Doling Out Pain Pills Post-Surgery: An Ingrown Toenail Not The Same As A Bypass

KFF Health News, June 22, 2018

A group at Johns Hopkins took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific surgical procedures.

This article first appeared June 22, 2018 on Kaiser Health News.

By Julie Appleby

What’s the right painkiller prescription to send home with a patient after gallbladder surgery or a cesarean section?

That question is front and center as conventional approaches to pain control in the United States have led to what some see as a culture of overprescribing, helping spur the nation’s epidemic of opioid overuse and abuse.

The answer isn’t clear-cut.

Surgeon Marty Makary wondered why and what could be done.

So, Makary, a researcher and a professor of surgery and health policy at Johns Hopkins School of Medicine in Baltimore, took an innovative approach toward developing guidelines: matching the right number of opioid painkillers to specific procedures.

After all, most doctors usually make this decision based on one-size-fits-all recommendations, or what they learned long ago in med school.

Even Makary admitted that for most of his career he “gave [painkillers] out like candy.”

In December, he gathered a group of surgeons, nurses, patients and other leaders, asking them: What should we be prescribing for operation X?”

The answer was illuminating.

“The head of the hospital’s pain services said, ‘You’re the surgeon, what do you think?’” recalled Makary.

Makary didn’t know. Nor did the resident. And the nurse practitioner, who often is the one who most closely follows up with patients, said it varies.

“Wow,” recalls Makary of that day when they first considered appropriate limits. “We’re the experts, the heads of this and that, and we don’t know.”

After a quick couple of weeks of intense discussion, Makary’s group reached consensus and gave its blessing to guidelines setting maximum numbers of opioid-containing pills for 20 different common surgical situations, from relatively minor procedures to coronary bypass surgery.

“We’re in a crisis,” said Makary, explaining why the group didn’t go a more traditional route and publish its findings in a medical journal first, which could take months.

Sometimes the right number of opioids is zero, concluded the group.

Indeed, it recommends no opioids for patients heading home after uncomplicated labor and delivery, or after cardiac catheterization, a procedure in which a thin, hollow tube is inserted into the heart through a blood vessel to check for blockages.

For certain types of knee surgery, such as arthroscopic meniscectomy, the guidelines recommend no more than 12 pills upon discharge, while a patient going home after an open hysterectomy could require as many as 20.

Optimally, “no one should be given more than five or 10 opioid tablets after a cesarean section,” Makary said.

Oh, and for cardiac bypass surgery? No more than 30 pills.

But What About The Pain?

Tens of thousands of Americans are dependent upon opioid medications. An increasing number are dying from overdoses, both from prescription medication and street drugs.

Knowing that, Makary, as well as other surgeons, hospitals and organizations, are taking steps to change how they practice medicine.

After all, many experts view the use of opioid prescription painkillers after surgery as a gateway to long-term use or dependence. A study published last year in the journal JAMA Surgery found that persistent use of opioids was “one of the most common complications after elective surgery.”

In that study, University of Michigan researchers found that 6 percent of people who had never taken opioids but received them after surgery were still taking the medications three to six months later.

With about 50 million surgeries that occur in the U.S. each year, “there are millions who may become newly dependent,” said Chad Brummett, the study’s lead author and an associate professor of anesthesiology at the University of Michigan Medical School.

Smokers, and those diagnosed with certain conditions such as depression, anxiety or chronic pain before their operations, were most at risk of long-term use.

Each refill or additional week of use makes for a greater risk of misuse, other studies have shown.

Additional research points to another reason for concern. If patients don’t take all the pills they are prescribed following an operation, those pills can be stolen or diverted to other people, who then run the risk of becoming dependent.

Still, there is debate in medical circles about just how effective recommendations and guidelines will be in stemming the epidemic.

For one thing, some experts worry that if the fight against opioids focuses only on safe prescribing at the expense of seeking alternatives, it may miss the bigger picture.

“Are there better methods than opioids in the first place?” asks Lewis Nelson, chair of emergency medicine at Rutgers New Jersey Medical School. “Could you put a lidocaine patch over the wound or is there a better way to immobilize a joint?”

Studies have shown that sometimes a combination of ibuprofen and acetaminophen can be just as good as or better than opioids.

Alternatives should always be considered first, agreed Makary.

Another concern is that guidelines for prescribing relief — even those aimed at short-duration, acute pain, such as that following surgery — have carryover effects on patients with long-term pain. Advocates say all the attention around prescribing limits have made it difficult for chronic pain patients to get the medications they need.

Some people even apply these concerns to recommendations about the treatment of acute pain.

“It’s important for a physician to have the ability, if they feel there’s a medical necessity, to write a prescription for a longer duration,” said Steven Santos, president of the American Academy of Pain Medicine. “It’s challenging to lump all patients into one basket.”

A Different Focus: Duration

Lawmakers — desperate to address overdose problems that are destroying families and communities — have gone where they usually don’t: setting specific rules for doctors.

Legislatures in more than a dozen states, including New Jersey, Massachusetts and New York, have set restrictions, often on the number of days’ worth of pills prescribed for acute pain.

“States said that since physicians haven’t self-regulated, we’re going to do it for them,” said Nelson at Rutgers.

Congress, too, is getting involved, holding a flurry of hearings this spring, and considering legislation that would, among other things, set limits on prescribing opioids for acute pain. The recently passed federal spending bill includes $3 billion in new funding to help states and local governments with opioid prevention, treatment and law enforcement efforts.

To be sure, the medical profession has also responded to the crisis — with medical societies and other expert groups offering a growing number of standards for prescribing opioids.

Some are fairly generic, recommending the lowest dose for the shortest period of time for acute pain. Some are more prescriptive.

None is meant to address the needs of chronic pain patients or those with cancer.

And state rules vary. New Jersey’s, for example, says patients with acute pain should, initially, get no more than a five-day supply, while Massachusetts sets the cap at seven days for a patient prescribed opiates for the first time.

The Centers for Disease Control and Prevention recommends three days.

Makary and some other experts say that, while well-intentioned, such durational rules are too blunt.

A day’s worth of pills can vary, depending on how often the doctor instructs patients to take them. Under many of the state rules, patients could still head home with more than 50 pills.

“No one should have 50 tabs sitting in their medicine cabinet” for acute pain, said Makary.

Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management, supports guidelines but wants states to take their rules a step further.

“I don’t think the way the states are going at this makes much sense because the issue with overprescribing was quantity, yet they’re passing laws around duration,” he said.

Instead, the laws should require that “if physicians are going to prescribe more than three days, they have to warn the patients that this is an addictive drug and that taking it every day for as little as five days may cause them to become physiologically dependent,” Kolodny said.

That would create a disincentive to prescribing more than three days’ worth of opioid painkillers, he added, and lead to more informed patients among those who need a longer supply.

Rutgers’ Nelson, who sat on the CDC panel that developed recommendations, said durational rules — like those adopted by the states — can be effective.

“I personally think three days is enough,” said Nelson. “That doesn’t mean pain goes away in three days, but most people get better within three to five days.”

That said, Nelson called the Hopkins’ approach an “excellent idea” and one he has tried to do. “It’s a lot harder than it sounds because of the large number of procedures and the diversity of patient needs,” he said.

To get around overprescribing — or setting one-size-fits-all guidelines — physicians at Dartmouth-Hitchcock Medical Center have a developed their own data-based approach.

Dr. Richard Barth, the chief of general surgery at Dartmouth, and colleagues studied 333 patients discharged from the hospital following six common surgeries that included bariatric procedures; operations on the stomach, liver, colon and pancreas; and hernia repair.

