

The OPM has told government agencies "that they should have HR staff available during the lapse, specifically to process" such requests, which are called "qualifying life events," the spokeswoman said.

In a written statement Wednesday, Smith said: "Oliver's story is a powerful reminder that hundreds of thousands of real families have had their financial and personal lives turned upside down by this unnecessary shutdown." She called on the president to come back to the negotiating table.

For Daskalakis, there is some good news.

Tony Walsh, his union rep, said the OPM website and Daskalakis' insurer both indicated that the air traffic controller's request to change carriers so the hospital will be in-network will be retroactive to Oliver's birthday, and the out-of-network charges may not play a role.

Just to be safe, "Joe is currently working on an insurance appeal based on no in-network care [being available]," Walsh said in an emailed statement. The family has already received an initial $6,000 bill from the hospital, Walsh noted, saying the charges do not include costs associated with Oliver's birth or his stay in the intensive care unit.

Walsh said the shutdown is affecting a broad swath of employees in ways many lawmakers had never anticipated.

The workers "are essential to the system, and it's unfair they are being treated this way," he said.

California's Top Lawyer Cements His Role As Health Care Defender-In-Chief

California's Top Lawyer Cements His Role As Health Care Defender-In-Chief

KFF Health News, January 15, 2019

California Attorney General Xavier Becerra scores a win for California and other states in his effort to block Trump administration birth control rules.

This article first appeared January 15, 2019 on Kaiser Health News.

By Samantha Young

SACRAMENTO, Calif. — Xavier Becerra, the political savvy Democratic attorney general of California, has sued the Trump administration 45 times in the past two years, often with much fanfare.

In winning a legal challenge Sunday against new government rules limiting birth control, he once against cemented himself as a national figure leading a fight against the administration across a range of issues — especially health care.

The 12 other states and the District of Columbia that had joined Becerra's lawsuit also gained a last-minute reprieve from the federal regulations that would have taken effect Monday. They would have allowed most employers to refuse to provide insurance coverage for workers’ birth control by raising a religious or moral objection.

Those rules were also halted for the rest of the country on Monday when a Pennsylvania judge granted a nationwide injunction in a similar lawsuit.

The contraception case is one of several fronts where Becerra has led state coalitions to defend the Affordable Care Act in lawsuits in Texas, California and Washington, D.C.

"The Trump administration is trying to chip away at those protections," said Andrew Kelly, an assistant professor at the Department of Health Sciences at California State University-East Bay. "It's left to states like California and Attorney General Becerra in taking a lead in confronting these efforts."

Becerra is perhaps best known for leading the opposition to the Texas v. U.S. lawsuit. In that suit, the Texas attorney general argued that the Affordable Care Act should be rendered unconstitutional because Congress eliminated the tax penalty on the uninsured. A federal judge last month sided with Texas, ruling that the federal health care law is unconstitutional.

Becerra, who said he helped write the health care law, said he felt compelled to step in when the Trump administration decided not to defend the law. Sixteen states and the District of Columbia joined that lawsuit, which is now on appeal.

The multistate strategy is one that attorneys general have used often in the past few decades when they don't agree with policies coming out of Washington, legal and political experts say. And it's not unique to one political party.

Republican attorneys general, for example, sued the Obama administration to block the expansion of Medicaid in their states. When George W. Bush was president, the state of Massachusetts led Democratic states in an effort to force the Environmental Protection Agency to regulate greenhouse gas emissions from cars.

The legal tit for tat is what Nicholas Bagley, a professor at the University of Michigan Law School, described as a disconcerting "militarization" of the state attorneys general offices to press an agenda in the courts.

"At a time of polarized politics, there's every incentive to pull whatever levers are available to you to try to advance your goals," Bagley said. "Over time, the state attorneys general have come to the view that the courts are an important forum to have these fights over important questions."

The behavior of the attorneys general also comes in response to an administration that is using its executive authority to push initiatives that it can't get Congress to approve.

President Donald Trump is left "to try to use either the regulatory process or executive order to accomplish his goals," said Gerald Kominski, a professor of health policy at UCLA. "Anyone who opposes those goals has to proceed through the legal process to challenge them."

Becerra, the first Latino to serve as California attorney general, has sued the Trump administration on a wide range of issues: health care, immigration, the Muslim travel ban, citizenship questions on the census, the border wall, climate change and clean-water rules.

