Male OB-GYNs Are Rare. Is That A Problem?

KFF Health News, April 27, 2018

The gender that at one time dominated the field is now at some schools considered a diversity hire.

This article first appeared April 27, 2018 on Kaiser Health News.

By Alex Olgin, WFAE

As she left a 12-hour day on the labor and delivery shift, Dr. Katie Merriam turned off her pager.

"I don't know what I'd do without it, you know? It's another limb. I always know where it is," she said, laughing.

The third-year resident in obstetrics and gynecology at the Carolinas Medical Center hospital in Charlotte, N.C., works in a medical specialty dominated by women, treating women. She feels a special connection to her patients, Merriam said.

"You just, you can feel what they feel and understand why they feel certain ways. I do feel a special bond," she said.

Nationally, 82 percent of doctors matching into OB-GYN residency programs are women. Many OB-GYN patients say they prefer female doctors. Merriam's residency class is a bit of an anomaly — half of its members are men. Though it's nice to work with so many women, Merriam said, she and some of her female colleagues also like the perspective that men bring to the work environment.

"No one could really pinpoint about what balance they bring, but there's something nice about having them," she said.

It's important to have men in the field, she said, if only to continue to give patients options in their choice of providers. But most of her friends and other women she talks to, she said, want female doctors.

Blake Butterworth, a fourth-year obstetrics and gynecology resident at the Medical University of South Carolina in Charleston, said he doesn't take it personally when he hears that sort of thing from a patient.

"I don't get discouraged; I don't get offended," Butterworth said. "I gladly hand that patient off."

He's one of only two male residents in the program of 24 at MUSC and said he finds it rewarding when he can win a new patient's confidence.

"I have patients that clearly express disdain to have to see a guy," he said. "Then I develop rapport with her. And she says, 'I expected you to be X, Y, Z, and you were better than that.'"

Butterworth said he chose obstetrics and gynecology because it lets him develop long-term relationships with patients — providing routine OB-GYN care and more complicated surgeries, if need be.

"Once you really get into it, and get involved in it, I don't think that bias [that the field is best left to women] holds true," he said.

Butterworth said he believes it is incumbent on male OB-GYNs to talk to male medical students about the benefits of having men in the field. Students need to know it's OK to have an interest in the field, he said, and that they will find work.

In fact, says Dr. Ashlyn Savage, an associate professor of obstetrics and gynecology at MUSC, it may be the opposite.

"In an effort to really diversify the applicant pool, we will apply in some cases different screening standards to decide who we are going to interview," Savage said. "For example, we might consider an applicant with a slightly lower board score — just to enhance how many men we are interviewing and considering."

It has been a challenge to find male OB-GYNs for the program, she said. The gender that at one time dominated the field is now at some schools considered a diversity hire. But Savage questions whether balancing the number of men and women in the specialty is as important as racial or ethnic diversity.

"The interesting thing to me is the primary motivation to [seek a diverse candidate pool] is so that patients have the opportunity to seek out physicians who might...feel like themselves," she said. "In this particular case...all of the patients for OB-GYNs are women."

Among practicing OB-GYNs in the U.S., a little fewer than half are men, according to the American College of Obstetricians and Gynecologists, formerly known as the American Congress of Obstetricians and Gynecologists. But ACOG predicts that 10 years from now, two-thirds of the doctors in that specialty will be female.

Still, male doctors hold many key posts in OB-GYN professional organizations.

"Leadership tends to be held by people who are older," Savage said. "And we are still in a scenario where [more of] our older faculty tend to be men."

A study published last fall found that women are underrepresented in leadership roles in medical school departments of obstetrics and gynecology throughout the country. That ratio was most lopsided in men's favor in the South.

It's perhaps only a matter of time before that, too, changes. Savage said she recently learned that her program's incoming class of OB-GYN residents next year will be all female.

Dissecting The Rhetoric Vs. Reality Of Trump's Tough Talk On Drug Prices

KFF Health News, April 27, 2018

Trump promised a speech on prescription drug prices, and it's expected anytime.

This article first appeared April 27, 2018 on Kaiser Health News.

By Sarah Jane Tribble

President Donald Trump has railed against the high price of prescription drugs and famously bemoaned how pharmaceutical companies are “getting away with murder.” Yet, many Americans aren’t seeing a change in what they pay out-of-pocket.

Trump promised a speech on prescription drug prices, and it’s expected anytime.

Here’s a look at the rhetoric thus far versus the results.

"You’ll be seeing drug prices falling very substantially in the not-too-distant future, and it’s going to be beautiful."

What’s Happening:

The White House and administration leaders, including Health and Human Services Secretary Alex Azar and Food and Drug Administration Commissioner Scott Gottlieb, say increasing competition is a priority. Gottlieb — whom Trump has called a star — said the FDA has approved a record number of generic drugs and eliminated a backlog in approvals.