Surveying the patients, they asked how many opioid pills they went home with, how many they actually took, how many went unused and how much pain they experienced.

The data helped them land on a way to recommend a specific number of pills. “If they took none the day before discharge, then over 85 percent of patients did not take any when they went home,” said Barth.

Dartmouth-Hitchcock now uses that data as a recommended starting point for physicians.

Under the guidelines, patients taking no opioid pain pills the day before discharge go home with none. Those who take one to three pills get 15, an amount Barth’s study found satisfied 85 percent of patients, and those who took four or more get 30 pills.

“We came out with a very easy to implement and remember guideline,” said Barth. “We actually called patients and asked them how many [pills] they used. That’s what differentiates us from other places.”

Brummett, at Michigan, says the Opioid Prescribing Engagement Network, a collaboration of hospitals, insurers, physicians and others in his state, has used similar data methods to come up with procedure-specific guidelines.

“We’ve taken a data-driven approach,” he said. “We believe patient-reported outcomes are a better way to guide than expert consensus.”

For his part, Makary admitted it is harder to develop guidelines like those at Hopkins and Dartmouth, but he said the effort is vital.

“It’s mind-boggling to me” that so many opioid-prescribing guidelines do not specify the procedure, said Makary. “An ingrown toenail is not the same as cardiac bypass surgery.”

'Holy Cow' Moment Changes How Montana's State Health Plan Does Business

KFF Health News, June 20, 2018

Instead of starting with the hospital's list price and negotiating down for discounts, the state began telling these facilities how much it was willing to pay.

This article first appeared June 20, 2018 on Kaiser Health News.

By Julie Appleby

Marilyn Bartlett, the director administrator of Montana's Health Care and Benefits Division, recalls thinking "holy cow" when she got an urgent directive from state legislators in late 2014: "You have to get these costs under control, or else."

Increasing health care costs in the state workers' health plan were helping hold down workers' wages. The plan's financial reserves were dwindling, heading for negative territory.

So began Barlett's high-stakes game of chicken designed to change how the state did business with its 60 hospitals, which accounted for 43 percent of employee health care costs, turning the normal purchasing process on its head.

Instead of starting with the hospital's list price and negotiating down for discounts, the state began telling these facilities how much it was willing to pay — a "reference price" — for each type of hospitalization. State officials used generally conservative Medicare rates as a baseline and starting point for the discussion.

Before the plan took effect, hospital charges for state employees for the same service had varied widely, with some hospitals charging three to six times the Medicare rate for some services.

To even out the disparities and save money, the state decided it would pay an average of 234 percent of Medicare rates — a level of payment that hospitals indicated they would accept and an amount the state calculated would allow an efficient hospital to deliver high-quality care and still profit.

While other states and some private employers have set prices they are willing to pay for some standardized procedures — such as a colonoscopies or hip replacements — Montana's experiment is more sweeping, covering all hospital services, and it uses Medicare as a common yardstick.

Two years in, the state calls the effort a success, saving $15.6 million this year over the estimate of what it would have paid without the change. Meanwhile, its reserve fund has grown and is so healthy the state dipped into it for other needs.

Did The State Get The Payments Right?

"A centralized price-setting model has danger. It can overpay or underpay," said Glenn Melnick, director of the Center for Health Policy and Management at the University of Southern California.

Like some other cost-control efforts, the Montana approach might lead to smaller numbers of hospitals that agree to participate in the state plan, he noted.

So far, there's been no sign of that, said Bartlett: "No hospital has gone broke."

But resistance is natural, said Damon Haycock, head of Nevada's public employees' benefits plan, because, ultimately, money saved for state workers is money hospitals don't get.

There could be a ripple effect, as others in the community will want parity.

"If a state takes a hard line and says, we're not paying more than X, then cities and counties and large employers would want the same deal," he said. "And that becomes a massive political hurdle."

To get buy-in, the state settled on the 234 percent, which many economists consider a relatively generous mark-up from standard Medicare payments.

Medicare doesn't negotiate prices with hospitals or use hospital-set charges in its calculations. Instead, Medicare sets reimbursement through a complex formula that includes the cost of providing the service and the type of diagnoses. By its calculations, the government program pays hospitals enough to cover their services as well as a small profit.

Hospital officials, including many of those in Montana, disagree.

"When you look at total costs, Medicare probably pays 75 to 80 percent," said Jay Doyle, president of St. James Healthcare in Butte. The facility, part of the SCL Health system, reported losing $9 million on its Medicare patients in 2016, the latest data available.

But economists say the prices are adequate if the hospitals spend the money wisely.

"Hospitals will say Medicare pays 90 cents on the dollar," said Zack Cooper, an assistant professor of health policy and economics at Yale, which makes their argument sympathetic "for the first 15 seconds."

In fact, for most hospitals, Medicare covers their costs, he added.

Reaching Out To The Holdouts

The Montana effort took aim at hospital-set prices, often called "chargemaster rates," which to Bartlett were seemingly "going up and up." She and the third-party administrator the state hired gathered data and dove into the new negotiations.

At some hospitals, Montana was shelling out more than three times what Medicare paid for inpatient care. Outpatient services showed an even wider range. Some hospitals were paid more than six times the Medicare rates.

When Bartlett's team settled on paying an average of 234 percent of Medicare for inpatient and outpatient care, the decision involved a delicate balance: Set the bar too high and some hospitals would raise prices; too low, and some could cut back services or refuse to sign on.

As the July 1, 2016, deadline approached, five hospitals were holding out — and the state didn't want huge gaps in its hospital network.

"I was absolutely freaking," said Bartlett.

Four of the five remaining agreed before the deadline. The last major holdout was Benefis Health System in Great Falls, which argued that it was already one of the lower-cost hospitals in the state and that it should save its biggest discounts for its biggest customers.

Benefis declined requests for an interview.

At the time, state workers and their unions began a classic public relations arm-twisting campaign. Workers were told they might get hit with out-of-network bills from Benefis if it did not sign on. Such bills represent the balance between what the state pays and what hospitals charge.

Employee unions urged members and other interested groups to call or write Benefis, urging it to get on board.

The hospital is "kind of a monopoly, used to calling their own tune," because it is the only major hospital within 90 miles, recalls Keith Leathers, an investigator with Montana's Department of Public Health and Human Services. He was among those employees who picked up the phone, left messages and wrote notes.

By the end of July, Benefis finally signed on.

Will Others Follow Suit?

"A lot of states could learn from Montana," said William Kramer, executive director for National Health Policy with the Pacific Business Group on Health, a coalition of employers. Within the state, companies and cities in the state are watching the experiment as well.

There are discussions underway about expanding Montana's program beyond 35,000 state workers to cover city, county and university employees.

"If you want to get at pricing abuse by hospitals, why wouldn't every single employer do that," said Francois de Brantes, an independent benefits consultant and former director of the Center for Payment Innovation at Altarum, a Washington, D.C.-based nonprofit research and consulting firm.

That, of course, makes hospitals nervous since they have traditionally compensated for low reimbursement from some insurers by charging others more.

"If [that] happened, it would have huge economic impact," including layoffs at his hospital, said Doyle of St. James Healthcare.

But Cooper, the Yale economist, suggested that hospitals paid based on multiples of Medicare will be fine if they deploy their earning wisely rather than on duplicative services, additional MRI machines or gleaming, marble-filled lobbies.

For many, he said, "it's a function of investment decisions, not that Medicare doesn't pay enough."

First Female Dean 'A Sea Of Change' At USC's Scandal-Plagued Medical School

KFF Health News, June 20, 2018

Laura Mosqueda, MD, will oversee more than 4,150 full-time and voluntary faculty members who educate 800 medical students and 1,000 others pursuing graduate and postgraduate degrees.

