Energy-Hog Hospitals: When They Start Thinking Green, They See Green

KFF Health News, August 16, 2018

The healthcare sector is responsible for nearly 10% of all greenhouse gas emissions. Increasingly, though, health systems are paying attention.

This article first appeared August 08, 2018 on Kaiser Health News.

By Julie Appleby

Hospitals are energy hogs.

With their 24/7 lighting, heating and water needs, they use up to five times more energy than a fancy hotel.

Executives at some systems view their facilities like hotel managers, adding amenities, upscale new lobbies and larger parking garages in an effort to attract patients and increase revenue. But some hospitals are revamping with a different goal in mind: becoming more energy-efficient, which can also boost the bottom line.

"We're saving $1 [million] to $3 million a year in hard cash," said Jeff Thompson, the former CEO of Gundersen Health System in La Crosse, Wis., the first hospital system in the U.S. to produce more energy than it consumed back in 2014. As an added benefit, he said, "we're polluting a lot less."

The health care sector — one of the nation's largest industries — is responsible for nearly 10 percent of all greenhouse gas emissions — hundreds of millions of tons worth of carbon each year. Hospitals make up more than one-third of those emissions, according to a paper by researchers at Northeastern University and Yale.

Increasingly, though, health systems are paying attention:

  • Gundersen Health System in Wisconsin employs wind, wood chips, landfill-produced methane gas — and even cow manure — to generate power, reporting more than a 95 percent drop in its emissions of carbon monoxide, particulate matter and mercury from 2008 to 2016.
     
  • Boston Medical Center analyzed its hospital for duplicative and underused space, then downsized while increasing patient capacity. Among other changes, it now has a gas-fired 2-megawatt cogeneration plant that traps and reuses heat, saving money and emissions, while supplying 41 percent of the hospital's needs and acting as a backup for essential services if the municipal power grid goes out.
     
  • Theda Clark Medical Center in Wisconsin is saving nearly $800,000 a year — 30 percent of its energy costs — after making changes that included retrofitting lights, insulating pipes, taking the lights out of vending machines and turning off air exchangers in parts of its building after hours.
     
  • Kaiser Permanente aims to be "carbon-neutral" by 2020, mainly by incorporating solar energy at up to 100 of its hospitals and other facilities. One already in use — at its Richmond (Calif.) Medical Center — is credited with reducing electric bills by about $140,000 a year. (Kaiser Health News is not affiliated with Kaiser Permanente.)
     

While the environmental benefits are important, "what I've seen over the years is cost reductions are the prime motivator," said Patrick Kallerman, research manager at the Bay Area Council Economic Institute, which released a report this spring outlining ways the hospital industry can help states such as California reach environmental goals by becoming more efficient.

Some of its recommendations are simple: replacing old lighting and windows. Others are more complex: powering down heating and cooling in areas not being used and updating ventilation standards first set back in Florence Nightingale's day. Such tight standards "might not be necessary," Kallerman said. Loosening them could help save money and energy.

When Bob Biggio was hired in 2011 to oversee Boston Medical Center's facilities, hospital leaders were about to launch a broad redesign. Yet the hospital was also facing serious financial struggles. He put the move on hold while analyzing how the hospital was using its existing space, looking for unused or duplicative areas.

"My first impression with data I had gathered was our campus was about 400,000 square feet bigger than it needed to be, said Biggio. "A square foot you never have to build is most efficient of all."

The new design is smaller but more efficient, handling 20 percent higher patient volume and eliminating the need for ambulance transportation between far-flung areas of the campus. It also cut power consumption by 42 percent from a 2011 baseline.

While the hospital sunk a lot of money into the renovation, the center was able to sell off some of its land to help offset the costs, leading to about a five-year return on investment, Biggio said.

"We are a safety-net hospital with a large Medicaid population," he said. "So this is the last place people expect to see the type of investments and progress we've made."

But how to sell that in the C-suite?

The environmental argument wasn't how Thompson convinced executives at Gundersen.

"At no point did I mention climate change or polar bears," said Thompson.

Instead, he focused on the organization's mission to improve health — and the potential cost savings.

"There are multiple examples — at Gundersen and other places — where, if we're thoughtful, we can improve the local economy, lower the cost of health care and decrease the pollution that is making people sick," he said.

But hospitals' energy efficiency efforts vary, with only about 10 percent attempting changes as dramatic as those done at Gundersen, estimated Alex Thorpe, a hospital energy expert at Optum Advisory Services, a consulting firm owned by UnitedHealth Group.

"About 50 percent are in the middle," he added, perhaps because these investments are weighed against other capital needs.

"If you have a well-known doctor that wants a new cutting-edge piece of equipment, then it can be hard to make the business case [for investing in alternative energy]," said Thorpe.

Of the more than 5,000 hospitals in the country, about 1,100 are members of Practice Greenhealth, a nonprofit that promotes environmental stewardship. Fewer than 300 hospitals qualify as Energy Star facilities, an Environmental Protection Agency program that recognizes buildings that rank in the top quartile for energy conservation among their peers.

Greenhealth estimates its members average about a million dollars a year in savings, but it all depends what steps they take.

There are modest savings from such things as reducing the heating and air conditioning in operating rooms during hours they are not in use, with median annual cost savings of $45,398, a report from the group notes. Other energy reduction efforts net another median $53,599 in annual savings, while swapping older lighting for new LED bulbs in operating rooms saves another $3,329.

Individually, those savings are not even rounding errors in most hospitals' total expenses, which are measured in the millions of dollars.

Still, within facility expenses, energy use accounts for 51 percent of spending, so even modest cuts are "significant," said Kara Brooks, sustainability program manager for the American Society for Healthcare Engineering.

Ultimately, that may affect what hospitals charge insurers and patients.

"If hospitals can lower peak demand through energy efficiency efforts, that will directly impact their pricing," said Thorpe.

States Leverage Federal Funds To Help Insurers Lower Premiums

KFF Health News, August 15, 2018

Even as the Trump administration has blocked other provisions of the ACA and pushed Congress to repeal the law, it has encouraged states to establish reinsurance programs and seek federal funding.

This article first appeared August 15, 2018 on Kaiser Health News.

By Steven Findlay

When Tracy Deis decided in 2016 to transition from a full-time job to part-time contract work, the loss of her employer's health insurance was not a major worry because she knew she could get coverage through the marketplace set up by the Affordable Care Act.