The agency is looking for ways to boost price competition for biologics, which are made from natural sources and are among the most expensive drugs on the market. Currently, pharmacists cannot substitute a lower-cost “biosimilar” version when the doctor prescribes a biologic. FDA has proposed “interchangeability” rules that could change the status quo.

The Outlook:

Driving down drug prices through competition may take awhile. That’s because even after gaining FDA approval, generic drugs often have trouble being launched, according to Chip Davis, president of the Association for Accessible Medicines, a trade group for makers of generics and biosimilars. Only three of nine biosimilars approved are available for patients, largely due to patent protections.

"We have to get the prices of prescription drugs way down and unravel the tangled web of special interests that are driving prices up for medicine and for really hurting patients."

What’s Happening:

To say health care is complicated is an understatement. The system that dictates how patients get prescriptions and what they pay includes an array of buyers and payers, such as insurance companies and pharmacy benefit managers. In February, the White House pitched the idea of passing on the discounts and rebates negotiated by PBMs, the financial middlemen between insurers and drugmakers, to seniors who buy drugs through Medicare Part D. This idea, first floated under President Barack Obama’s administration, would mean seniors would pay less out-of-pocket but could also increase premiums if insurers took on added costs.

The Outlook:

Late last year, the administration released a request for public comment on this idea, and pressure is building for the administration to take action. “It’s the one thing you could say that has immediate benefit to consumers,” said John Rother, president of the National Coalition on Health Care. But House Minority Leader Nancy Pelosi said she isn’t convinced much will really change: “At this point, no one is surprised that President Trump has found another reason not to act on prescription drug costs,” Pelosi said in a statement to Kaiser Health News. “While President Trump is making more excuses, Democrats will be discussing real solutions.”

"I have directed my administration to make fixing the injustice of high drug prices one of our top priorities for the year. And prices will come down substantially. Watch."

What’s Happening:

The White House has pitched moving drugs covered under Medicare Part B into the popular Part D program. Part B is the bucket of Medicare that covers drugs that are administered in hospital outpatient settings and doctor’s offices, including expensive chemotherapy and rheumatoid arthritis infusions. Insurers compete for business in Part D and negotiate prices for their members, but there is no such price negotiation in Part B. Total drug spending in the Part B program was about $26 billion in 2015, and the upward trend is ominous.

The Outlook:

While providers and insurers are likely to fight it, there’s no reason the idea wouldn’t work, said Tom Scully, the former Centers for Medicare & Medicaid Services administrator who designed the Medicare prescription drug programs in the early 2000s. He worked closely with HHS’ current leader, Azar, who was then general counsel for HHS. “There’s no reason to have Part B,” said Scully, adding that moving the drugs under Part D would require price negotiation. “If you really want to drive down drug prices, you have to put somebody’s money at risk other than the taxpayers’.”

"For Medicare, for Medicaid, we have to get the prices way down, so that’s what we’re going to be talking about."

Trump, Jan. 31, 2017, while holding a listening session with pharmaceutical industry leaders

What’s Happening:

When the White House announced Trump’s forthcoming speech, it also noted that it would coincide with a formal request for information from Health and Human Services on various drug-pricing ideas. The request leaves the door wide open for proposed changes in Medicare and Medicaid. Several experts predict the administration will test payment models through demonstrations under the broad authority of the Center for Medicare & Medicaid Innovation, or CMMI.

The Outlook:

Ideas such as moving drugs to Part D as well as allowing certain states to create drug lists under their Medicaid formularies, as Massachusetts has requested, and other value-based pricing models would be possible under a CMMI demonstration, said Andrea Harris, who leads the health care team at Height Capital Markets. Still, this process could take awhile, and Harris said, “I don’t think anything will meaningfully impact drug-related stocks between now and the midterms [elections].”

"Prescription drug prices are out of control. The drug prices have gone through the roof. … The drug companies, frankly, are getting away with murder.”

What’s Happening:

While there has been no direct proposal that would force the pharmaceutical industry to lower the launch price of its drugs, the industry lost a battle last month when Congress reduced how much seniors would pay for prescription drugs in Medicare. It was a rare loss and signaled that the powerful industry may be in a defensive position. And Trump has another card to play with the Federal Trade Commission.

The Outlook:

Trump has nominated Joe Simons, a Washington antitrust lawyer, to lead the FTC. During his nomination hearings in February, he said he’s “very concerned” with price increases for prescription drugs. The agency, which polices anticompetitive behavior, has several vacancies to fill.