This article first appeared June 20, 2018 on Kaiser Health News.

By Susan Abram

The University of Southern California veered sharply and deliberately from tradition in naming the first woman — and the first geriatrician — to lead its 133-year-old medical school.

Dr. Laura Mosqueda, who took over the position on May 1, said she'll work hard to steer more young doctors toward elderly care to treat the country's aging population. At the same time, she will face a stiff challenge trying to help rehabilitate the image of USC as it grapples with the growing fallout from recent drug and sexual misconduct scandals.

Mosqueda's appointment is partly the result of USC's #MeToo moment. It sends an unmistakable message that campus officials want to open a new chapter after the sobering revelations that toppled Mosqueda's two immediate predecessors and the university's president — all men.

"I think it signals a sea of change at USC," Mosqueda, 58, said in an interview. "I think as a woman I'm probably more likely to bring a less competitive and more collaborative, more nurturing approach. I think we women are tough in different ways."

She added that the decision to put her in charge of the university's Keck School of Medicine was "a really odd choice at this university. It's an obvious action that says we're doing things differently."

Mosqueda's ascent also signals that Keck is ready to embrace a new perspective reflecting the nation's changing demographics. It shows that the field of geriatrics "is coming of age," said Dr. Sharon Brangman, chief of geriatrics at the State University of New York's Upstate Medical University.

Care for the elderly is a "crucial" part of training health care professionals, Brangman said. "Every doctor-to-be, nurse-, physical therapist- and pharmacist-to-be should have some training in caring for older adults, because that population is growing."

Close to 50 million people living in the United States, or about 15 percent of the population, are 65 and older, according to the U.S. Census Bureau. That number is expected to rise to about 98 million, or nearly 25 percent, by 2060. Of those, about 20 million will be over age 85.

Geriatrics is "not about curing," Mosqueda said. "We're about caring. It's not a heroic specialty. It takes a bit more of an understanding to appreciate it as a specialty. Yet it's tremendously rewarding. We need to get it into the curriculum."

As dean, Mosqueda will oversee more than 4,150 full-time and voluntary faculty members who educate 800 medical students and 1,000 others pursuing graduate and postgraduate degrees. The school also trains more than 900 resident physicians in more than 50 specialties or sub-specialties.

Mosqueda comes to the job with Trojan pride deep in her blood. Both her parents graduated from the USC medical school when "there was a quota of six women per class," Mosqueda said. Mosqueda herself is also a USC medical school graduate, and she later returned as a professor and chair of the family medicine department before being named interim dean last October.

Mosqueda's mother, a radiologist specializing in mammography, and her father, a gastroenterologist, had successful careers at Kaiser Permanente in Los Angeles. But they never pressured their daughter to become a physician, Mosqueda recalled. (Kaiser Health News is not affiliated with Kaiser Permanente.)

She took an initial interest in veterinary medicine and marine biology — she's still an avid scuba diver — but later found her path in primary care, family medicine and geriatrics, as well as the detection and treatment of elder abuse.

In a memo announcing Mosqueda's appointment to the USC community, provost Michael Quick said support for her among faculty, staff and students had been overwhelming.

"It was clear to us, and to the vast majority of the Keck community, that we had identified the right dean," Quick said.

The institution Mosqueda now heads was forced late last year to acknowledge alleged misconduct by two former deans, Dr. Carmen Puliafito and Dr. Rohit Varma.

Puliafito, a renowned eye surgeon, led the medical school from 2007 until March 2016, when he abruptly resigned as dean, saying he wanted to pursue other opportunities, though he remained on the faculty. The Los Angeles Times later reported that three weeks before his resignation he had been in a Pasadena hotel room with a young woman who overdosed in his presence and was rushed to the hospital.

Puliafito was later fired from the school after the Times reported he had associated with criminals and drug abusers. In September, the state suspended his license to practice medicine. Varma, who succeeded Puliafito as dean, resigned last fall after reports surfaced he had once sexually harassed and then retaliated against a female fellow.

More recently, the university has been embroiled in a controversy over allegations of sexual abuse spanning decades by USC gynecologist George Tyndall. The allegations have landed the university in a heap of legal trouble, drawing numerous lawsuits and a federal investigation.

Late last month, USC president Max Nikias agreed to step down under pressure from students and faculty. And earlier this month, students marched on campus to protest how the university has handled the Tyndall case.

"Students are feeling largely unheard, neglected and misled," said Nivedita Kar, a doctoral student in biostatistics at Keck. "At places like Keck, where men hold a tremendous amount of privilege and therefore institutional power, the new dean must completely change the medical school culture to hear the voices of the underrepresented, restore trust and actually protect its students."

Mosqueda knows she's got her work cut out for her.

"We've been through a bad series here and we have to accept responsibility for the part of this that is our own doing," she said. "I don't want to be distracted. I want to own up to what was wrong and make it right."

Making it right includes addressing the ongoing concerns of students, she said, and changing the way women's health is discussed.

Mosqueda recalled sexist comments by male physicians when she was a medical student at USC in the 1980s. "I would hear things like 'You're a good girl,' in the operating room," she said. "In my time, it wasn't OK to make those comments, but [there was] just acceptance of the fact that it was going to happen."

Mosqueda is respected by her peers nationwide as a researcher and an expert in geriatrics and family medicine. She directs the National Center on Elder Abuse, a federally funded initiative, and she co-founded the nation's first Elder Abuse Forensic Center.

"Physicians like Dr. Mosqueda, who was one of the first wave of doctors specializing in geriatrics, have had to innovate and revamp programs and teach medical schools about the value of geriatrics," said Brangman, the Upstate Medical University geriatrics chief. "All of these things created the leadership skills that have come to fruition."

One of the challenges in improving elder care will be to make geriatrics an attractive field for new doctors, Brangman and Mosqueda said. Older adults have complicated health care issues but the specialty doesn't pay well.

In addition, the stigma attached to aging persists even now. "We live in an ageist society," Mosqueda said.

Mosqueda said she is eager to tackle head-on the challenges facing USC. Honesty and humility are the two elements that make a good doctor, and that's what is needed to heal the university and move beyond its current troubles, she said.

"I don't view myself as a token," Mosqueda said of being the medical school's first female dean. "I want to do the right things for the right reasons."

Texas state flag

Most Texans Want State To Expand Medicaid And Help Poor Get Health Care

KFF Health News, June 15, 2018

Texas is 1 of the 17 states that have not expanded Medicaid under the Affordable Care Act.

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

By Ashley Lopez, KUT

Texans think the Legislature should expand Medicaid to more low-income people and make health care more affordable, according to a survey released Thursday.

Researchers surveyed 1,367 Texans between March and May of this year about topics ranging from Medicaid, the Affordable Care Act, maternal mortality and the role of government in tackling health care issues.

Here are some takeaways from the survey by the Kaiser Family Foundation and the Episcopal Health Foundation. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

1) Almost All Texans See A Role For The Texas Legislature

Texans overwhelmingly agree that the state should have a role in making health systems work. According to the survey, 67 percent of those surveyed said the state should have a “major role” and 28 percent said a “minor role” in health care. Only 5 percent of Texans said the state should have no role.

“A majority of Texans say that the state has an important role to play in health care,” said Elena Marks, the president and chief executive officer of the Episcopal Health Foundation. “The state is not doing enough and the state should spend more. And people also believe that the state has a role to play in increasing access to insurance.”