But price was a big concern.

"The ACA made it possible to make the switch in my life," said Deis, 48, who lives in Minneapolis. But she quickly added, "I was really worried about the cost."

Her anxiety was understandable. In Minnesota, the average cost of insurance in the state-run exchange soared 57 percent in 2017, after a 40 percent rise in 2016.

Amid a public outcry, the legislature last year took several steps to stabilize its individual insurance marketplace.

Among those moves, lawmakers launched a "reinsurance" program. The program helps pay the costs insurers incur for people with high medical bills. In turn, the companies — knowing that these "outlier" expenses will be covered — can lower premiums. Alaska had launched a similar program in 2016.

The Alaska and Minnesota models have now become touchstones for other states eager to prevent startling premium increases in the individual insurance marketplace.

Critically, much of the money comes from the federal government. A provision in the ACA allows states to experiment with their marketplaces as long as they honor ACA requirements and don't cost the federal government more money. (Federal reinsurance funding for high-cost patients reduces premium subsidies, which are fully paid by the federal government.)

Notably, even as the Trump administration has blocked other provisions of the ACA and pushed Congress to repeal the law, it has encouraged states to establish reinsurance programs and seek federal funding.

In Alaska, lawmakers used only state funds to cut an anticipated 43 percent premium increase to 7 percent in 2017. As the program continued in 2018 with $58 million in federal funds, the lone insurer in the state, Premera Blue Cross Blue Shield, lowered premiums by an average 22.4 percent. And on Aug. 2, Premera announced it had asked the state if it could reduce premiums by an average 3.9 percent in 2019.

Alaska's program, unlike other states', covers all the costs for people with 33 high-cost conditions. In 2017, about half of all expenses for enrollees in the exchange were for people with one or more of those conditions.

"We have unique issues here," said Jim Grazko, president of Premera Blue Cross Blue Shield of Alaska. "Without the reinsurance program, things would be untenable in the individual market."

The federal Department of Health and Human Services approved Minnesota's waiver request for a 2018 reinsurance program, with $131 million in funding. The program covers medical bills between $50,000 and $250,000 for marketplace customers.

It worked. Premium rates declined by 13 percent in 2018 compared with 2017 and are projected to drop again in 2019 by 5 to 8 percent, according to Eileen Smith, a spokeswoman for the Minnesota Council of Health Plans.

That was good news for Deis. Her monthly premium this year is $317, down from $355 in 2017. She's in a plan that includes the doctors she wanted and is happy with her coverage, although it has a deductible of $7,050.

"I wouldn't mind if my premiums came down again for 2019," she said. "Every little bit helps."

Pushing Premiums Down

Oregon also launched a federally approved reinsurance program in 2018. And last month, the Trump administration notified Wisconsin and Maine that their requests for reinsurance program funding had been approved.

Four other states — Idaho, Louisiana, Maryland and New Jersey — are seeking federal approval for reinsurance programs enacted this year. All hope to have plans in place for 2019.

Eric Cioppa, Maine's insurance commissioner, estimates his state's reinsurance program will reduce premiums in 2019 by an average 9 percent compared to what they would have been without the program.

"Reinsurance is possibly the best proven mechanism to restrain premium increases and keep health insurance affordable," said Trish Riley, executive director of the National Academy for State Health Policy in Portland, Maine. "The biggest plus is that it's a tool with support across the political spectrum."

That includes some deep conservatives, such as Wisconsin Gov. Scott Walker, a Republican and longtime critic of Obamacare. He strongly supports the reinsurance program and touts it on the campaign trail as he seeks a third term.

Wisconsin's program establishes a $200 million fund — $166 million of it federal money — to pay about 50 percent of the costs for individuals with medical expenses between $50,000 and $200,000.

The state's insurance department estimates the program will yield premiums in 2019 that will be 11 percent lower on average than they would have been without reinsurance. Premiums rose 44 percent in 2018, leading 25,000 people to drop coverage.

For Amy Brooks, of Madison, Wis., the initiative is especially timely. Brooks, 48, who pays $150 a month for subsidized coverage in an ACA plan because her job didn't come with insurance, was diagnosed in April with a benign brain tumor that required surgery.

She lost her job after the diagnosis and said having insurance coverage "takes a gigantic weight off my shoulder. I would have gone bankrupt. … Anything that keeps the costs down is a huge help because I could need this coverage for some time."

No Panacea

Insurance analysts say that state-based reinsurance programs are a potent mechanism to lower premiums, but not a panacea.

The programs don't address underlying medical costs, for example. And if money for the programs is not sustained — or increased — over time, reinsurance can yield a one-time decline in premiums over a year or two.

"That initial decrease is meaningful, to be sure," said Matthew Fiedler, a health policy researcher at the Brookings Institution in Washington, D.C. "But other steps are needed to help stabilize the exchanges." That could include more money for reinsurance as time goes on, he said.

The every-state-for-itself approach also frustrates insurers and consumer advocates.

"A sustained federal approach would be much preferable and what we'd like to see," said Kris Haltmeyer, vice president for legislative and regulatory policy at the Blue Cross Blue Shield Association, which represents 36 Blues plans nationwide.

After Republicans in Congress failed to repeal and replace the ACA in 2017, Sens. Patty Murray (D-Wash.) and Lamar Alexander (R-Tenn.) launched a bipartisan effort to stabilize the ACA marketplaces. A prominent part of their plan was a $30 billion reinsurance pool — $10 billion a year.

The effort failed in March amid discord over an unrelated abortion measure in the bill.

Feds Urge States To Encourage Cheaper Plans Off The Exchanges

KFF Health News, August 14, 2018

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were this year.

This article first appeared August 14, 2018 on Kaiser Health News.

By Michelle Andrews

For those who make too much money to qualify for health insurance subsidies on the individual market, there may be no Goldilocks moment when shopping for a plan. No choice is just right.

A policy with an affordable premium may come with a deductible that's too high. If the copayments for physician visits are reasonable, the plan may not include their preferred doctors.

These consumers need better options, and in early August federal officials offered a strategy to help bring down costs for them.

The guidance is from the Centers for Medicare & Medicaid Services, which oversees the insurance marketplaces set up by the Affordable Care Act. CMS is encouraging states to allow the sale of plans outside of those exchanges that don't incorporate a surcharge insurers started tacking on last year.