'Rapid Autopsy' Programs Seek Clues To Cancer Within Hours Of Death

KFF Health News, April 26, 2018

Rapid-autopsy technology has been available for decades. But only in recent years have more hospitals been launching and expanding programs.

This article first appeared April 26, 2018 on Kaiser Health News.

By JoNel Aleccia

After Keith Beck died of bile duct cancer last year, family members said more than 900 people showed up to pay respects to the popular athletic director at the University of Findlay in northwestern Ohio.

Many were former students who recalled acts of kindness during Beck's nearly 30-year career: $20 given to a kid who was broke, textbooks bought for a student whose parents were going through bankruptcy, a spot cleared to sleep on Beck's living room floor.

But few knew about Beck's final gesture of generosity. The 59-year-old had agreed to a "rapid autopsy," a procedure conducted within hours of his death on March 28, 2017, so that scientists could learn as much as possible from the cancer that killed him.

"He was 100 percent for it," recalled his ex-wife, Nancy Beck, 63, who cared for Beck at the end of his life. "It wasn't the easiest thing to do, but it was important."

Beck donated his body to a rapid-autopsy research study at the Ohio State University, part of a small but growing effort by more than a dozen medical centers nationwide. The idea is to obtain tumor tissue immediately after death — before it has a chance to degrade. Scientists say such samples are the key to understanding the genetics of cancers that spread through the body, thwarting efforts to cure them.

"People are recognizing that cancer is more heterogeneous than we realize," said Dr. Sameek Roychowdhury, a medical scientist at OSU's Comprehensive Cancer Center. "Different parts of your body may have different cancer cells, even though they originated from the same cancer."

In Beck's case, results from the rapid autopsy showed he had developed a mutation that caused the experimental drug he was taking, known as an FGFR inhibitor, to stop working. Roychowdhury and colleagues plan to report on Beck's case in an upcoming paper.

"This is helping us shape how we develop this new drug," Roychowdhury said. "How can we make a better drug? Or can we make a better drug combination?"

Rapid-autopsy technology has been available for decades. Researchers at the University of Washington in Seattle have been using the technique to study prostate cancer since 1991. Scientists at the University of Nebraska Medical Center launched a now-robust program in 2000.

But only in recent years have more hospitals been launching and expanding programs, said Dr. Jody Hooper, director of the Legacy Gift Rapid Autopsy Program at Johns Hopkins Medicine in Baltimore. At last count, there were 14 similar programs in the U.S.

Funding for them varies, Hooper said, but typically they're supported by a mix of cancer program resources, grants and researcher fees.

Scientists recognize the value of examining tissue from multiple sites soon after death and obtaining larger samples than they could while a patient was living. Cancer cells can be retrieved during such autopsies and kept alive, allowing researchers to experiment with ways to treat — or kill — them.

"It's the power of sampling over the entire body at the same time," said Hooper, who conducts about one rapid autopsy a month, often providing tissue for up to a half-dozen researchers interested in different questions.

Most programs focus on cancer, but efforts are underway to expand the practice, possibly to shed light on virus reservoirs in HIV patients, for instance.

Speed is essential to preserve RNA and DNA, the building blocks of cells, which can degrade quickly after death. It's best to obtain specimens of living cells within six hours of death and other tissue within 12 hours, Hooper said.

The need for speed is also what makes such autopsies challenging. Families must consent to the procedure, often while freshly grieving their loved one's death. And the logistics surrounding retrieving a body, conducting an autopsy and then returning the body for a funeral are often complicated. Traffic is unpredictable and "one time, there was a blizzard," Hooper said.

Roychowdhury said he and one of his clinical fellows are on call at all times.

"The patients have our cellphone numbers, as well as the next of kin," he said.

Broaching the subject with patients and families requires tact and compassion. Most patients are enrolled in clinical trials and learn about the autopsies from their doctors or pathologists like Hooper. Many are willing, even eager, to cooperate, she said.

"These are mostly patients with metastatic cancer," she said. "They've made their peace with the outcome long before."

For some, the rapid autopsy is simply the final phase of the clinical trial.

"They want to do something not only for themselves, but also to help others," Roychowdhury said.

That's how Linda Boyed, 52, of Lewis Center, Ohio, sees it. Like Beck, she has bile duct cancer and is enrolled in a trial to treat it. The drugs are working now, but Boyed said she has agreed to a rapid autopsy after death so scientists can learn from her when they're no longer effective.

"I have a strong Christian faith," she said. "I believe we're put on this Earth to help each other."

Because the rapid autopsies are paid through program funds and grants, there's no cost to the families. Bodies are returned within a day and in a condition that doesn't affect funeral plans.

"My emphasis is that it was all done with dignity and respect," said Nancy Beck. "We felt honored to be able to do this."

Performing the autopsy after treating a patient in life is an honor for doctors, too, Roychowdhury said.