When the former congressman was sworn in to his second term last week, he declared that he had "been a little busy keeping the dysfunction and insanity in Washington, D.C., from affecting California," and defending the state from the "overreach of the federal government." And he doesn't have any plans to let up.

"Whether it's the criminals on our streets or the con man in the boardrooms or the highest office of the land," Becerra said, "we've got your back."

But Becerra's record has been mixed.

The victory in court Sunday was limited. Oakland-based U.S. District Judge Haywood Gilliam Jr. blocked the rules from taking effect in the District of Columbia and the 13 states that challenged them, but he refused to stop them from taking effect in the rest of the country. That national reprieve came a day later in a Pennsylvania court, with U.S. District Judge Wendy Beetlestone describing the harm to women as "actual and imminent."

If the administration appeals, as expected, Pennsylvania, along with California and its legal coalition would move ahead with their cases to permanently throw out the rules, arguing that the Affordable Care Act guaranteed women no-cost contraception as part of their preventive health care, a provision that they say has benefited more than 62 million women since 2012, when the regulations went into effect.

The Trump rules, California argued in legal filings, would "transform contraceptive coverage from a legal entitlement to an essentially gratuitous benefit wholly subject to an employer's discretion." In its proposed regulations, the U.S. Department of Health and Human Services described the exemption as narrow and one that would affect a fraction of women — no more than 127,000.

That's a number Becerra disputes.

In claiming victory on the birth control lawsuit, Becerra said Sunday that his coalition will continue to advocate for women's access to reproductive health care.

How much more will Becerra fight during the next four years? Addressing the crowd who gathered this month to see him sworn in to a second term, he conveyed a simple response:

"The sky is the limit."

Providers Walk 'Fine Line' Between Informing And Scaring Immigrant Patients

KFF Health News, January 15, 2019

The proposed 'public charge' rule would allow the federal government to consider immigrants' use of an expanded list of public benefit programs, including Medicaid, as a reason to deny green card status.

This article first appeared January 15, 2019 on Kaiser Health News.

By Ana B. Ibarra

While the Trump administration decides whether to adopt a controversial policy that could jeopardize the legal status of immigrants who use public programs such as Medicaid, doctors and clinics are torn between informing patients about the potential risks and unnecessarily scaring them into dropping their coverage or avoiding care.

"We are walking a fine line," said Tara McCollum Plese, chief external affairs officer at the Arizona Alliance for Community Health Centers, which represents 176 clinics. "Until there is confirmation this indeed is going to be the policy, we don't want to add to the angst and the concern."

However, if immigrants do come to a clinic wondering whether using Medicaid can affect their legal status, trained staff members will answer their questions, she said.

Other providers prefer to prepare their patients proactively in case the proposal is adopted. At Asian Health Services, a clinic group that serves Alameda County, Calif., staff members pass out fact sheets about the proposed changes, provide updates via their patient newsletter and host workshops where patients can speak to legal experts in several Asian languages.

"We can't just sit back and watch," said CEO Sherry Hirota. "We allocate resources to this because that's part of our job as a community health center — to be there not only when they're covered, but to be there always," even when that coverage is in jeopardy, she said.

The proposed "public charge" rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants' use of an expanded list of public benefit programs including Medicaid, CalFresh and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people.

Currently, people are considered public charges if they rely on cash assistance (Temporary Assistance for Needy Families or Supplemental Security Income) or need federal help paying for long-term care.

Should the rule go into effect, it could force patients to choose between health care and their chance at a green card, McCollum Plese said. "And most people will probably not take the services," she said.

The rule would not be retroactive, meaning it wouldn't take into account past use of public benefits like Medicaid, according to legal experts.

But health centers and medical providers know that if they tell patients about it now, they risk scaring some of them into premature decisions about their benefits, including dropping coverage.

Some immigrant patients already are skipping medical appointments out of fear stoked by the proposed rule, providers and advocates report.

"For now, our focus has been on correcting misinformation, not necessarily raising awareness among those who haven't heard about the potential changes," said Erin Pak, CEO of KHEIR Center, a clinic group with three locations in Los Angeles. "This is a proposal that thrives on fear and misunderstanding, so we wanted to be thoughtful about how and when to engage patients on the issue, given that nothing has passed into law."

The Department of Homeland Security is reviewing more than 200,000 comments from the public before it issues a final rule. It's possible the department won't adopt the rule at all, legal experts say.