Many insurers added the premium surcharges last fall to plans sold on the individual market. It was a response to the Trump administration's announcement that it would no longer pay the companies for the "cost-sharing reduction" subsidies required under the health law. The subsidies help cover deductibles and other out-of-pocket costs for lower-income consumers who buy marketplace plans.

Insurers typically added the cost to silver-level plans because those are the type of plans that consumers have to buy in order to receive the cost-sharing subsidies. "Silver loading," as it's called, added an estimated 10 percent to the cost of those plans, according to the Congressional Budget Office.

People who qualified for federal premium subsidies — those with incomes up to 400 percent of the federal poverty level (about $48,000 for one person or $100,000 for a family of four) — were shielded from the surcharge because their subsidies increased to cover the cost.

But people with higher incomes faced higher premiums. The new guidance is geared to help them.

"It encourages states to encourage silver loading only on the exchange," said Aviva Aron-Dine, vice president for health policy at the Center on Budget and Policy Priorities.

But some analysts say they're unsure if the new federal policy will make a difference since states have already implemented similar strategies.

Many states moved last fall to limit silver loading to plans sold on the exchanges, while allowing or, in the case of California, requiring, very similar plans to be sold off the exchanges without the extra premium charge.

Yet CMS' endorsement of the strategy removes doubts states may have had, said David Anderson, a research associate at Duke University's Margolis Center for Health Policy who has tracked the issue.

Eighty-three percent of people who bought a plan during the open-enrollment period for 2018 qualified for premium tax credits. The average monthly premium per subsidized enrollee was $639; after accounting for premium tax credits, however, enrollees owed just $89 on average. That amount was 16 percent lower than the monthly premium the year before.

For people who don't qualify for premium tax credits, the picture is very different. The average monthly premium for 2018 was $522. That total was 28 percent higher than the previous year's total of $407, according to an analysis by the Center on Budget and Policy Priorities of CMS enrollment data.

In general, federal rules require that insurers charge the same rates for identical qualified health plans that are sold on and off the exchanges. The CMS guidance suggests that the unloaded plans could be tweaked slightly in terms of cost sharing or other variables so that they are not identical to those on the marketplaces.

Tracing what type of coverage is purchased off the exchange is difficult because there is no centralized source. Consumers can buy plans directly from insurers, or they may use a broker or an online web portal. According to one such portal, eHealth, 28 percent of unsubsidized consumers on its site bought silver plans in 2018, while 42 percent bought bronze plans, whose coverage is less generous than silver plans and typically have lower premiums. Conversely, on the exchanges nearly two-thirds of people bought silver plans in 2018 while 29 percent bought bronze plans, according to federal data.

If fewer insurers add the CSR load to silver plans sold off the exchange, those plans may be more affordable next year than they were in 2018, said Cynthia Cox, director of health reform and private insurance at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

"This makes silver plans an option for [unsubsidized] people who wanted to buy a silver plan but might have been pushed off onto a bronze plan," she said.

Consumers who want to consider off-exchange plans have to find them first. Some experts suggest checking with insurers that are selling on the marketplace in an area, because it's possible that they'll also be selling plans off the exchange.

But that's not a given. A health insurance broker can help people find and evaluate plans sold off the exchange. But experts urge consumers to stay on their toes and make sure they understand whether the plans they're considering provide comprehensive coverage.

Starting in October, insurers can offer short-term plans with limited benefits that last up to a year.

"Differentiating between the two may not be easy, and the off-exchange unsubsidized market is the target market for short-term plans," said Anderson.

Hospital at Home initiatives gain momentum

Medicaid Officials Target Home Health Aides' Union Dues

KFF Health News, August 13, 2018

The proposed rule comes on the heels of June's landmark Supreme Court ruling, in which a 5-4 majority held that public-sector workers don't have to pay unions for the cost of collective bargaining, calling it a violation of their free speech.

This article first appeared August 13, 2018 on Kaiser Health News.

By Shefali Luthra

Medicaid home care aides — hourly workers who help the elderly and disabled with daily tasks like eating, getting dressed and bathing — are emerging as the latest target in the ongoing power struggle between conservatives and organized labor.

About half a million of these workers belong to the Service Employees International Union, a public-sector union that represents almost 1.9 million workers in the United States and Canada. The union is an influential donor to liberal politicians and boasted strong ties to the Obama administration.

A proposed rule from the federal Centers for Medicare & Medicaid Services would prohibit home health aides paid directly by Medicaid from having their union dues automatically deducted from their paychecks, though it doesn't name the fees explicitly.

Blocking these direct Medicaid payments means the workers — especially those who don't work in a single, centralized office, or don't have a credit card or a bank account — are far less likely to pay dues, diminishing the union's potential influence.

CMS' language affects only "individual providers" — that is, those who aren't employed by the private, for-profit agencies that dominate this industry. Individual providers, who are technically state employees, are far more likely to be unionized.

The directive, which would overturn an Obama administration policy put in place to ease the collection of union dues and pay for other fees, such as health benefits, could take effect by the end of this year. A month-long comment period, ending Monday, has attracted more than 3,300 responses.

"This is just another way to make life more difficult for public-sector unions," said Jake Rosenfeld, an associate professor of sociology at Washington University in St. Louis, who studies unions and their influence.

The proposed rule comes on the heels of June's landmark Supreme Court ruling, in which a 5-4 majority held that public-sector workers don't have to pay unions for the cost of collective bargaining, calling it a violation of their free speech.

That decision expanded on the Supreme Court's 2014 ruling in Harris v. Quinn, in which the high court found that home care workers must explicitly state their desire to be in a union before the organization can collect dues. But because these workers are not attached to a single office or meeting point, organizing them into a collective unit poses a distinct challenge; collecting membership dues, even more so.

As union membership has waned in other sectors, organized labor has doubled down on home care, lobbying liberal governors to declare thousands of workers as state employees, rendering them eligible to organize and engage in collective bargaining.

The median annual salary for home health aides in 2017 was $23,100, with about 67 percent turnover in 2017. The federal Bureau for Labor Statistics projects that demand for home care will increase by as much as 41 percent from 2016 to 2026, as more Americans age.

Both SEIU and the National Employment Law Project, an advocacy group, said that, if the rule takes effect, they expect to file a lawsuit seeking to reverse the decision. And a spokesperson for California Attorney General Xavier Becerra, who has frequently clashed with the White House, said the state will "take any action necessary" to blunt its impact.