"This was once a living, breathing person that came into my office every other week," he said. "The thing I want to think about each day is that they've given so much so that others can benefit.

"Everyone has something to teach us after death."

Hospitals Lure Diabetes Patients With Self-Care Courses, But Costs Can Weigh Heavily

KFF Health News, April 26, 2018

The classes, targeting a disease that affects 30 million Americans, have become a revenue generator for hospitals and an opportunity for marketing and branding.

This article first appeared April 26, 2018 on Kaiser Health News.

By Julie Appleby

When a routine physical revealed mildly elevated blood-sugar levels, Michael Phillips was strongly encouraged to sign up for a diabetes self-management class.

Phillips never asked about the cost of the two half-day sessions he attended in a conference room at St. Mary’s Hospital in Athens, Ga., and doesn’t recall the instructor mentioning it.

But the 64-year-old retired bank analyst was flabbergasted when he opened his bill after attending.

“What, $1,044 for a class?" said Phillips, who fought the bill with the hospital and his insurer, Blue Cross Blue Shield of Georgia. “The hospital is charging an exorbitant rate, but BCBS is going along with it — why aren’t they screaming about being gouged?"

There are about 1.5 million Americans newly diagnosed with Type 2 diabetes each year. Unlike Type 1 diabetes, an autoimmune disease in which people produce no insulin that begins in childhood, Type 2 diabetes is a condition of adulthood, typically associated with weight and a sedentary lifestyle.

Diabetes self-management programs teach patients how to monitor their blood sugars, what to eat and the importance of exercise as strategies to delay or avoid the disease’s serious complications.

Patients like Phillips, with early or mild diabetes, can modify their habits so that their blood sugar returns to normal.

But the classes, targeting a disease that affects 30 million Americans, have also become a revenue generator for hospitals and an opportunity for marketing and branding.

“If you can get 25 in the class and charge $500 each, you can make a lot of money," said Gerard Anderson, a professor of health policy and management Johns Hopkins University Bloomberg School Public Health. An additional incentive is that the classes bring “people into the hospital that they expect will need the hospital in the future."

Phillips' class had about a dozen students, who got a free lunch, free parking and a sample of Glucerna, a nutrition drink formulated for diabetics. The instructor noted that St. Mary’s operates a gym that participants could join for a fee.

Diabetes is among the costliest of medical conditions. The American Diabetes Association estimates that average medical expenditures for those diagnosed with diabetes are 2.3 times higher than those without.

The classes, say experts, are a chance to rein in some of that spending. When Harvard Law School researchers ran the numbers in 2015, they found an estimated savings of $1,309 over three years for every Medicare Advantage patient who completed an education program.

But for many patients, the cost of the classes can either become a barrier to actually attending, or leave them with unanticipated bills.

After St. Mary’s billed Phillips’ insurer $1,044 for the two half-day classes he attended, Blue Cross Blue Shield of Georgia, in turn, lowered that to $626, or the “allowed amount" it had negotiated with St. Mary’s. Because he had not yet met his $3,500 annual deductible, Phillips is responsible for the entire $626.

Phillips, who took early retirement from his job in 2005 to care for his elderly parents, said he likely would not have attended had he known the price. He’d expected the instruction to cost about $50, noting that he’d already paid $120 for a one-on-one session with one of the hospital’s certified diabetes educators or CDEs.

Medicare sets an average reimbursement of $356 for an entire nine-hour group course, with the beneficiary’s share of that amount estimated at $71.

St. Mary’s said it is proud of its fully accredited program, which helps diabetes patients manage their condition.

"Our charges are in line with other similarly recognized programs in the state," according to a written statement from Mark Ralston, public relations director for the St. Mary’s Health Care System.

“Prior to enrollment, we send patients a letter that includes information that there will be a charge," the statement said, noting that the amount “the patient will pay depends on the patient's insurance coverage."

Ralston also noted that, because St. Mary’s is a Catholic health care system, “we are always happy to work with patients who have financial difficulties, up to and including applications for charity care."

Phillips’ charges seem high even though they were for a program that might actually save the insurer money over the long term, said William Custer, who studies health care markets as the director of the Center for Health Services Research at Georgia State University.

He questioned why the insurer didn’t drive a harder bargain.

“If the course has a benefit in terms of increasing health and reducing utilization, Blue Cross has an incentive to cover it and an incentive to negotiate," said Custer.

Blue Cross is one of the state and the region’s major insurers, Custer said, so it should have negotiated a better price.

Colin Manning, a spokesman for the insurer said, “We do have questions about the amount charged for this class and we are reaching out to St. Mary’s Hospital to discuss reimbursement for this service."

Diabetes management courses vary considerably in length and format, and even more so in price.