At KHEIR Center, the patient population is predominantly Korean immigrants, a group that is highly aware of the proposed public charge rule because of the coverage it has received in Korean-language media, according to Kirby Van Amburgh, the center's director of external affairs.

Other groups served by the clinic, such as Latino and Bengali immigrants, have asked few questions, she said.

Trained staff address patients' questions one-on-one, and hand out a fact sheet when needed.

Last month, L.A. Care health plan, which covers more than 2 million Medicaid enrollees in Los Angeles County, hosted a public charge webinar for about 180 providers. David Kane, an attorney at Neighborhood Legal Services of Los Angeles, led the webinar and urged doctors to tell concerned patients that nothing has changed yet, and that most immigrants would not be affected.

He also explained that if the federal government adopts the rule, it would not be effective immediately. There would most likely be a 60-day grace period before the changes take effect, Kane said. After that, implementation could be further delayed in court.

John Baackes, CEO of L.A. Care, who has been critical of the public charge proposal, said his organization offered the webinar because of the estimated 170,000 legal immigrants on his plan who could potentially be affected.

"I think we've got to let people know what could come, and try to give them more accurate information so that they don't act imprudently," he said. To do that, "we have to stay current."

Emergency Medical Responders Confront Racial Bias

Emergency Medical Responders Confront Racial Bias

KFF Health News, January 11, 2019

Unconscious bias can be subtle, but, as this new report shows, it may be one of the factors behind race-linked health disparities seen across the U.S.

This article first appeared January 11, 2019 on Kaiser Health News.

By Kristian Foden-Vencil, Oregon Public Broadcasting

A recent study out of Oregon suggests emergency medical responders — EMTs and paramedics — may be treating minority patients differently from the way they treat white patients.

Specifically, the scientists found that black patients in their study were 40 percent less likely to get pain medication than their white peers.

Jamie Kennel, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was presented in December at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in these cases, unconscious bias may be at work.

A few years ago, Leslie Gregory was one of a very few black female emergency medical technicians working in Lenawee County, Mich. She said the study's findings ring true based on her experience.

She remembered one particular call — the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that's when one of her colleagues groaned.

"I think it was something like: 'Oh, my God. Here we go again,'" Gregory said. She worried — then, as now — that because the patient was black, her colleague assumed he was acting out to get pain medication.

"I am absolutely sure this was unconscious," added Gregory, who now lives and works in Portland, Ore., where she founded a nonprofit to spread awareness about racial disparities in health care. "At the time, I remember, it increased my stress as we rode up on this person. Because I thought, 'Now am I going to have to fight my colleague for more pain medication, should that arise?'"

Unconscious bias can be subtle — but, as this new report shows, it may be one of the factors behind race-linked health disparities seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients from 2015 to 2017. It found that minority patients were less likely to receive morphine and other pain medication compared with white patients — regardless of socioeconomic factors, such as health insurance status.

During a shift change at American Medical Response headquarters in Portland, EMTs and paramedics discussed the issue with a reporter as they got their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, was adamant that her work is not affected by race.

"I've never treated anybody different — regardless," said Sanders.

Most of the emergency responders interviewed, including Jason Dahlke, said race doesn't affect the treatment they give. But Dahlke also said he and some of his co-workers are thinking deeply about unconscious bias.

"Historically it's the way this country has been," Dahlke said. "In the beginning, we had slavery and Jim Crow and redlining — and all of that stuff you can get lost in on a large, macro scale. Yeah. It's there."

Asked where he thinks unconscious bias could slip in, Dahlke talked about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient's house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man's blood sugar level was low.

"So it's my decision to treat this blood sugar first. Make sure that number comes up," Dahlke said.

He gave the patient glucose — but no pain medicine.

Dahlke said he did not address the man's pain in this case because by the time he had stabilized the patient they had arrived at the hospital — where it was the responsibility of the emergency department staff to take over.

"When people are acutely sick or injured, pain medication is important," Dahlke said. "But it's not the first thing we're going to worry about. We're going to worry about life threats. You're not necessarily going to die from pain, and we're going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care."

Dahlke said he is not sure whether, if the patient had been white, he would have administered pain medicine, though he doesn't think so.

"Is it something that I think about when I come across a patient that does not look like me? I don't know that it changes my treatment," he said

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiled.

"I wonder that — if, in this study, if we're talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we're overtreating white people with narcotic medicines."