In states where home care workers are unionized, the group can have the state withhold membership fees from their paycheck and transfer them directly to the union. Workers must actively choose to join the union.

In California, where most home care workers don't work for private agencies, about 250,000 belong to the state SEIU chapter.

"They'll effectively lose their voice on the job and their ability to advocate," said Laphonza Butler, president of SEIU Local 2015, the California branch of the union.

Beyond California, home care aides have unionized in states including Connecticut, Massachusetts, Minnesota, Illinois, Oregon, Vermont and Washington.

The government is arguing that federal law does not allow states to divert Medicaid dollars to pay for a home care worker's other benefits, such as health care or job training.

"The law provides that Medicaid providers must be paid directly and cannot have part of their payments diverted to third parties outside of a few very specific exceptions," said Tim Hill, acting director for CMS' Center for Medicaid and CHIP Services, in a statement.

Supporters of the rule, such as the National Federation of Independent Businesses, argue it stops powerful unions from using taxpayer dollars to pad their lobbying budget.

But it's a controversial take. Critics said CMS' argument inappropriately casts workers' paychecks as government property, instead of as their own money. And they said it leaves vulnerable workers — arguably, the backbone of elderly care — unable to fend for themselves.

"When a state pays a worker, and the worker pays the union, it's the worker's money going into the union," said Benjamin Sachs, a professor at Harvard Law School who studies labor law. "CMS doesn't have the authority to decide."

Some conservatives suggested that limiting union membership is less about home care policy and more about curtailing a powerful liberal lobbying force.

"There have been steps taken in underlying law and practice to provide extra favors to public sector unions. They are as much political bodies as they are representatives," argued Thomas Miller, a resident fellow at the conservative American Enterprise Institute.

But labor advocates warned the consequences could be steep, and not just for home care workers.

Surveys from the National Employment Law Project suggest that unionized home care workers stay in their jobs longer when represented by unions, partially because they can negotiate better pay and benefits. Higher pay also makes the job more appealing, especially as need grows.

That, many experts argued, means patients also benefit.

"We can be putting more money into making these good quality jobs. The shortages and turnover we are facing —it is not rocket science what is causing that," said Caitlin Connolly, who runs the National Employment Law Project's campaign to increase home care wages. "If we made these quality jobs, we would be able to ensure that people had access to quality care."

Advances In Treating Hep C Lead To New Option For Transplant Patients

KFF Health News, August 13, 2018

The number of people donating organs after dying from drug overdoses has risen more than 200 percent since 2012.

This article first appeared August 13, 2018 on Kaiser Health News.

By Julie Appleby

After her kidneys failed from the same illness that took the lives of her mother and brother, Anne Rupp went on dialysis in May 2016, spending three hours a day, three times a week undergoing the blood-cleaning procedure. She hated it.

Rupp, who had polycystic kidney disease, joined more than 95,000 other Americans on kidney transplant lists. She knew the wait could stretch out for years.

But an experimental — and controversial — source of donated organs provided a far quicker resolution: Expensive medicines to treat hepatitis C have made it possible to use organs donated by victims of opioid overdoses who were infected with the once-deadly virus.

Six months after agreeing to be in a study in which patients in need of a kidney transplant would accept infected donor organs, Rupp got a 7:30 a.m. call at her home in York, Pa. "We have a kidney for you!"

The number of people donating organs after dying from drug overdoses has risen more than 200 percent since 2012, data from the United Network for Organ Sharing (UNOS) show — more than 13 percent of donors overall. About 30 percent of the 1,382 overdose-death donors in 2017, however, tested positive for hepatitis C.

In the past, organs exposed to hep C were typically discarded or given only to patients who already had the illness. Using them in patients who don't have the virus could shorten the transplant wait time for hundreds of patients each year.

"This is super exciting because five years ago 100 percent of [the donated] hep C hearts were being buried and now some are being used," said Dr. Peter Reese, an associate professor at University of Pennsylvania. "The world has changed."

But patients who receive such organs would almost certainly need simultaneous treatment with drugs to treat hepatitis C, generally a six- to 12-week course of drugs that costs tens of thousands of dollars. And it's unknown whether long-term use of the drugs is safe and effective in this population.

"'We haven't done this before,'" Rupp, 76, remembers her doctor at Johns Hopkins Hospital in Baltimore telling her when he offered her the option. But, he explained, the new antiviral medications nearly always cure hepatitis C.

While some hep C patients have no symptoms, over time, the untreated virus can cause chronic liver disease and lead to liver failure.

The Hopkins study — and several others nationally — are opening up new medical possibilities, while exposing patients to potential costs.

Since the procedure is considered experimental, many health plans don't have a specific coverage policy on the expensive antiviral drugs that go hand in hand with it.

Insurers that responded to questions for this story generally said they take each request on a case-by-case basis, and cover the drugs if they deem them medically necessary.

Researchers and ethics experts say coverage must be clarified before the new procedure becomes more widely available.

"How can you intentionally infect someone if not 100 percent sure their third-party payer will pay for [treatment] it?" said Dr. Christine Durand, an assistant professor of medicine at Johns Hopkins University School of Medicine.

At Hopkins, patients start the antiviral drugs just before being wheeled into the operating room. Other programs wait until the patient tests positive for hepatitis C, usually in the first few days after a transplant. Generally, when part of a study, the drugs are paid for by the manufacturer or the institutions conducting the research.

When the drugs first hit the market at the end of 2013, a course of treatment cost $100,000. As more antivirals have become available, prices have fallen and coverage limits have eased for people with chronic hepatitis C. The average net price for a round of hep C antiviral therapy is now $25,167, according to SSR Health, part of SSR LLC, a boutique investment research firm.

Outside of those trials, transplant surgeons say they've sought — and often obtained — insurance coverage for the drugs. Durand said the move is cost-effective because the drugs cost less than ongoing dialysis for kidney failure or mechanical heart assist devices.

Researchers are split on whether there's enough evidence to take the procedure out of the realm of scientific study.

"It isn't the standard of care today, but it's going in that direction," said Durand.

Others advise caution until long-term results can be seen.

While the first 20 patients at Hopkins and Penn who received kidneys in a published study were all cured of hep C, "if we had 100 patients, or 200, then we would get a better sense as to whether the cure rate is 100 percent," said Penn's Reese.