Internet searches and phone calls uncovered some cost examples, ranging from a $396, nine-hour course in Ohio to one in Wisconsin that lasted six hours and had a $420 price.

One of the most expensive — a 7½-hour diabetes self-management group course that included two-hour individual sessions with a dietitian and a diabetes educator — cost $1,700 in Washington state.

Howard County General Hospital in Maryland has decided to bypass insurance and charge patients $50 upfront for a six-hour course taught by a certified diabetes educator. That price was selected because in many cases it was less than what people with insurance would pay in copayments or deductibles under the former price, which was billed to insurers at a rate of about $1,000.

Before they made the switch about a year and a half ago, patients would often cancel after learning how much they would owe, said Mike Taylor, a clinical manager and diabetes educator who runs the hospitals program. “We would literally lose half the appointments we would schedule."

The Maryland hospital also offers free classes by a lay instructor.

Meanwhile, thinking his original bill was in error, Phillips in late January appealed St. Mary’s $1,044 charge to his insurer. It was denied a month later as the insurer noted the bill was “coded correctly." Hospitals can charge what they like for their services.

And after being contacted by the hospital billing office in early April to confirm he was aware of his bill’s “delinquent status," he wrote a second appeal letter.

Phillips said the class was well-taught, though he noted that he was already dieting before he took the class. He “followed what they said" and he has lost 31 pounds. His blood sugar, he added, is also back in the normal range.

“At least now I’m well-informed about what to eat and not eat if I ever do have diabetes," he said wryly.

Peak Health Plan Premiums Give Rise To Activism - And Unconventional Solutions

KFF Health News, April 25, 2018

The situation in Charlottesville has left many residents at their wits' end about how to pay for their health insurance, thrusting the costs of coverage into the center of local politics.

This article first appeared April 25, 2018 on Kaiser Health News.

By Rachel Bluth

CHARLOTTESVILLE, Va. — When Garnett and Dave Mellen sent their 19-year-old daughter, Gita, off to college an hour away at Virginia Commonwealth University last fall, they didn’t expect to follow her.

But in November, the family received notice that its monthly health insurance premium in Charlottesville would triple for 2018, from $1,200 to an unaffordable $3,600.

So, the Mellens, both longtime local business owners, packed their bags and spent time with Gita in her off-campus apartment in Richmond.

“My whole life has been rearranged around trying to get health insurance,” Garnett Mellen, 56, said, as she explained that claiming residency with her daughter in the new ZIP code had cut their premiums by more than half.

Charlottesville now claims the dubious distinction of having the highest individual-market health insurance costs in the country — prompting families like the Mellens to look for extreme solutions.

An exodus of carriers, which was blamed on losses caused by the instability of the Obamacare marketplace, created a coverage vacuum, leaving locals and insurance regulators scrambling.

Only one carrier — Virginia Beach-based Optima Health — decided to continue to participate in the individual market, but it did so with monthly premium increases that were, on average, in the high double-digits and for some consumers as much as 300 percent, according to people interviewed for this story.

It’s a problem that’s likely to be replicated elsewhere, said Timothy Jost, an emeritus professor of law at Washington and Lee University in Virginia and expert on the health law.

“In many states, it’s going to be hard to maintain a functional individual market,” he said. “Charlottesville is sort of ahead of everybody else in this … but this is the direction things are heading.”

Insurers nationwide that intend to participate in the individual market face spring deadlines to file forms for 2019 plans and rate proposals. In Virginia, these dates are April 20 and May 4, respectively.

The situation in Charlottesville has left many residents at their wits’ end about how to pay for their health insurance, prompting the evolution of an angry and rebellious civic movement and thrusting the costs of coverage into the center of local politics.

Charlottesville for Reasonable Health Insurance, a grass-roots organization and Facebook group of more than 700 people, has already claimed small victories in the state legislature, such as propelling the passage of a bill that will alleviate the cost burden for some of its members.

But its highest priority has been pressing state regulators to explain and possibly reconsider the decision that allowed for the stunning premium increase.

In the midst of various bureaucratic fits and starts, the state Bureau of Insurance (BOI) responded to the group April 11 by reiterating that Optima’s rates were “actuarially justified.” Ian Dixon, one of the group’s organizers, said it plans to appeal this finding to the State Corporation Commission.

“We’re not going away, that’s for sure,” said Dixon. “They’re hoping they can wait us out. … They would drag this out for a year if they could.”

At the same time, the group has expanded its focus to other issues on health care costs, such as price transparency and regulatory reform.

How It Came To This

The trouble started in summer 2017, when the state’s major insurance carriers announced they would be leaving the individual market in Virginia, saying the market was “shrinking and deteriorating” — pointing to the instability of Obamacare under the Trump administration.