2) Texans Are Concerned About Maternal Deaths

When asked what the state Legislature should make a top health care priority, 59 percent of Texans said “reducing the number of women who die from causes related to pregnancy and childbirth.”

That response came in a close second to “lowering the amount individuals pay for health care” (61 percent).

Marks says she thinks a lot of this concern is probably related to media coverage around maternal mortality and that the question itself is really a "no-brainer."

"'You mean people are dying from pregnancy and childbirth?’" she said. "I think people may just look at that and go, 'Well, of course you should be doing something about that.'”

3) Medicaid Expansion Is Popular

About two-thirds of Texans (64 percent) said they think Texas should expand Medicaid to cover more low-income people. Texas is 1 of the 17 states that have not expanded Medicaid under the Affordable Care Act.

Even though feelings in the state are still mixed on the ACA, the survey found that Medicaid is quite popular.

"Roughly 4 million people are covered by Medicaid in Texas, nearly three-quarters of whom are children," according to the survey's authors. When asked, 6 in 10 Texans said Medicaid is important to their families.

Marks said she thinks the conversation about Medicaid expansion in Texas is limiting for people seeking more insurance coverage here. She says the state should have a conversation about coming up with its own way to expand access to affordable coverage, which is a popular idea across the political spectrum.

“Let’s stop talking about Medicaid expansion and let’s start talking about expanding access to affordable health insurance coverage,” Marks said.

4) Texans Say We Aren’t Helping The Poor Enough

Roughly two-thirds of Texans also say the state is not doing enough to make sure low-income people get the health care they need.

Respondents also think lawmakers could do more to help children (45 percent) and immigrants (41 percent) get coverage. Broken down by party, Republicans were less likely to say that the state is not doing enough to help vulnerable populations get health care services.

5) A Lot Of Texans Don't Know Basic Facts About Health Care Here

One of the standouts in this survey is how little people know about the state's health care system. Consistently, however, Republican respondents were more likely to be misinformed.

For example, groups asked Texans whether the state’s uninsured rate is higher compared to other states. According to the survey, 3 in 10 Texans (31 percent) correctly answer that it is higher. Broken down by party, only 24 percent of Republicans knew Texas has a larger than average share of uninsured people, while 38 percent of Democrats did.

Marks says that could explain why Republicans are less likely to say they think there are problems with the state’s health care system.

“If you think we have about the same or lower uninsured rates, then you don’t think there’s a problem unique to us that we need to solve,” she said.

Texans were also asked whether Medicaid had been expanded in the state; 51 percent of those surveyed correctly said the state had not expanded it.

According to the study's authors, “Democrats are somewhat more likely than Republicans and independents to know that Texas has not expanded its Medicaid program" (62 percent, 43 percent, and 52 percent, respectively).

As Medicaid Costs Soar, States Try A New Approach

KFF Health News, June 15, 2018

Nationwide, a dozen states are experimenting with Medicaid ACOs and 10 more are making plans for them.

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

By Phil Galewitz

MINNEAPOLIS — Sandy Dowland has been to the emergency room 10 times in the past year and was hospitalized during four of those visits. She has had a toe amputated and suffers from uncontrolled diabetes, high blood pressure, major depression, obesity and back pain.

But her health is not high on the 41-year-old woman’s priority list.

“I have a lot going on,” said the unemployed mother of five who lives in a homeless shelter. She said it’s a struggle just to get herself and children through each day.

Her health bills are covered by Medicaid, the state-federal health insurance program for the poor. That’s a relief for her, she said. But state officials say Medicaid is busting Minnesota’s budget, particularly with patients like Dowland and its system of paying hospitals for each admission, ER visit and outpatient test.

To ease that financial strain, Minnesota is at the forefront of a growing number of states testing a Medicaid payment system. It rewards hospitals and physician groups holding down costs by keeping enrollees healthy.

Under this arrangement, those health care providers are asked to do more than just treat medical issues such as diabetes and heart disease. They are called on to address the underlying social issues — such as homelessness, lack of transportation and poor nutrition — that can cause and exacerbate health problems.

It’s why North Memorial arranged for a community health worker and paramedic to meet Dowland on a recent weekday at a day care center for homeless families. They advised her on how to take her insulin, prodded her to use a patch to quit smoking and helped her apply for Social Security disability payments and food stamps.

“This is nice to have someone who I can talk to about everything in my life and give me access to the community resources I need,” said Dowland, who added that she puts off her own health needs in order to care for her children and look for housing and a job. “I appreciate the help because, at the clinic, the doctor doesn’t have time for this.”

North Memorial is among 21 health systems in Minnesota participating in this new model of care, called accountable care organizations. ACOs get to share in money they save Medicaid by keeping spending under a budget and by reaching quality targets, such as averting hospital-acquired infections and controlling patients’ blood pressure and asthma.

The shift toward ACOs is occurring with Medicare and employer-sponsored insurance, too. But for Medicaid programs, it presents unique challenges. Medicaid enrollees, by definition, are low-income. Many have little experience navigating health systems and large numbers are homeless or dealing with mental health problems, conditions that can lead to difficulties in encouraging healthy behaviors.

“The goal [of ACOs] is really exciting to make health systems more responsive to what people need to be healthy,” said Ann Hwang, director of the center for consumer engagement and health innovation at Community Catalyst, a Boston-based consumer advocacy group. “But the jury is still out as to whether they are really moving the needle in addressing social services such as transportation, housing and food insecurity — the things we know affect people’s ability to be healthy.”

Nationwide, a dozen states are experimenting with Medicaid ACOs and 10 more are making plans for them.

About half of Minnesota’s 1 million Medicaid recipients are in ACOs, which officials said saved the state $213 million since 2013. Hospitals and doctors received $70 million of that.

In addition to North Memorial, other participating health systems include the Mayo Clinic and Hennepin Healthcare, the state’s largest safety-net provider based in Minneapolis.

‘Going To Where The Patient Is’

For giant health systems that for years have competed by adding the latest technology or building sleek facilities, the ACOs are a huge shift. In effect, the ACOs push hospitals to address patients’ problems before they end up in the ER or operating rooms.

“We are learning to have to do a better job of going to where the patient is … as we now realize we are responsible for the patient when they are engaged with us and when they are not here,” said Robert Stroebel, who helps leads the ACO effort at Mayo Clinic.

So far, the model isn’t proving to be a panacea.

In six states using ACOs, a March federal study in found, Medicaid enrollees received more primary care services — such as doctor visits — but the program did not reduce hospital visits in most states or lower costs.

“Changing provider and beneficiary behavior may take more time than the few years this report covers,” concluded the study.

Minnesota’s experience demonstrates the challenges of changing to a new Medicaid payment system. In 2016, the latest year for which data are available, only six of the 16 ACOs were eligible to share in cost savings.

But Marie Zimmerman, Minnesota’s Medicaid director, noted the state’s program has seen a 7 percent cut in ER visits and a 14 percent reduction in hospital stays in areas where health providers participate in an ACO.

“Medicaid is 20 percent of Minnesota’s population, and we have to care about getting the best deal and the long-term fiscal ability of the program and not cutting eligibility and provider rates and benefits to show sustainability,” she said.

Struggle To Change Behaviors

The switch to ACOs accelerated efforts by hospitals and physician groups to attack so-called social determinants of health, such as the lack of stable housing and poor nutrition. But providers still struggle to change patients’ behaviors, particularly helping those with addiction and mental health problems, according to interviews with officials at several ACOs.

Doctors, nurses and social workers at Hennepin dealt with that head-on during a recent routine review of their patients. When they came to a 58-year old man suffering from alcoholism, anxiety and heart problems and living in a homeless shelter, they noted how they couldn’t get him into a primary care clinic and saw him only during frequent hospital admissions.