The heart transplant program at Vanderbilt University Medical Center in Nashville has transplanted 42 non-infected patients with hearts exposed to hep C, and continues to follow them. Dr. Ashish Shah, the program's director, noted that some people with untreated or long-term hepatitis C have a higher incidence of coronary artery disease.

"We'll have to watch that," he said, but noted that many patients with severe heart failure would otherwise die waiting for a transplant. "It's reasonable to think that risks [of accepting an organ from a hepatitis-infected donor] are far lower."

Jay Fuentes, a 45-year-old registered nurse in Quakertown, Pa., agreed to participate in the study at Penn in hopes of getting a transplant more quickly after his kidneys failed in 2017.

"It seemed like a no-brainer to me," said Fuentes. "If I was in the first group where it had never been tried before, I might have hesitated."

He tested positive for hepatitis C shortly after the surgery and took the antiviral drugs for 90 days. He said he no longer tests positive and has gotten back into performing in local theater with his children.

"I have a whole new lease on life," said Fuentes.

Trump Administration Sinks Teeth Into Paring Down Drug Prices, On 5 Key Points

KFF Health News, August 10, 2018

Two HHS officials who are rolling out the plan, Dan Best and John O’Brien, described their efforts to Kaiser Health News not as a public relations strategy but a push to reform the system.

This article first appeared August 10, 2018 on Kaiser Health News.

By Sarah Jane Tribble

Three months after President Donald Trump announced his blueprint to bring down drug prices, administration officials have begun putting some teeth behind the rhetoric.

Many details have yet to be announced. But experts who pay close attention to federal drug policy and Medicare rules say the administration is preparing to incrementally roll out a multipronged plan that tasks the Centers for Medicare & Medicaid Services (CMS) and the Food and Drug Administration with promoting competition, attacking the complicated drug rebate system and introducing tactics to lower what the government pays for drugs.

Mark McClellan, director of the Duke-Margolis Center for Health Policy in Durham, N.C., and a former CMS administrator, said that although none of the initial steps has "fundamentally transformed drug prices," there is "a lot going on inside the administration."

Two HHS officials who are rolling out the plan, Dan Best and John O'Brien, described their efforts to Kaiser Health News not as a public relations strategy but a push to reform the system.

"This administration is trying to go after root causes" of high drug prices, said Wells Fargo analyst David Maris.

But others are not so optimistic.

Ameet Sarpatwari, an instructor in medicine at Harvard Medical School in Boston, said policies the administration has rolled out thus far "alone will not translate into meaningful cost savings for most Americans."

Broadly, the strategy falls under a handful of steps:

1. Attacking The Rebates

Health and Human Services Secretary Alex Azar has said Americans "do not have a real market for prescription drugs" because drug middlemen and insurers get a wide range of hidden rebates from drugmakers, but those savings may not be passed on to consumers or Medicare. In July, the administration submitted a proposed rule that could change the way rebates are handled.

Details of the proposal have not been made public. But O'Brien, a deputy assistant secretary at HHS, explained during a recent conference on federal drug spending sponsored by the Pew Charitable Trust: "You don't have to use market power to get rebates, you can use market power to obtain discounts, to actually lower the price of the drug on the front end."

Umer Raffat, an investment analyst with EverCore ISI, said "it's not clear [that drug prices are going down]" but the "rebate structure is changing."

2. Bringing More Negotiation To Medicare

This week, CMS Administrator Seema Verma announced that Medicare Advantage insurers can use a step-therapy approach to negotiate better prices for Part B drugs — those administered in hospitals and doctors' offices. These private plans will be allowed to require patients to first select the least expensive drug before stepping up to more costly drugs if the original medications aren't working.

The administration is also looking at ways to introduce more competition into Part B drug purchasing. That idea was mentioned deep inside the annual Medicare outpatient payment rule released last month.

Peter Bach, director of Memorial Sloan Kettering's Center for Health Policy and Outcomes in New York, pointed to the possible introduction of a competitive purchasing program in which a firm negotiates with drugmakers to buy their drugs and then sells them to the doctors and hospitals that will administer the medications. Bach said that helps ensure that hospitals and doctors can't make more money by prescribing more expensive drugs.

Currently, Medicare pays the average sales price plus 6 percent to doctors or hospitals when they purchase drugs, a pricing mechanism that can benefit the providers if the drug costs go up. If there were a third party buying the drugs, it would "have a huge effect," Bach said.

3. Paying For Value

Trump's blueprint calls for CMS to encourage "value-based care" to lower drug prices, shifting from paying a set fee for drugs to basing payments on how well the patient does on them.

Louisiana's Medicaid program could show the way. The state is working with CMS to explore a subscription-based model to pay for hepatitis C medicines. Louisiana would pay a fixed price to a drug manufacturer that would then get unlimited access to treat patients enrolled in Louisiana's Medicaid program or in prison.

The program would move "from a big payment upfront to paying less over time based on actual outcomes," said McClellan, who also serves on the boards of health care giant Johnson & Johnson and insurer Cigna.

CMS also approved a Medicaid waiver from Oklahoma in June. Medicaid programs are allowed to negotiate drug prices. Oklahoma's plan would expand that to negotiate additional prescription price reductions based on value-based purchasing agreements.

Still, CMS' recent rejection of a related Massachusetts proposal makes it difficult to believe negotiating drug prices will really happen, said Sara Rosenbaum, a professor of health law and policy at George Washington University.

That proposal would have allowed Massachusetts' Medicaid program to choose drugs based on cost and how well the medicines work.

"They have been very good and quite careful with their [Medicaid] program and so why not let them try this?" Rosenbaum said.

4. Tackling Foreign Drug Costs

Pharmaceutical makers often sell their drugs at substantially lower prices in many foreign countries than they do in the United States. Trump emphasized in May that "it's time to end the global freeloading once and for all," saying U.S. consumers were paying part of the cost of the medicines that patients in other countries use.

He directed U.S. Trade Representative Robert Lighthizer to address the situation. Lighthizer's office declined to comment.

When Sen. Todd Young (R-Ind.) asked during a Senate health committee hearing in June whether trade agreements with other countries should be used to "level the playing field," Azar's response was swift: "We absolutely believe we should be using our trade agreements to get them to pay more even as we have our job to pay less."