Research has found African-Americans more likely to be deeply distrustful of the medical community, and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, said Gregory.

"How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?" she asked.

Gregory wrote an open letter to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a threat to public health.

Past declarations of crisis — such as those focusing attention on problems such as smoking or HIV — have had significant results, Gregory noted.

But the CDC told Gregory, in its emailed response, that while it supports government policies to combat racial discrimination and acknowledges the role of racism in health disparities, "racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S."

Kennel said false stereotypes about race-based differences in physiology that date to slavery also play a role in health care disparities. For example, despite a lack of any supporting science, some medical professionals still think the blood of African-Americans coagulates faster, Kennel said, citing a recent study of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites. "An uncomfortably large percentage of medical students said, 'Yes, that's true,'" said Kennel.

On top of that, he said, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. "In these situations, providers are much more likely to default to making decisions [based] on stereotypes," he said.

Disparities in health care are well-documented. Whites tend to get better care and experience better outcomes, whether they're in a doctor's office or the ER. But before Kennel's study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn't get to know, because the research required ambulance companies to release highly sensitive data.

"We were prepared to maybe not look that great," said Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation's largest ambulance organizations, and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel said he controlled for those variables.

So now that AMR knows about disparities in its care, what can the company do?

"My feeling is we're probably going to put some education and training out to our folks in the field," McDonald said.

In addition, he said, AMR is going to hire more people of color.

"We want to see more ethnicities represented in EMS — which has historically been a white, male-dominated workforce," McDonald said.

AMR's policies must change, too, he added. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

Federal Shutdown Mostly Spares Health Coverage, But Other Issues Loom

Federal Shutdown Mostly Spares Health Coverage, But Other Issues Loom

KFF Health News, January 11, 2019

The length of the shutdown will dictate how furloughed and unpaid workers will be affected.

This article first appeared January 11, 2019 on Kaiser Health News.

By Julie Appleby

As the partial government shutdown drags on, about 800,000 federal employees who work for the shuttered agencies — and their families — are facing the reality of life without a paycheck.

And those workers need to consider a host of other related issues as they attempt to make ends meet.

For starters, what will happen to their health insurance?

For the most part, federal employees needn't worry about that, according to the Office of Personnel Management (OPM) in an FAQ blog post.

Both the online FAQ and the health insurance industry's trade association confirm that coverage through the Federal Employees Health Benefits (FEHB) program will continue even if some federal agencies affected by the shutdown aren't issuing those paychecks or paying premiums.

"The shutdown should not impact their coverage," said Kristine Grow, spokeswoman for America's Health Insurance plans, the trade group that represents insurers, including those that offer coverage through the federal program. "It's business as usual."

Once the shutdown ends and those payments resume, workers should expect that their usual share of premiums plus some of the accumulated amount that wasn't deducted during the missed pay periods will be taken out.

"Procedures may vary somewhat by payroll office, but the maximum additional deduction allowed under regulations is one pay period's worth of premiums (in addition to the current pay period's premium)," said an OPM spokeswoman.

What about government contract workers?

Less clear is what happens to workers under contract with the affected federal agencies — including some people working as analysts, administration assistants and janitorial staff — who are mostly excluded from the FEHB program.

Many companies that contract with the federal government offer workers insurance. The federal Office of Personnel Management recommends these contracted employees consult the human resources office at their company for answers regarding the shutdown.

"In 95 percent of cases, even if it's not required by law, I would think most everyone would continue that coverage," said Rachel Greszler, a senior policy analyst and research fellow at the Heritage Foundation who studies economics, budget and labor issues.

For contract workers who buy their own coverage and are struggling to pay bills without their paychecks, it's a different story. One strategy may be to ask their insurers for a grace period in paying their premiums, similar to how the government has suggested workers seek accommodation from mortgage lenders and other creditors. But there is no requirement that insurers grant such a request.

"We are concerned about the disruption that this shutdown has caused our members and their families," noted a corporate statement from CareFirst BlueCross BlueShield. "We are currently exploring how to best address this issue should the shut-down continue."

What else could be affected?

Depending on how long the shutdown lasts, dental, vision and life insurance programs may start sending bills directly to workers.

Federal workers pay the premiums for these benefits themselves, according to Dan Blair, who served as both acting director and deputy director of the OPM during the early 2000s. He is now a senior counselor and fellow the Bipartisan Policy Center.