“Best we can hope for him is if we can facilitate a safe ending,” said Dr. Rachel Silva, a Hennepin internist, acknowledging that despite their best intentions, health providers likely would not be able to prevent his early death.

Even with teams of nurses, social workers and community health workers, Hennepin officials say they struggle to keep up with many Medicaid enrollees who have addiction problems, and many patients still go to the ER out of habit or convenience rather than the organization’s primary care clinics, which are as close as across the street.

Yet, there are success stories, too. The Mayo Clinic has started a community health worker program to help at-risk patients connect to social services such as housing and transportation.

Nancy Zein, 47, a Medicaid recipient who uses the Mayo Clinic, said having weekly meetings with community health worker Tara Nelson has been life-changing for her and her mother, who is also on Medicaid.

“She’s been a godsend,” said Zein, who noted how Nelson helped her get Social Security disability payments and her mom find affordable housing for disabled adults, as well as get both enrolled for food stamps.

“It’s made such an impact on our health,” Zein said. “My mom has depression issues, and with Tara helping us with housing, it helped her depression.”

With the opportunity to share in financial savings, North Memorial has hired additional community paramedics to visit high-risk patients. Mayo Clinic has added community health workers to help patients find housing and transportation and nurses to make home visits to patients after leaving the hospital. Hennepin set up special clinics for the most challenging Medicaid patients and sends doctors to care for patients in homeless centers, jails and the county’s mental health center — to reach people who may need help even before they are likely to end up in their ER and on Medicaid.

Nearly 20 percent of Hennepin’s adult Medicaid ACO members are homeless. In the past four years, social workers and other staff have helped more than 500 of their Medicaid patients — including in the ACO — get into public housing.

Cuts For Managed-Care Companies

The ACO model has raised concerns among managed-care companies that Minnesota and other states have used for decades to control Medicaid spending. Those companies get a monthly fee from Medicaid for each enrollee and often require those patients to seek care with doctors and hospitals that have contracts with the managed-care firm. The companies profit if they spend less on care than they receive in the state allotment.

“We are aligned with the goals … to explore innovation and provide better delivery of care,” said Scott Keefer, vice president of Minnesota Blue Cross and Blue Shield of Minnesota, which has 300,000 Medicaid members. But, he added, much of the ACO savings cited by state officials are dollars taken from managed-care company profits.

His health plan lost more than $200 million from Medicaid operations during the past two years, partly because it had to pay part of its state funding to ACOs.

“We are not magically saving money. … We are moving the financial deck chairs around,” he said.

medicaid patient with caregiver

5 Things To Know About Medicaid Work Requirements

KFF Health News, June 14, 2018

The Trump administration’s decision in January to give states the power to impose work requirements on Medicaid enrollees faces a federal court hearing Friday.

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

By Phil Galewitz

The Trump administration’s decision in January to give states the power to impose work requirements on Medicaid enrollees faces a federal court hearing Friday.

The lawsuit before the U.S. District Court in Washington, D.C., will determine whether tens of thousands of low-income adults in Kentucky will have to find jobs or volunteer in order to retain their health coverage.

But the ruling could have far-reaching implications affecting millions of enrollees nationwide and determining how far the Trump administration can go in changing Medicaid without congressional action.

Kentucky was the first of four states, so far, to win federal approval to advance a work requirement. Indiana, Arkansas and New Hampshire are the others. Each is now in the early stages of implementation.

Arkansas, for instance, in June began having Medicaid enrollees inform the state about their work status. In September, the state could begin disenrolling members who fail to report or meet the work rules.

Seven more states — Arizona, Kansas, Maine, Mississippi, Ohio, Utah and Wisconsin — have applications pending and several others are poised to join them.

Kentucky’s legal challenge encapsulates a debate about two competing views of the role of Medicaid, the nation’s largest health program that covers nearly 75 million low-income Americans.

The Trump administration and many conservatives see it as a welfare program that should provide only temporary help and should prepare enrollees to gain employment and negotiate private health insurance.

Democrats, advocates for the poor and most legal experts see Medicaid as a health program meant to help the nation’s poorest citizens access health coverage. They say the administration’s approach of requiring enrollees to work to get health coverage is backward because enrollees need health coverage so they are healthy enough to work.

“There is zero evidence to suggest that depriving people of Medicaid will lead to greater levels of employer insurance,” 40 health policy scholars wrote in an amicus brief supporting the lawsuit filed on behalf of several Kentucky Medicaid enrollees.

“The CMS work ‘demonstration’ destroys, not improves, Kentucky’s substantial health care achievements and defeats, rather than promotes, Medicaid’s purpose as a safety net insurer,” according to the brief.

The 2010 Affordable Care Act spurred 33 states to expand Medicaid to nondisabled adults without children. Before that, the program mainly served children, pregnant women and people with disabilities.

That expansion, which provided billions in new federal funding to states, triggered an unprecedented drop in uninsured rates nationwide and tempted some Republican governors to pursue the additional health care dollars. But some of these GOP-controlled states also sought to add the new work requirement, in part to show conservative voters they weren’t simply providing a government handout to poor adults.

States that didn’t expand Medicaid and have some of the strictest eligibility limits in the country —including Kansas and Mississippi — also applied for work requirement waivers.

Here are five things to know as this court case unfolds:

1. Why do the Trump administration and states want to add the new work requirement?

Top Trump officials say the work requirement is meant to help enrollees find jobs. They say people who work or do volunteer service are healthier. Seema Verma, administrator of the U.S. Centers for Medicare & Medicaid Services, said Medicaid should be a “hand up” not a handout.

According to CMS, while the work requirement is a change in policy, it still fits within the agency’s long-standing missions of promoting health and improving health outcomes.

2. How does the work requirement work?

Kentucky’s program would require nondisabled adults each month to participate in 80 hours of work, job training, education or other qualified “community engagement.”

Those who are exempt include children and former foster care kids; pregnant women; seniors; people who are the primary caretakers for a child or a disabled adult; those who are deemed medically frail or diagnosed with an acute medical condition that would prevent them from working; and full-time students.

Adults in northern Kentucky would have to begin registering their work hours this summer, and the rest of the state would follow by the end of 2018.

State officials acknowledge the new requirement could be complicated for many enrollees. “We need to be careful and thoughtful how we roll out the ‘community engagement,’ recognizing this is a huge change,” said Kristi Putnam, deputy secretary for Kentucky’s Cabinet for Health and Family Services.

States have set up different rules on how many hours a month Medicaid enrollees must work or volunteer and who is exempt.

In Arkansas, everyone enrolled in Medicaid has to document their work hours through an online portal created by the state — with no option to submit information in person, over the phone or by mail. Critics of the work requirement fear that will be a barrier, considering the state has the second-lowest rate of home internet access in the nation.

3. What are the main objections to the work requirement from a legal and practical standpoint?

Critics say the requirement would lead many low-income people to lose their health coverage and, therefore, hinder their ability to get medical care. They note Kentucky’s own projections show that 95,000 Medicaid enrollees would lose coverage within five years.

The work-requirement approvals were based on the Health and Human Services secretary’s authority to test new ways of providing Medicaid coverage. The critics also argue, though, that the Trump administration is overstepping its statutory boundaries because the requirement would reduce eligibility rather than expand it.

Lastly, work requirement opponents note most people on Medicaid already work — or go to school, have a disability or care for relatives.