Avalere Health President Matt Brow, who has been involved in talks with the administration, said it's clear the focus on overseas pricing isn't going away and the administration is "talking a lot about how to get the president what he wants."

5. Increasing Competition

FDA Commissioner Scott Gottlieb has become the Trump administration's lead proponent for increasing competition among drugmakers.

Competition resonates with Americans "because people see it every day in their experience in Costco and other places," said Rena Conti, an assistant professor at the University of Chicago.

Gottlieb has announced plans to bolster the use of generic drugs and an "action plan" to encourage the development of biosimilars, which are copycat versions of expensive biologic drugs made from living organisms.

And to combat anti-competitive behavior in the market, Gottlieb said the FDA has passed along information to the Federal Trade Commission and hinted at potential action to come: "I think we've handed them some pretty good facts."

Clinicians Who Learn Of A Patient's Opioid Death Modestly Cut Back On Prescriptions

KFF Health News, August 9, 2018

The ones who knew about the overdose death cut the overall volume of opioids they prescribed by almost 10% over three months, while those who didn’t know prescribed roughly the same amount as before.

This article first appeared August 10, 2018 on Kaiser Health News.

By Anna Gorman

Physicians and other medical providers modestly reduced the volume of opioids they prescribed after being told one of their patients had died of an overdose, according to research published Thursday.

"You can hear a lot of statistics about the crisis," said Jason Doctor, lead author of the study, published Thursday in the journal Science. "But it always feels like it is happening elsewhere if you are not aware of any deaths in your own practice."

The research included more than 800 clinicians — doctors, nurse practitioners, physician assistants and dentists — comparing those who received a letter from the medical examiner about a patient's death and those who didn't. The ones who knew about the overdose death cut the overall volume of opioids they prescribed by almost 10 percent over three months, while those who didn't know prescribed roughly the same amount as before.

The study shows that awareness and education can change prescribing behavior, said Doctor, lead author and associate professor at University of Southern California's Price School of Public Policy. The modest size of the reduction among those who were notified of a death suggests "that clinicians exercised greater caution with opioids rather than abandoning use," according to the study.

The providers in the study who were informed about patients' deaths were also 7 percent less likely to start new patients on opioids.

The letter did not blame providers for the deaths but showed that authorities were paying attention, according to the study.

"We were providing them with important information and also giving them a way to make things better by changing prescribing," Doctor said. "Anyone who got the letter could continue to prescribe as much as they wanted, but we found that they didn't. They became more judicious prescribers."

Over 19,000 people died from prescription opioids in 2016, roughly double the number 14 years earlier, according to the National Institute on Drug Abuse. Most of that increase occurred from 2002 to 2011, and the numbers have been relatively stable since then, according to the NIDA.

Meanwhile, prescriptions of opioids are declining, and health officials are seeking ways to accelerate the trend.

The study did not measure whether the letters from the medical examiner or the changes in prescribing patterns had any effect on patient deaths.

Across the country, physicians have been accused of overprescribing opioids and have even faced charges related to patient overdose deaths. In an effort to better track prescribing patterns, states have started prescription drug monitoring databases.

The CDC recommends that providers avoid opioids if possible, but if they are necessary, they should start with the lowest effective dose.

Pharmacy-Made Pain Creams Flagged On Fears Of Medicare Fraud And Risk

KFF Health News, August 9, 2018

Most of the prescriptions were for pain treatment, made from ingredients such as lidocaine, an anesthetic, or diclofenac sodium, an anti-inflammatory drug.

This article first appeared August 09, 2018 on Kaiser Health News.

By Julie Appleby

Medicare pays hundreds of millions of dollars each year for prescription creams, gels and lotions made-to-order by pharmacies — mainly as pain treatments. But a new report finds that officials are concerned about possible fraud and patient safety risks from products made at nearly a quarter of the pharmacies that fill the bulk of those prescriptions.

"Although some of this billing may be legitimate, all of these pharmacies warrant further scrutiny," concludes the report from the Office of the Inspector General for the Department of Health and Human Services.

In total, 547 pharmacies — nearly 23 percent of those that submit most of the bills to Medicare for making these creams — hit one or more of five red-flag markers set by investigators. Those included what the researchers called "extremely high" prices; large percentages of Medicare members getting identical drugs — 16 of the pharmacies billed for identical drugs for 200 or more customers; "greatly increased" year-over-year billing — 20 pharmacies increased their billing by more than 10,000 percent; or having a single medical provider writing more than 131 prescriptions. More than half of those pharmacies hit two or more measures — and 10 hit all five.

One Oregon pharmacy, for example, submitted claims for 91 percent of its customers. A pharmacy in New York submitted 5,342 prescriptions ordered by one podiatrist, while a Florida pharmacy saw its Medicare billing for such treatments go from $7,468 in 2015 to $1.8 million the following year.

Many of the pharmacies are clustered in four cities: Detroit, Houston, Los Angeles and New York.

The report comes amid ongoing concern by Medicare officials about these custom-made — or compounded — drugs. In addition to questions like those raised in the report about overuse and pricing, safety has been a key issue in recent years. A meningitis outbreak in 2012 was linked to a Massachusetts pharmacy that did not maintain sterile conditions and sold tainted made-to-order injections that killed 64 Americans.

When done safely, pharmacy-made compounded drugs provide a legitimate option for patients whose medical needs can't be met by commercially available products mass-produced by pharmaceutical companies. For example, a patient who can't swallow a commercially available prescription pill might get a liquid version of a drug.

State boards of pharmacy generally oversee compounding pharmacies, and the drugs they produce are not considered approved by the Food and Drug Administration.

The new report focuses on concerns with compounded topical medications.

Medicare spending for such treatments has skyrocketed, rising more than 2,350 percent, from $13.2 million in 2010 to $323.5 million in 2016. Price hikes and an increase in the number of prescriptions written drove the increase, the report said.

It is not the first time the inspector general has looked at compounded drugs. A 2016 report found that overall spending on all types of compounded drugs — not just topical medications — rose sharply. The U.S. Postal Service inspector general and the Department of Defense also have raised concerns about rising spending and possible fraud for compounded drugs.

In response to those previous reports, the International Academy of Compounding Pharmacists, the industry's trade group, has said that legitimately compounded drugs "can dramatically improve a patient's quality of life," noting that proper billing controls need to be in place. The inspector general's report in 2016, it added, found that "such controls are not in place."