Their departures left Albemarle County, home to Charlottesville, bare — meaning residents had no insurance options.

When Optima opted to continue to offer plans in and around Charlottesville, state insurance regulators breathed a collective sigh of relief.

But Optima’s decision came with updated rate increase proposals, which gained the OK of the under-the-gun BOI, led by Commissioner Scott White.

“I think the [regulators] decided they were willing to accept almost anything to get someone to cover Albemarle County and Charlottesville,” Jost said.

About 15 miles north of Charlottesville on U.S. 29, there’s a billboard that some residents now view with bitter irony. It features a smiling man with the message: “I chose Optima.”

On one hand, Optima did fill a void and offer health plans where no other insurer would. Still, many residents found their only choice came with a 300 percent boost in premium costs. They felt that state regulators had fallen short of their consumer-protection responsibilities.

“Any assumption that I had … that I thought [the Bureau of Insurance would be] protecting the people … was completely naive,” said Sarah Stovall, 40, who works for a small software company, lives in Charlottesville with her husband and two sons and has struggled to find affordable coverage.

But Ken Schrad, the director of the Division of Information Resources for the State Corporation Commission, said the bureau is still questioning Optima, checking its math and evaluating its actuarial decisions.

He couldn’t answer specific questions about a matter he said is pending.

Schrad said the bureau reached out to carriers and worked with them last summer when it was clear that much of the commonwealth wouldn’t be covered.

“It wasn’t a question of what the premiums would be,” Schrad said. “It was whether there would be any coverage.

“[Filings] must be based on actuarially sound decisions, and that’s all the bureau can review. The market is the market.”

A Movement Is Born

Stovall, 40, teamed up with Dixon, 38, a web app developer, to manage the emerging Facebook group, which was originally set up as a support system for people in search of new insurance options in a short window of time. Soon, Karl Quist, 46, who had been actively calling the BOI to lodge complaints, joined the effort.

“The three of us did not know each other before November,” Dixon said. “We feel like we’re relatives now.”

Others quickly piled on, including the Mellens and Gail Williamson, 64, a part-time secretary at a private school who needed insurance for herself and her husband, who owns a business restoring antiques.

Like many of the people in the group, the Williamsons made too much money to qualify for federal subsidies, but too little to be able to afford the $3,725 monthly premium that Optima would have charged them.

Sharing their knowledge, many Charlottesville for Reasonable Health Insurance members have resorted to imperfect jury-rigged policies that do not come with many of the coverage guarantees that protect patients from unexpected costs under the Affordable Care Act.

Instead of paying $2,920 a month for Optima’s least generous family health plan, Quist is saving $2,300 a month by purchasing two non-ACA-compliant plans, one for sickness and one for accidents.

Williamson has settled on a “silly little” three-month policy for $1,400 per month, plus an extra $35 a month in supplemental accident insurance for her husband.

“If I won the lottery, the first thing I’d do before giving my kids any money would be to buy health insurance for everyone in that group,” Williamson said.

Washington and Lee’s Jost said he worries about the impact of such cobbled-together coverage.

He said having these plans could damage the ACA market further by skimming the healthier people away from the more comprehensive coverage, leaving behind those who are ill or have chronic conditions.

“It makes the situation worse because the only people who are going to pay premiums that high are people who are desperate,” Jost said.

Forward Motion

Over the past months, the community-based effort has evolved beyond being an ad hoc information clearinghouse into a powerful organizing tool.

For instance, it has raised almost $20,000 to hire lawyer Jay Angoff, a former federal and state insurance official, to appeal to Optima and state regulators about the Charlottesville-area rates.

Dixon, Stovall and Quist also regularly pile into Stovall’s minivan, drive to Richmond and become lobbyists for their cause.

“The insurance companies pay people very good money to lobby for them on a regular basis,” Stovall said. “Meanwhile, I have to take off work, Ian [Dixon] has to leave his business for a day.”

“On some level, I have faith that if we keep pushing, I don’t know what the eventual outcome will be, but we’ll find some type of justice,” Dixon added.

Their greatest victory came with the passage of SB 672. This law redefined what a “small employer” is so that self-employed people can buy insurance in the small-group market.

The group sought this change because many people, including Dixon, found that the cost of adding an employee to a company of one allowed them to save money by obtaining insurance as a small group, though it still added significant overhead costs to these businesses.

Many in the group see this success as only a band-aid fix. Though it allows some people to obtain cheaper insurance, it doesn’t address the root of the problem: Optima’s rate increases.

For Garnett Mellen, though, the issue seems resolved, at least for now. She found a job with health benefits in Charlottesville, which enabled her and her husband to move back there.

It’s a big relief — both for her and for Gita, her college-aged daughter.