A June 12 Kaiser Family Foundation study concluded that only 6 percent of able-bodied adults on Medicaid who are targeted by states’ work requirements are not already working and unlikely to qualify for an exemption. In addition, 6 in 10 nondisabled adults on Medicaid work at least part time, although they often aren’t offered health benefits through those jobs or can’t afford them. (Kaiser Health News is an editorially independent program of the foundation.)

Surveys show that many Medicaid enrollees who don’t work are in job training, go to school or are taking care of a child or an elderly relative, conditions that would make them exempt from the new mandate.

4. When is the court expected to rule, and could this issue go to the Supreme Court?

Both sides expect a quick decision, likely by late June. But an appeal is likely no matter who wins.

If the Trump administration wins, it’s uncertain if plaintiffs will be able to get a stay on the work requirement taking effect while an appeal is in process.

5. While the work requirement is getting most of the attention, what else is at stake in the court case Friday?

The lawsuit filed by advocates on behalf of Medicaid enrollees seeks to overturn the entire Kentucky Medicaid waiver approved by the Trump administration in January.

Kentucky’s waiver also sets precedent because it would become the first state to charge Medicaid premiums of up to 4 percent of an individual’s income. The current limit has been 2 percent. Moreover, Kentucky would become the first state to lock out Medicaid enrollees from coverage for up to six months for failure to timely renew their coverage or failure to alert the state if their income or family circumstances have changed.

That ‘Living Will’ You Signed? At The ER, It Could Be Open To Interpretation

KFF Health News, June 14, 2018

"Don’t resuscitate this patient; he has a living will," the nurse told Dr. Monica Williams-Murphy, handing her a document.

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

By Judith Graham

“Don’t resuscitate this patient; he has a living will,” the nurse told Dr. Monica Williams-Murphy, handing her a document.

Williams-Murphy looked at the sheet bearing the signature of the unconscious 78-year-old man, who’d been rushed from a nursing home to the emergency room. “Do everything possible,” it read, with a check approving cardiopulmonary resuscitation.

The nurse’s mistake was based on a misguided belief that living wills automatically include “do not resuscitate” (DNR) orders. Working quickly, Williams-Murphy revived the patient, who had a urinary tract infection and recovered after a few days in the hospital.

Unfortunately, misunderstandings involving documents meant to guide end-of-life decision-making are “surprisingly common,” said Williams-Murphy, medical director of advance-care planning and end-of-life education for Huntsville Hospital Health System in Alabama.

But health systems and state regulators don’t systematically track mix-ups of this kind, and they receive little attention amid the push to encourage older adults to document their end-of-life preferences, experts acknowledge. As a result, information about the potential for patient harm is scarce.

A new report out of Pennsylvania, which has the nation’s most robust system for monitoring patient safety events, treats mix-ups involving end-of-life documents as medical errors — a novel approach. It found that in 2016, Pennsylvania health care facilities reported nearly 100 events relating to patients’ “code status” — their wish to be resuscitated or not, should their hearts stop beating and they stop breathing. In 29 cases, patients were resuscitated against their wishes. In two cases, patients weren’t resuscitated despite making it clear they wanted this to happen.

The rest of the cases were “near misses” — problems caught before they had a chance to cause permanent harm.

Most likely, this is an undercount since reporting was voluntary, said Regina Hoffman, executive director of the Pennsylvania Patient Safety Authority, adding that she was unaware of similar data from any other state.

Asked to describe a near miss, Hoffman, co-author of the report, said: “Perhaps I’m a patient who’s come to the hospital for elective surgery and I have a DNR (do not resuscitate) order in my [medical] chart. After surgery, I develop a serious infection and a resident [physician] finds my DNR order. He assumes this means I’ve declined all kinds of treatment, until a colleague explains that this isn’t the case.”

The problem, Hoffman explained, is that doctors and nurses receive little, if any, training in understanding and interpreting living wills, DNR orders and Physician Orders for Life-Sustaining Treatment (POLST) forms, either on the job or in medical or nursing school.

Communication breakdowns and a pressure-cooker environment in emergency departments, where life-or-death decisions often have to be made within minutes, also contribute to misunderstandings, other experts said.

Research by Dr. Ferdinando Mirarchi, medical director of the department of emergency medicine at the University of Pittsburgh Medical Center Hamot in Erie, Pa., suggests that the potential for confusion surrounding end-of-life documents is widespread. In various studies, he has asked medical providers how they would respond to hypothetical situations involving patients with critical and terminal illnesses.

In one study, for instance, he described a 46-year-old woman brought to the ER with a heart attack and suddenly goes into cardiac arrest. Although she’s otherwise healthy, she has a living will refusing all potentially lifesaving medical interventions. What would you do, he asked more than 700 physicians in an internet survey?

Only 43 percent of those doctors said they would intervene to save her life — a troubling figure, Mirarchi said. Since this patient didn’t have a terminal condition, her living will didn’t apply to the situation at hand and every physician should have been willing to offer aggressive treatment, he explained.

In another study, Mirarchi described a 70-year-old man with diabetes and cardiac disease who had a POLST form indicating he didn’t want cardiopulmonary resuscitation but agreeing to a limited set of other medical interventions, including defibrillation (shocking his heart with an electrical current). Yet 75 percent of 223 emergency physicians surveyed said they wouldn’t have pursued defibrillation if the patient had a cardiac arrest.

One issue here: Physicians assumed that defibrillation is part of cardiopulmonary resuscitation. That’s a mistake: They’re separate interventions. Another issue: Physicians are often unsure what patients really want when one part of a POLST form says “do nothing” (declining CPR) and another part says “do something” (permitting other interventions).

Mirarchi’s work involves hypotheticals, not real-life situations. But it highlights significant practical confusion about end-of-life documents, said Dr. Scott Halpern, director of the Palliative and Advanced Illness Research Center at the University of Pennsylvania’s Perelman School of Medicine.

Attention to these problems is important, but shouldn’t be overblown, cautioned Dr. Arthur Derse, director of the center for bioethics and medical humanities at the Medical College of Wisconsin. “Are there errors of misunderstanding or miscommunication? Yes. But you’re more likely to have your wishes followed with one of these documents than without one,” he said.

Make sure you have ongoing discussions about your end-of-life preferences with your physician, surrogate decision-maker, if you have one, and family, especially when your health status changes, Derse advised. Without these conversations, documents can be difficult to interpret.

Here are some basics about end-of-life documents:

Living wills. A living will expresses your preferences for end-of-life care but is not a binding medical order. Instead, medical staff will interpret it based on the situation at hand, with input from your family and your surrogate decision-maker.

Living wills become activated only when a person is terminally ill and unconscious or in a permanent vegetative state. A terminal illness is one from which a person is not expected to recover, even with treatment — for instance, advanced metastatic cancer.

Bouts of illness that can be treated — such as an exacerbation of heart failure — are “critical” not “terminal” illness and should not activate a living will. To be activated, one or two physicians have to certify that your living will should go into effect, depending on the state where you live.

DNRs. Do-not-resuscitate orders are binding medical orders, signed by a physician. A DNR order applies specifically to cardiopulmonary resuscitation (CPR) and directs medical personnel not to administer chest compressions, usually accompanied by mouth-to-mouth resuscitation, if someone stops breathing or their heart stops beating.

The section of a living will specifying that you don’t want CPR is a statement of a preference, not a DNR order.

A DNR order applies only to a person who has gone into cardiac arrest. It does not mean that this person has refused other types of medical assistance, such as mechanical ventilation, defibrillation following CPR, intubation (the insertion of a breathing tube down a patient’s throat), medical tests or intravenous antibiotics, among other measures.

Even so, DNR orders are often wrongly equated with “do not treat” at all, according to a 2011 review in the Journal of General Internal Medicine.