This report, which the compounding trade group has not yet reviewed, focuses on topical drugs and a subset of the 15,290 pharmacies that provide at least one such prescription each year. It looked at billing records from the 2,388 pharmacies that do at least 10 such prescriptions a year — providing 93 percent of all compounded topical drugs paid for by Medicare.

Most of the prescriptions were for pain treatment, made from ingredients such as lidocaine, an anesthetic, or diclofenac sodium, an anti-inflammatory drug.

On average, those compounds were more expensive than non-compounded drugs with the same ingredients.

For example, Medicare paid an average of $751 per tube of compounded lidocaine, and $1,506 for the diclofenac, according to the inspector general's report. Non-compounded tubes of those drugs averaged $445 and $128, respectively.

FDA Commissioner Scott Gottlieb recently outlined new efforts his agency is taking to oversee compounded drugs in the wake of legislation passed by Congress following the meningitis outbreak.

"The FDA is inspecting compounding facilities to assess whether drugs that are essentially copies of FDA-approved drugs are being compounded for patients" who could otherwise take a product sold commercially, he said in a statement issued on June 28.

Gottlieb also said the FDA plans to make more information available to patients and their doctors about compounded topical pain creams, including information about their effectiveness and any potential safety risks.

Not being effective is a safety risk, noted Miriam Anderson, a researcher with the inspector general's office who helped write the report.

The report urged the Centers for Medicare & Medicaid Services to clarify some of its policies to emphasize that insurers can limit the use of compounded drugs by requiring prior authorization or other steps. The agency concurred with the recommendations, according to the report, including the need to "follow up on pharmacies with questionable Part D billing and the prescribers associated with these pharmacies."

Anderson said the inspector general's office is continuing to probe the issue.

"We will investigate a number of leads on specific pharmacies and prescribers who were identified as having these questionable patterns," she said. "Whenever we see that kind of increase in spending, it raises concern about fraud, waste and abuse."

Once Its Greatest Foes, Doctors Are Embracing Single-Payer

KFF Health News, August 7, 2018

The battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles.

This article first appeared August 07, 2018 on Kaiser Health News.

By Shefali Luthra

When the American Medical Association — one of the nation's most powerful health care groups — met in Chicago this June, its medical student caucus seized an opportunity for change.

Though they had tried for years to advance a resolution calling on the organization to drop its decades-long opposition to single-payer health care, this was the first time it got a full hearing. The debate grew heated — older physicians warned their pay would decrease, calling younger advocates naïve to single-payer's consequences. But this time, by the meeting's end, the AMA's older members had agreed to at least study the possibility of changing its stance.

"We believe health care is a human right, maybe more so than past generations," said Dr. Brad Zehr, a 29-year-old pathology resident at Ohio State University, who was part of the debate. "There's a generational shift happening, where we see universal health care as a requirement."

The ins and outs of the AMA's policymaking may sound like inside baseball. But this year's youth uprising at the nexus of the medical establishment speaks to a cultural shift in the medical profession, and one with big political implications.

Amid Republican attacks on the Affordable Care Act, an increasing number of Democrats — ranging from candidates to established Congress members — are putting forth proposals that would vastly increase the government's role in running the health system. These include single-payer, Medicare-for-all or an option for anyone to buy in to the Medicare program. At least 70 House Democrats have signed on to the new "Medicare-for-all" caucus.

Organized medicine, and previous generations of doctors, had for the most part staunchly opposed to any such plan. The AMA has thwarted public health insurance proposals since the 1930s and long been considered one of the policy's most powerful opponents.

But the battle lines are shifting as younger doctors flip their views, a change that will likely assume greater significance as the next generation of physicians takes on leadership roles. The AMA did not make anyone available for comment.

Many younger physicians are "accepting of single-payer," said Dr. Christian Pean, 30, a third-year orthopedic surgery resident at New York University.

In prior generations, "intelligent, motivated, quantitative" students pursued medicine, both for the income and because of the workplace independence — running practices with minimal government interference, said Dr. Steven Schroeder, 79, a longtime medical professor at the University of California-San Francisco.

In his 50 years of teaching, students' attitudes have changed: "The 'Oh, keep government out of my work' feeling is not as strong as it was with maybe older cohorts," said Schroeder. "Students come in saying, 'We want to make a difference through social justice. That's why we're here.'"

Though "single-payer" health care was long dismissed as a left-wing pipe dream, polling suggests a slim majority of Americans now support the idea — though it is not clear people know what the term means.

A full single-payer system means everyone gets coverage from the same insurance plan, usually sponsored by the government. Medicare-for-all, a phrase that gained currency with the presidential campaign of Sen. Bernie Sanders (I-Vt.), means everyone gets Medicare, but, depending on the proposal, it may or may not allow private insurers to offer Medicare as well. (Sanders' plan, which eliminates deductibles and expands benefits, would get rid of private insurers.)

Meanwhile, lots of countries achieve universal health care — everyone is covered somehow — but the method can vary. For example, France requires all citizens purchase coverage, which is sold through nonprofits. In Germany, most people get insurance from a government-run "public option," while others purchase private plans. In England, health care is provided through the tax-funded National Health System.

American skeptics often use the phrase "socialized medicine" pejoratively to describe all of these models.

"Few really understand what you mean when you say single-payer," said Dr. Frank Opelka, the medical director of quality and health policy for the American College of Surgeons, which opposes such a policy. "What they mean is, 'I don't think the current system is working.'"

But the willingness to explore previously unthinkable ideas is evident in young doctors' ranks.

Recent surveys through LinkedIn, recruiting firm Merritt Hawkins and trade publication NEJM Catalyst indicate growing support. In the March NEJM survey, 61 percent of 607 respondents said single-payer would make it easier to deliver cost-effective, quality health care.

Delving further, that survey data shows support is stronger among younger physicians, said Dr. Namita Mohta, a hospitalist at Brigham and Women's Hospital and clinical editor at NEJM Catalyst.

But it's unclear whether these findings reflect young doctors' feelings about the policy or whether they are tapping in to broader frustrations with the American health system.

Much like the general public, doctors often use terms like single-payer, Medicare-for-all and universal health care interchangeably.

"Our younger generation is less afraid to come out and say we want universal health care," said Dr. Anna Yap, 26, an emergency medicine resident at UCLA, who served as a medical student delegate to the AMA until this past June. "But how? It's different in what forms we see."