Because workers' checks are not being processed, the amounts usually sent to these carriers each pay period also aren't being paid. If the shutdown lasts longer than two or three pay periods, workers will get premium bills directly from these firms and should pay them "on a timely basis to ensure continuation of coverage," the OPM says in its FAQ. Blair agrees.

There also may be a delay in processing claims for flexible spending accounts. These are special accounts in which workers use pretax money deducted from their paychecks to cover certain eligible medical expenses, such as eyeglasses, braces, copayments for doctor visits or medications, including some over-the-counter products. With no paychecks going out, these deductions are not being made and transferred into FSAs. Once paychecks start up again, the amount deducted will be adjusted so the worker will get the annual total they had requested.

During the shutdown, though, reimbursement claims to these accounts also won't be processed, the OPM says. Blair suggests holding off on big-ticket purchases during the shutdown, if possible, and always keeping paperwork on the purchases.

Another consideration: Those who changed plans before the furlough may find their paperwork wasn't processed in time.

In those cases, the OPM says to stick with the old health plan until the shutdown ends and the new plan is processed. The new plan will pick up any claims incurred.

How will workers know if their change was processed? The OPM's FAQ says workers who receive an ID card in the mail are enrolled.

"The new policy will be what applies and pays benefits, but there could be some administrative burdens and hassles on the part of workers if the shutdown continues much longer, if the initial bills are not going to the right insurance company," Greszler said.

Overall, Blair says workers should continue to monitor news media sites, particularly those that focus on federal workers and issues, looking for any updates.

"We're getting into uncharted territory and there are always things that pop up that no one has planned for," said Blair, who did not face any shutdowns during his tenure at OPM.

Medicaid Plans Cover Doctors' Visits, Hospital Care — And Now Your GED

Medicaid Plans Cover Doctors' Visits, Hospital Care — And Now Your GED

KFF Health News, January 7, 2019

'I think this sets the standard for the unique role of Medicaid managed care in bridging health care and social services,' said a George Washington University health law and policy professor.

This article first appeared January 07, 2019 on Kaiser Health News.

By Phil Galewitz

Emilia Ford became pregnant at 15 and, after her daughter was born, dropped out of high school.

As she held down different jobs during the past decade — including housekeeping and working in a relative's retail store — she always thought about going for her GED to show she met high school academic skills.

But the Brookhaven, Pa., woman needed assistance finding tutors and paying for the set of four tests, which cost $20 each.

She found help from an unexpected source: her Medicaid health plan.

AmeriHealth Caritas, a Philadelphia-based insurer with 2 million Medicaid members in Pennsylvania and five other states, helps connect members with nonprofit groups providing GED test preparation classes, offers telephone coaching to keep members on track and pays the testing fees.

Ford is one of 62 plan members who have earned a GED certificate since the benefit began in 2013.

"I could not believe this was something a health insurance company would do," said Ford, 25. "I thought health insurers only paid for medical costs."

Not anymore.

Medicaid health plans are starting to pay for non-traditional services such as meals, transportation, housing and other forms of assistance to improve members' health and reduce medical costs.

That change follows efforts by state Medicaid programs to give health plans financial incentives to control spending, said Jill Rosenthal, senior program director for the National Academy for State Health Policy.

Rather than continue to pay a set fee each month to cover members' health costs, many states are implementing policies that let health plans share in any savings they can demonstrate. That provides motivation for insurers to address factors such as literacy and poor housing, which can drive up health costs.

"Health plans now have incentives for them to find the root causes of problems that will reduce costs that will benefit the plan, its beneficiaries and the states," Rosenthal said.

AmeriHealth Caritas CEO Paul Tufano said studies show people with lower educational levels tend to be in poorer health. "Helping members attain their GED can be incredibly consequential for them to live the kind of life they want to live," he said.

But Tufano acknowledged that only a small fraction of people who need the assistance reach out for it. About 1,000 members have started GED training through the insurer in Pennsylvania, Louisiana, South Carolina and Delaware.

"Many of our members are just surviving to keep their heads over water, holding on to jobs and dealing with issues like safe housing, access to food and transportation to get to work or doctor," he said.

AmeriHealth Caritas is one of just a handful of Medicaid health plans that offer a GED benefit.

WellCare, which covers 2.2 million Medicaid recipients in Missouri, Nebraska, Georgia, Kentucky, Hawaii and Illinois, had 226 members sit for their GED exams since the plan began paying for it in 2012, said spokeswoman Alissa Lawver. The Tampa-based plan does not know how many passed.