POLST forms. A POLST form is a set of medical orders for a patient expected to die within a year, signed by a physician, physician assistant or nurse practitioner.

These forms, which vary by state, are meant to be prepared after a detailed conversation about a patient’s prognosis, goals and values, and the potential benefits and harms of various treatment options.

Problems have emerged with POLST’s increased use. Some nursing homes are asking all patients to sign POLST forms, even those admitted for short-term rehabilitation or whose probable life expectancy exceeds a year, according to a recent article authored by Charlie Sabatino, director of the American Bar Association Commission on Law and Aging. Also, medical providers’ conversations with patients can be cursory, not comprehensive, and forms often aren’t updated when a patient’s medical condition changes, as recommended.

“The POLST form is still relatively new and there’s education that needs to be done,” said Amy Vandenbroucke, executive director of the National POLST Paradigm, an organization that promotes the use of POLST forms across the U.S. In a policy statement issued last year and updated in April, it stated that completion of POLST forms should always be voluntary, made with a patient’s or surrogate decision-maker’s knowledge and consent, and offered only to people not expected to live beyond a year.

Medicare Takes Aim At Boomerang Hospitalizations Of Nursing Home Patients

KFF Health News, June 13, 2018

“Oh my God, we dropped her!” Sandra Snipes said she heard the nursing home aides yell as she fell to the floor. She landed on her right side where her hip had recently been replaced. She cried out in pain. A hospital clinician later discovered her hip was dislocated.

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

By Jordan Rau

Deborah Ann Favorite sits in her Los Angeles apartment last month. Favorite’s mother died after a lapse in communication about the need to resume her thyroid medication. (Heidi de Marco/KHN)

“Oh my God, we dropped her!” Sandra Snipes said she heard the nursing home aides yell as she fell to the floor. She landed on her right side where her hip had recently been replaced.

She cried out in pain. A hospital clinician later discovered her hip was dislocated.

That was not the only injury Snipes, then 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her twice a day with a potent blood thinner despite written instructions to stop.

“She said, ‘I just feel so tired,’” her daughter, Laura Clark, said in an interview. “The nurses were saying she’s depressed and wasn’t doing her exercises. I said no, something is wrong.”

Her children also discovered that Snipes’ surgical wound had become infected and infested with insects. Just 11 days after she arrived at the nursing home to heal from her hip surgery, she was back in the hospital.

The fall and these other alleged lapses in care led Clark and the family to file a lawsuit against the nursing home. Richmond Pines declined to discuss the case beyond saying it disputed the allegations at the time. The home agreed in 2017 to pay Snipes’ family $1.4 million to settle their lawsuit.

While the confluence of complications in Snipes’ case was extreme, return trips from nursing homes to hospitals are far from unusual.

With hospitals pushing patients out the door earlier, nursing homes are deluged with increasingly frail patients. But many homes, with their sometimes-skeletal medical staffing, often fail to handle post-hospital complications — or create new problems by not heeding or receiving accurate hospital and physician instructions.

Patients, caught in the middle, may suffer. One in 5 Medicare patients sent from the hospital to a nursing home boomerang back within 30 days, often for potentially preventable conditions such as dehydration, infections and medication errors, federal records show. Such rehospitalizations occur 27 percent more frequently than for the Medicare population at large.

Nursing homes have been unintentionally rewarded by decades of colliding government payment policies, which gave both hospitals and nursing homes financial incentives for the transfers. That has left the most vulnerable patients often ping-ponging between institutions, wreaking havoc with patients’ care.

“There’s this saying in nursing homes, and it’s really unfortunate: ‘When in doubt, ship them out,’” said David Grabowski, a professor of health care policy at Harvard Medical School. “It’s a short-run, cost-minimizing strategy, but it ends up costing the system and the individual a lot more.”

In recent years, the government has begun to tackle the problem. In 2013, Medicare began fining hospitals for high readmission rates in an attempt to curtail premature discharges and to encourage hospitals to refer patients to nursing homes with good track records.

Starting this October, the government will address the other side of the equation, giving nursing homes bonuses or penalties based on their Medicare rehospitalization rates. The goal is to accelerate early signs of progress: The rate of potentially avoidable readmissions dropped to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress’ Medicare Payment Advisory Commission.

“We’re better, but not well,” Grabowski said. “There’s still a high rate of inappropriate readmissions.”

The revolving door is an unintended byproduct of long-standing payment policies. Medicare pays hospitals a set rate to care for a patient depending on the average time it takes to treat a patient with a given diagnosis. That means that hospitals effectively profit by earlier discharge and lose money by keeping patients longer, even though an elderly patient may require a few extra days.

But nursing homes have to hospitalize patients. For one thing, keeping patients out of hospitals requires frequent examinations and speedy laboratory tests — all of which add costs to nursing homes.

Plus, most nursing home residents are covered by Medicaid, the state-federal program for the poor that is usually the lowest-paying form of insurance. If a nursing home sends a Medicaid resident to the hospital, she usually returns with up to 100 days covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a “bed-hold” fee when a patient is hospitalized.

None of this is good for the patients. Nursing home residents often return from the hospital more confused or with a new infection, said Dr. David Gifford, a senior vice president of quality and regulatory affairs at the American Health Care Association, a nursing home trade group.

“And they never quite get back to normal,” he said.

‘She Looked Like A Wet Washcloth’

Communication lapses between physicians and nursing homes is one recurring cause of rehospitalizations. Elaine Essa had been taking thyroid medication ever since that gland was removed when she was a teenager. Essa, 82, was living at a nursing home in Lancaster, Calif., in 2013 when a bout of pneumonia sent her to the hospital.

When she returned to the nursing home — now named Wellsprings Post-Acute Care Center — her doctor omitted a crucial instruction from her admission order: to resume the thyroid medication, according to a lawsuit filed by her family. The nursing home telephoned Essa’s doctor to order the medication, but he never called them back, the suit said.

Deborah Ann Favorite holds a photograph of her mother, Elaine Essa. The nursing home and Essa’s primary care practice settled a lawsuit brought by the family. (Heidi de Marco/KHN)

Without the medication, Essa’s appetite diminished, her weight increased and her energy vanished — all indications of a thyroid imbalance, said the family’s attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Family Medical Group never visited her, sending instead their nurse practitioner. He, like the nursing home employees, did not grasp the cause of her decline, although her thyroid condition was prominently noted in her medical records, the lawsuit said.

Three months after her return from the hospital, “she looked like a wet washcloth. She had no color in her face,” said Donna Jo Duncan, a daughter, in a deposition. Duncan said she demanded the home’s nurses check her mother’s blood pressure. When they did, a supervisor ran over and said, “Call an ambulance right away,” Duncan said in the deposition.

At the hospital, a physician said tests showed “zero” thyroid hormone levels, Deborah Ann Favorite, a daughter, recalled in an interview. She testified in her deposition that the doctor told her, “I can’t believe that this woman is still alive.”

Essa died the next month. The nursing home and the medical practice settled the case for confidential amounts. Cynthia Schein, an attorney for the home, declined to discuss the case beyond saying it was “settled to everyone’s satisfaction.” The suit is still ongoing against one other doctor, who did not respond to requests for comment.

Dangers In Discouraging Hospitalization

Out of the nation’s 15,630 nursing homes, one-fifth send 25 percent or more of their patients back to the hospital, according to a Kaiser Health News analysis of data on Medicare’s Nursing Home Compare website. On the other end of the spectrum, the fifth of homes with the lowest readmission rates return fewer than 17 percent of residents to the hospital.