“She [was] not entirely happy with us being there,” Mellen said.

4 New Ways Consumers Can Avoid Fines For Not Having Health Insurance

KFF Health News, April 24, 2018

Under the new rules, people can apply for a hardship exemption that excuses them from having to have health insurance if they, for example, live in an area where there is just one insurer selling marketplace plans.

This article first appeared April 24, 2018 on Kaiser Health News.

By Michelle Andrews

There are already more than a dozen reasons people can use to avoid paying the penalty for not having health insurance. Now the federal government has added four more “hardship exemptions” that let people off the hook if they can’t find a marketplace plan that meets not only their coverage needs but also reflects their view if they are opposed to abortion.

It’s unclear how significant the impact will be, policy analysts said. That’s because the penalty for not having health insurance will be eliminated starting with tax year 2019, so the new exemptions will mostly apply to penalty payments this year and in the previous two years.

“I think the exemptions … may very marginally increase the number of healthy people who don't buy health insurance on the individual market,” Timothy Jost, emeritus professor of law at Washington and Lee University in Virginia who is an expert on health law.

Under the new rules, people can apply for a hardship exemption that excuses them from having to have health insurance if they:

  • Live in an area where there are no marketplace plans.
  • Live in an area where there is just one insurer selling marketplace plans.
  • Can’t find an affordable marketplace plan that doesn't cover abortion.
  • Experience “personal circumstances” that make it difficult for them to buy a marketplace plan, including not being able to find a plan in their area that gives them access to specialty care they need.

The first new exemption isn’t relevant for consumers this year. Since the Affordable Care Act’s marketplaces opened, there have been no “bare” counties that lack insurers.

However, in about half of the U.S. counties — in which 26 percent of enrollees live — there is only one marketplace insurer this year, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

As for the abortion exemption, in many places it won’t be an issue either. Women in 31 states didn’t have access to a marketplace plan that covered abortion in 2016, according to a Kaiser Family Foundation analysis. Still, a few states — California, New York and Oregon — generally require abortion coverage in their marketplace plans, and women who live there might have trouble finding a plan that excludes that coverage, experts said.

The ACA established several different types of exemptions from the penalty for not having coverage. Among them are exemptions for not being able to find coverage that is considered affordable or being without insurance for less than three consecutive months in a year. People claim these more common exemptions when they file their tax returns.

Hardship exemptions that had already been on the books protected people who faced eviction, filed for bankruptcy or racked up medical debt, among other difficulties. Consumers apply for these exemptions by submitting an application to the ACA insurance marketplace.

The new hardship exemptions apply to people in all 50 states, according to an official at the federal Centers for Medicare & Medicaid Services, which oversees the health law’s insurance marketplaces. To apply, people generally need to provide a brief explanation of the circumstances that made it a hardship for them to buy a marketplace plan, along with any available documentation, when they submit their application to marketplace officials. They can apply for the current calendar year or going back two years, to 2016.

It’s difficult to gauge how many people will try to take advantage of the changes, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities.

“People aren’t sure how to apply or if they’re eligible, and that discourages them from applying,” Straw said.

The penalty for not having health insurance in 2018 is the greater of $695 or 2.5 percent of household income.

During the 2017 filing season, there were more than 106 million tax returns reporting that all family members had health insurance, and nearly 11 million tax returns that claimed an exemption from the requirement to have it, according to a report from the Treasury Department’s inspector general for tax administration. In addition, more than 4 million returns reported paying penalties totaling nearly $3 billion for not having health insurance.

People often don’t realize they may owe a penalty until it’s time to do their taxes, said Alison Flores, a principal tax research analyst at H&R Block’s Tax Institute. H&R tax preparers first work to see if clients can qualify for an exemption that can be claimed on their tax returns. If that doesn’t work, they move on to the hardship exemptions. The preparers help people get the hardship exemption application, but it’s up to consumers to send it to the marketplace and get the exemption certificate.

The federal guidance about the new exemptions was released April 9, shortly before the end of the income tax filing season. People who’ve already filed their taxes and qualify for the new exemptions for 2016 or 2017 and get marketplace approval can file an amended tax return to receive a refund of any penalty they paid, said Katie Keith, a health policy consultant who writes regularly about health reform.

“You have to really be motivated,” Keith said.

Nearly Three-Quarters Of Commonly Used Medical Scopes Tainted By Bacteria

KFF Health News, April 24, 2018

Researchers said the findings confirm earlier work showing that these issues aren't simply confined to duodenoscopes.

This article first appeared April 23, 2018 on Kaiser Health News.

By Chad Terhune

In an ominous sign for patient safety, 71 percent of reusable medical scopes deemed ready for use on patients tested positive for bacteria at three major U.S. hospitals, according to a new study.