A Wellcare survey of its Medicaid adult members in Georgia in 2012 found that about 20 percent did not have a high school diploma or a GED.

"There is a significant relationship between education and health," Wendy Morriarty, president of WellCare's Ohana Health Plan in Hawaii, said when launching the benefit in 2016. "A GED is a tool that can lead to increased opportunities for our members to attend college, seek higher-paying jobs and find stable housing. This benefit has the ability to improve the health and well-being of local families and communities."

Advocates for Medicaid praise the health plans' efforts.

"I think this sets the standard for the unique role of Medicaid managed care in bridging health care and social services," said Sara Rosenbaum, health law and policy professor at George Washington University.

Ford said having a coach at AmeriHealth walk her through the sign-up process for GED classes, help her register for tests and call her twice a week to keep her motivated was vital to her success. The program also offered child care and transportation to the prep classes and exam sites. She started in May 2017, taking two classes a week, and passed her exams last summer.

When she finished, AmeriHealth hired Ford as an intern in its member services department. In December 2017, the insurer hired Ford to a full-time position — with health benefits — to work as a GED coach for other Medicaid members.

The job meant Ford became the first of nine siblings to get off Medicaid and find employer-based coverage.

"I feel like I was saved from the struggle I was going through," Ford said. "This is something big that my family was proud of." While she was growing up, she said, her father drove a school bus and her mom took care of the kids.

In the past year, Ford has helped 12 plan members earn their GEDs and she's coaching 30 more.

"I can tell them I have been where you are on the other side of the phone and can share my experience and it helps give them more trust in me," Ford said.

"The hardest thing is not giving up even after failing a test and being able to get back up and push yourself and get over the discouragement," she said. "There is always something good that you can take from a bad situation."

After Bitter Closure, Rural Texas Hospital Defies The Norm And Reopens

After Bitter Closure, Rural Texas Hospital Defies The Norm And Reopens

KFF Health News, January 7, 2019

For weeks on end, a small group gathered at the shuttered hospital to pray for some avenue to reopen. Then, as the odds looked increasingly long, they got a call out of the blue from two Austin-based doctors.

This article first appeared January 07, 2019 on Kaiser Health News.

By Charlotte Huff

Five months ago, the 6,500 residents of Crockett, Texas, witnessed a bit of a resurrection — at least in rural hospital terms.

A little more than a year after the local hospital shut its doors, the 25-bed facility reopened its emergency department, inpatient beds and some related services, albeit on a smaller scale.

Without a hospital, residents of Crockett, located 120 miles north of Houston, were 35 miles away along rural roads from the next closest hospital when a medical crisis struck, said Dr. Bob Grier, board president of the Houston County Hospital District, which is the county's governmental authority that oversees Crockett, a public hospital. "Someone falls off the roof. A heart attack. A stroke. A diabetic coma. Start naming these rather serious things and health care is known for its golden hour," he said.

The late-July reopening of the newly named Crockett Medical Center makes it a bit of a unicorn in a state that has led nationally in rural hospital closures. Since January 2010, 17 of the 94 shuttered hospitals have been in Texas, including two that closed in December, according to data from the University of North Carolina's Cecil G. Sheps Center for Health Services Research.

But Crockett's story also reflects some of the challenges faced by rural hospitals everywhere. Board members frequently have limited background in health care management and yet are responsible for making financial decisions. Add to that mix a Lone Star State resistance to raising local property taxes. An effort to increase the county's 15 cents per $100 property valuation for the hospital district has been defeated twice since the hospital closed.

And a small rural hospital like Crockett's has "no leverage" when negotiating reimbursement rates with insurers, Grier repeatedly points out.

The tough reality is that too many rural hospitals in Texas and elsewhere, when negotiating with insurers and other financial players, "are almost always negotiating from weakness and sometimes from literally leaning out over the edge of the [survival] cliff," agreed Dr. Nancy Dickey, executive director of the A&M Rural and Community Health Institute at Texas A&M Health Science Center.

Rural communities must think more creatively about how to meet at least some of their health needs without a traditional hospital, whether it's forming partnerships with nearby towns or expanding telemedicine, Dickey said. "There is little doubt in my mind that many of these communities are going to see their hospitals close," she said, "and are not going to be able to make an economic case to reopen them."