Many health policy experts say that spread shows how much improvement is possible. But patient advocates fear the campaign against hospitalizing nursing home patients may backfire, especially when Medicare begins linking readmission rates to its payments.

“We’re always worried the bad nursing homes are going to get the message ‘Don’t send anyone to the hospital,’” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

Richmond Pines, where Sandra Snipes stayed, has a higher-than-average rehospitalization rate of 25 percent, according to federal records. But the family’s lawyer, Kyle Nutt, said the lawsuit claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

After Snipes was rehospitalized, her blood thinner was discontinued, her hip was reset, and she was discharged to a different nursing home, according to the family’s lawsuit. But her hospital trips were not over: When she showed signs of recurrent infection, the second home sent her to yet another hospital, the lawsuit alleged.

Ultimately, the lawsuit claimed that doctors removed her prosthetic hip and more than a liter of infected blood clots and tissues. Nutt said if Richmond Pines’ nurses had “caught the over-administration of the blood thinner right off the bat, we don’t think any of this would have happened.”

Snipes returned home but was never able to walk again, according to the lawsuit. Her husband, William, cared for her until she died in 2015, her daughter, Clark, said.

“She didn’t want to go back into the nursing home,” Clark said. “She was terrified.”

California's Attorney General Vows National Fight To Defend The ACA

KFF Health News, June 11, 2018

The state has been at the forefront in resisting many Trump Administration policies, including on health care and immigration.

This article first appeared June 11, 2018, on Kaiser Health News.

By Pauline Bartolone, Kaiser Health News

California Attorney General Xavier Becerra pledged Friday to redouble his efforts as the Affordable Care Act’s leading defender, saying attacks by the Trump Administration threaten health care for millions of Americans.

Becerra’s pledge came in response to an announcement from the administration Thursday that it would not defend key parts of the Affordable Care Act in court. The administration instead called on federal courts to scuttle the health law’s protection for people with preexisting medical conditions and its requirement that people buy health coverage.

Becerra accused the administration of going “AWOL.” It “has decided to abandon the hundreds of millions of people who depend on” the law, he said in an interview with Kaiser Health News.

“It’s, simply put, an attack on the health care that millions of Americans have come to count on, and California, being the most successful state in implementing the Affordable Care Act, stands to lose perhaps more than anyone else.”

About 1.5 million Californians buy coverage through the state’s ACA exchange, Covered California, and nearly 4 million have joined Medicaid as a result of the program’s expansion under the law.

The state has been at the forefront in resisting many Trump Administration policies, including on health care and immigration.

“This is not a new experience for us under this new Trump era of having to defend Californians,” Becerra said. In the case of health care, “fortunately we have 16 other [Democratic attorneys general] who are prepared to do it with us. ”

At issue is a lawsuit filed by 20 Republican state attorneys general on Feb. 26, which charged that Congress’ changes to the law in last year’s tax bill rendered the entire ACA unconstitutional. In the tax law, Congress repealed the penalty for people who fail to have health insurance starting in 2019.

Becerra is leading an effort by Democratic attorney generals from others states and the District of Columbia to defend the ACA against that lawsuit. In May, the court allowed them to “intervene” in the case.

The Trump administration filed a brief in the case on Thursday, arguing that without the tax to encourage healthy people to sign up, the parts of the law guaranteeing coverage to people with previous health conditions — without charging them higher rates — should be struck down as well.

In a letter to House Speaker Paul Ryan explaining the administration’s decision, U.S. Attorney General Jeff Sessions cited the Justice Department’s “longstanding tradition” of defending the constitutionality of federal laws “if reasonable arguments can be made in their defense.”

But in this case, he wrote, he could not find those arguments to defend the constitutionality of the provisions and “concluded that this is a rare case where the proper course is to forgo defense.”

The administration called on the court to declare the provisions that guarantee coverage to be invalid beginning on January 1, 2019, when the mandate penalty goes away.

Because the lawsuit could easily go all the way to the U.S. Supreme Court, a process that could take years, the protections for people with preexisting conditions are likely to stay in place during that period.

Lieutenant Governor Gavin Newsom, the Democratic front-runner in the race for California’s next governor, breathed the same fire as Becerra against the federal government on Friday.

“Trump and his cronies can’t unilaterally roll back preexisting protections for millions of Californians,” Newsom said. “California will fight like hell to protect our families and their healthcare.”

A spokesman for his opponent in the race, Republican gubernatorial candidate John Cox, declined to comment.

If the court ultimately declared the provisions targeted by the Trump Administration unconstitutional, California would be temporarily cushioned from the effects because there are laws already on the books should the ACA – or its provisions – go away.

For instance, existing rules would protect people with pre-existing conditions for twelve months if the ACA were struck down.

During that time, “policymakers in California would look really hard at being able to try to do something so we don’t lose those gains,” said Deborah Kelch, director of the Insure the Uninsured Project in Sacramento.

“It’s hard to look at California and imagine just folding it up and starting over.”

Some critics of the administration’s decision said California should go forward with enacting its own mandate for individual coverage, as a few other states have done. No one has pushed that issue forward in the Legislature.

Since he took office in January 2017, Becerra has emerged as a top opponent of the Trump administration, filing more than 30 lawsuits on health care and other issues.

In California’s primary election Tuesday, Becerra, a Democrat, dominated the race with 45 percent of the vote. He will face retired judge Steven Bailey, a Republican, in the November general election.

Bailey’s spokesman Corey Uhden said Friday that he wouldn’t comment on the constitutionality of the ACA provisions. However, he said, Bailey opposes the individual mandate and wants less government regulation of health insurance.

Alex Leeds Matthews contributed to this report.

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

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

HHS To Allow Insurers’ Workaround On 2019 Prices

KFF Health News, June 7, 2018

Federal officials will not block insurance companies from again using a workaround to cushion a steep rise in health premiums caused by President Donald Trump’s cancellation of a program established under the Affordable Care Act, Health and Human Services Secretary Alex Azar announced Wednesday.

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

By Julie Rovner

Federal officials will not block insurance companies from again using a workaround to cushion a steep rise in health premiums caused by President Donald Trump’s cancellation of a program established under the Affordable Care Act, Health and Human Services Secretary Alex Azar announced Wednesday.

The technique — called “silver loading” because it pushed price increases onto the silver-level plans in the ACA marketplaces — was used by many states for 2018 policies. But federal officials had hinted they might bar the practice next year.

At a hearing Wednesday before the House Education and Workforce Committee, Azar said stopping this practice “would require regulations, which simply couldn’t be done in time for the 2019 plan period.”

States moved to silver loading after Trump in October cut off federal reimbursement for so-called cost-sharing reduction subsidies that the ACA guaranteed to insurance companies. Those payments offset the cost of discounts that insurers are required by the law to provide to some low-income people to help cover their deductibles and other out-of-pocket costs.

States scrambled to let insurers raise rates so they would stay in the market. And many let them use this technique to recoup the lost funding by adding to the premium costs of midlevel silver plans in the health exchanges.

Because the formula for federal premium subsidies offered to people who purchase through the marketplaces is based on the prices of those silver plans, as those premiums rose so did the subsidies to help people afford them. That meant the federal government ended up paying much of the increase in prices.

At the committee hearing Wednesday, under questioning from Rep. Joe Courtney (D-Conn.), Azar declined to say if the department was considering a future ban.

“It’s not an easy question,” Azar said.

The fact that the federal government ended up effectively making the payments aggravated many Republicans, and there have been rumors over the past several months that HHS might require the premium increases to be applied across all plans, boosting costs for all buyers in the individual market.

Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, told reporters in April that the department was examining the possibility.

Apparently that will not happen, at least not for plan year 2019.

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