Younger doctors also pointed to growing concern about how best to keep patients healthy. They cited research that broadly suggests having health insurance tracks with better health outcomes.

"Medical students, I would say, are very interested in public health and improving social determinants of health — one of them being access to health insurance," said Dr. Jerome Jeevarajan, 26, a neurology resident at the University of Texas-Houston, referring to non-medical factors that improve health, such as food or housing.

Some of the shift in opinion has to do with the changing realities of medical practice. Doctors now are more likely to end up working for large health systems or hospitals, rather than starting individual practices. Combined with the increasing complexity of billing private insurance, many said, that means contracting with the government may feel like less of an intrusion.

The debate is, at this point, still theoretical. Republicans — who control all branches of the federal government — sharply oppose single-payer. Meanwhile, single-state efforts in California, Colorado and New York have fallen flat.

Also, doctors represent only one part of the sprawling health care industrial complex. Other health care interests — including private insurance, the drug industry and hospital trade groups — have been slower to warm to catchphrases like single-payer or universal health care, all of which would likely mean a drop in income.

But increasingly physicians seem to be switching sides in the debate, and young physicians want to be part of the discussion.

"There's tremendous potential … to be at the table if single-payer becomes a significant part of the political discourse, and create a system that is more equitable," Pean said.

In Weary Post-Storm Puerto Rico, Medicaid Cutbacks Bode New Ills

KFF Health News, August 6, 2018

Physicians, health insurers, and former government officials say the drastic cuts defy actuarial science and provide too little money.

This article first appeared August 06, 2018 on Kaiser Health News.

By Sarah Varney and Carmen Heredia Rodriguez

SAN JUAN, Puerto Rico — Blue tarps still dot rooftops, homes lack electricity needed to refrigerate medicines, and clinics chip away at debts incurred from running generators. Yet despite the residual effects from last year's devastating hurricanes, Puerto Rico is moving ahead with major cuts to its health care safety net that will affect more than a million of its poorest residents.

The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory's agreement with the federal government as the island claws its way back from fiscal oblivion.

Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory's historically astronomical Medicaid expenses — on an island where the average household earns $20,000 and diabetes and hypertension are widespread.

But physicians, health insurers and former government officials say the drastic cuts demanded defy actuarial science and provide too little money to care for a population still traumatized by Hurricane Maria.

The cutbacks will give private health insurance companies the incentive to shuttle around patients with costly chronic diseases or mental illness, critics warn. And they do nothing to address the underlying fiscal imbalance at the root of Puerto Rico's health care woes, which stem from the fact that the federal government contributes a tiny fraction of the island's Medicaid budget, compared to what it contributes to the 50 U.S. states.

"We are rearranging the chairs on the Titanic," said Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.

Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.

"These people who have been under our service for the last four or five years, all of a sudden I have to abandon them," said Dr. José Joaquín Vargas, chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.

Health Crippled By Debt

If Puerto Rico were a state, the federal government would pay 83 percent of Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in 10 states, according to a formula that takes a state's economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent, as a fixed annual payment — a so-called block grant.

In February, Congress approved $4.8 billion in additional funds to help pay the island's Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory's fiscal oversight board. That's a federal control board established by Congress in 2016 to oversee Puerto Rico's budget, negotiate with its creditors and help restructure at least some of the island's debt.

Gov. Ricardo Rosselló's administration aims to reduce Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló's plan, the companies will be forced to offer island-wide insurance plans and compete for customers.

"We do not have the luxury" of continuing to spend inefficiently, said Ángela Ávila Marrero, executive director of Puerto Rico's Health Insurance Administration.

If Rosselló's overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Some 1.1 million Puerto Rican residents on Medicaid — out of 1.6 million enrollees — are at risk of losing coverage next fall, their health held hostage to the island's need to pay back its crippling debt.

Puerto Rico's government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession, a corporate tax break that ended in 2006 and reckless spending by a bloated government.

But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico's staggering Medicaid burden.

Poverty is so pervasive here that nearly 1 in 2 people qualify for public health insurance; Medicaid expenses in 2016 totaled $2.4 billion. Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.

Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island's fiscal health, health economists say.

Researchers of health care say that, putting aside interest on Puerto Rico's debt, the territory's primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.

"The main issue is that we are not yet a state," said Rep. Jenniffer González-Colón, the commonwealth's nonvoting member of Congress. The island must pay for Medicaid, she added, "with local funds that we don't have."

Battered Even Before The Storm

Puerto Rico's health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act and 900,000 Puerto Rican residents would lose coverage.

Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology and fueled the exodus of thousands of physicians to the mainland in search of better incomes.

Today, Medicaid patients face long waits to see doctors on the island.

"If your kid needs a neurologist, for example, the waiting period is around six to 12 months," said Dr. Jorge Rosado, a pediatrician in San Juan. "For a genetics specialty, it's two to three years."

The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.

Little Time To Waste

Barring the unlikely passage of bills that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out next fall. González-Colón also authored a bill calling for statehood, which would eliminate the federal government's unequal treatment toward the island's Medicaid program.

The fiscal control board established by Congress openly acknowledges the impending disaster. In an April 19 report, the board projects monthly costs per Medicaid patient will rise nearly 40 percent over the next six years, barring any changes, and that Puerto Rico "will hit a 'Medicaid cliff.'"

Beginning this fall, Medicaid patients will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.

Puerto Rico has long capped monthly payments insurers receive for Medicaid patients regardless of how many medical services they use, a form of managed care. But the government here believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.

The island's government has vowed to pay private insurers extra money to care for those with expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.

"I support the government on what they're trying to do, but they didn't price it properly," said Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.

He added, "The oversight board is fixated on cuts, but we're never going to improve health care unless more money is put into the system."

Government health officials argue Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But the island's clinics and hospitals fear they will be squeezed by insurers seeking to lower costs, just as they are still reeling from hurricane-related expenses.

Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.

Many experts are skeptical that managed-care companies will hire the army of social workers and nurses like Calderón needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty. Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.

Many people displaced by the storm haven't yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.

"The managed-care companies need to produce revenue," said Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. "That's a setup for concern."

Bottom line? The economic overhaul doesn't rectify Puerto Rico's fundamental problem — it can't sustain its Medicaid program so long as Congress treats the territory differently than it treats states.

"Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens," said Torres. But, he added, "it's time the local government started thinking about a Plan B."

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