The A&M institute, which in December published a report looking at these challenges for three Texas communities, recently landed a $4 million, five-year federal grant to help rural hospitals nationwide keep their doors open or find other ways to maintain local health care.

Demographics And Decisions

The financial headwinds have been particularly fierce in Texas, one of 14 states that has not expanded Medicaid eligibility after the passage of the Affordable Care Act. "That makes a huge difference," said John Henderson, chief executive officer of the Texas Organization of Rural & Community Hospitals, known in Texas rural circles as TORCH. "But that doesn't change the reality that we aren't going to do it."

Leading up to the state's biennial legislative session, which begins in January, rural leaders are making the case that state legislators need to take steps to bolster the state's 161 rural hospitals, starting with rectifying underpayments for Medicaid patients. As the state's program has transitioned to managed care, over time reimbursements have shrunk to the point that rural hospitals are losing as much as $60 million annually, according to TORCH officials, who cite state data.

They also support a congressional bill, HR 5678, that would make it easier for rural hospitals to close their inpatient beds but retain some services, such as an emergency room and primary care clinic. Under current federal regulations, facilities that make such a move are no longer considered a hospital and can't be reimbursed by Medicare and Medicaid at hospital rates, which are often higher than payments to clinics or individual doctors. Those lower rates make it harder for stripped-down facilities to keep up their operations, said Don McBeath, TORCH's director of government relations.

Crockett's hospital, then called Timberlands Healthcare, abruptly shut down in summer 2017 after just a few weeks' notice from its management company, Texas-based Little River Healthcare. Little River, which was also the subject of an analysis by Modern Healthcare that showed several of its hospitals engaged in unusually high laboratory billing for out-of-state patients, has since filed for bankruptcy. Two other rural hospitals affiliated with Little River closed their doors in December

As it struggled to stay open, Crockett's hospital had been treating a population that was increasingly poor and aging, according to Texas A&M's report. The researchers describe in the report — Crockett is "community 1" among three communities featured — that the hospital was overstaffed with more than 200 employees given its daily average census of three hospitalized patients. Also, they wrote, board members should have more closely questioned the management company. The board said they were given data at each meeting, "but that data did not suggest the imminent demise of the hospital," the report's authors wrote.

Fighting The Closure Tide

Leaders in Crockett tried to capture the interest of other hospital systems to reopen and manage the facility, without success, Grier said. Along with staffers losing their jobs, the community knew it would be more difficult to persuade people to relocate or retire to the area without a hospital nearby, he said.

Every weekday at noon for weeks on end, a small group of two to 20 people gathered beneath the hospital's front portico to pray for some avenue to reopen, Grier said. Then, as the odds looked increasingly long, they got a call out of the blue from two Austin-based doctors. "I feel God was involved," Grier said. "They have told us that they were looking for some kind of a larger investment."

Those initial conversations resulted in a five-year lease arrangement between the hospital district and the management company, operating as Crockett Medical Center LLC.

The two physicians, Dr. Kelly Tjelmeland and Dr. Subir Chhikara, are listed on Crockett Medical Center's website as chairman and president, respectively. They failed to respond to requests for comment about their plans for the hospital. But in a presentation to the board before the lease was signed, they said that one of their goals was to get the facility classified as a critical access hospital, which enables a higher reimbursement for Medicare patients.

Along with operating a primary care clinic and 24/7 emergency room, Crockett Medical Center staffs a handful of hospital beds for patients who need more limited medical treatment, such as heart monitoring or intravenous antibiotics, Grier said. But when the Crockett hospital reopened, it didn't resume delivering babies. Only 66 of Texas rural hospitals still provide obstetrics services, according to McBeath.

Eliminating baby deliveries was one possibility on the table at another rural hospital if that hospital CEO hadn't pulled off the sort of Texas miracle that Crockett has yet to achieve — persuading local voters to support a tax increase. Adam Willmann, CEO of 25-bed Goodall-Witcher Hospital Authority, northwest of Waco, said that he and others made the case in dozens of meetings that a hospital property tax was needed to support the financially struggling hospital.

In November, 58 percent of the county's voters backed the new tax, despite the community's political leanings. During that same election, 80 percent voted to re-elect Republican Sen. Ted Cruz.

"They want to be 5 minutes, 15 minutes from an ER and not 35 miles down the road," Willmann said, referring to the nearest hospitals in Waco. "And they're willing to pay a little more for it."

Pages