The paper, published last month in the American Journal of Infection Control, underscores the infection risk posed by a wide range of endoscopes commonly used to peer deep into the body. It signals a lack of progress by manufacturers, hospitals and regulators in reducing contamination despite numerous reports of superbug outbreaks and patient deaths, experts say.

“These results are pretty scary,” said Janet Haas, president of the Association for Professionals in Infection Control and Epidemiology. “These are very complicated pieces of equipment, and even when hospitals do everything right we still have a risk associated with these devices. None of us have the answer right now.”

The study found problems in scopes used for colonoscopies, lung procedures, kidney stone removal and other routine operations. Researchers said the findings confirm earlier work showing that these issues aren’t simply confined to duodenoscopes, gastrointestinal devices tied to at least 35 deaths in the U.S. since 2013, including three at UCLA’s Ronald Reagan Medical Center. Scope-related infections also were reported in 2015 at Cedars-Sinai Medical Center in Los Angeles and Pasadena’s Huntington Hospital.

The bacteria this latest study found weren’t superbugs, but researchers said there were potential pathogens that would put patients at high risk of infection. The study didn’t track whether the patients became sick from possible exposure.

The study’s authors said the intricate design of many endoscopes continues to hinder effective cleaning and those problems are compounded when health care workers skip steps or ignore basic protocols in a rush to get scopes ready for the next patient. The study identified issues with colonoscopes, bronchoscopes, ureteroscopes and gastroscopes, among others.

“Sadly, in the 10 years since we’ve been looking into the quality of endoscope reprocessing, we haven’t seen improvement in the field,” said Cori Ofstead, the study’s lead author and an epidemiologist in St. Paul, Minn., referring to how the devices are prepared for reuse.

“If anything, the situation is worse because more people are having these minimally invasive procedures and physicians are doing more complicated procedures with endoscopes that, frankly, are not even clean,” Ofstead said.

The rise of antibiotic-resistant superbugs such as CRE (carbapenem-resistant Enterobacteriaceae), which can be fatal in up to half of patients, has made addressing these problems more urgent. About 2 million Americans are sickened by drug-resistant bacteria each year and 23,000 die, according to the federal Centers for Disease Control and Prevention.

“We’re not moving fast enough to a safer world of reusable medical devices,” Michael Drues, an industry consultant in Grafton, Mass., who advises device companies and regulators. “There is plenty of fault to go around on device companies, hospitals, clinicians, on basically everybody.”

Despite the potential risks, medical experts caution patients not to cancel or postpone lifesaving procedures involving endoscopes. These snake-like devices often spare patients from the complications of more invasive surgeries.

“Patients should speak to their provider and think about the risks versus the benefits,” said Haas, who is also director of epidemiology at Lenox Hill Hospital in New York City.

The Food and Drug Administration and Olympus Corp., a leading endoscope manufacturer in the U.S. and worldwide, both said they are reviewing the study.

Last month, the FDA issued warning letters to Olympus and two other scope makers for failing to conduct real-world studies on whether health care facilities can effectively clean and disinfect their duodenoscopes. The FDA ordered the manufacturers to conduct those reviews in 2015 after several scope-related outbreaks in Los Angeles, Seattle and Chicago made national headlines.

Olympus spokesman Mark Miller said the Tokyo-based company intends to “meet the milestones set forth by the FDA. … Patient safety has always been and remains our highest priority.”

The latest study examined 45 endoscopes, with all but two manufactured by Olympus. The other two were Karl Storz models.

Last year, researchers visited three hospitals, which weren’t named, and performed visual examinations and tests to detect fluid and contamination on reusable endoscopes marked ready for use on patients. One hospital met the current guidelines for cleaning and disinfecting scopes, while the other two committed numerous breaches in protocol.

Nevertheless, 62 percent of the disinfected scopes at the top-performing hospital tested positive for bacteria, including potential pathogens. It was even worse at the other two — 85 and 92 percent.

The study painted a troubling picture at the two lower-performing hospitals, which were well aware researchers were watching.

Among the safety issues: Hospital technicians wore the same gloves for handling soiled scopes fresh after a procedure and later, when they were disinfected and employees wiped down scopes with reused towels. Storage cabinets for scopes were visibly dirty and dripping wet scopes were hung up to dry, which is a known risk because bacteria thrive on the moisture left inside. The two hospitals also turned off a cleaning cycle on a commonly used “washing machine,” known as an automated endoscope reprocessor, to save time.

“It was very disturbing to find such improper practices in big health systems, especially since these institutions were accredited and we assumed that meant everything would have been done properly,” said Ofstead, chief executive of the medical research firm Ofstead & Associates.

Ofstead and her co-authors recommended moving faster toward sterilization of all medical scopes using gas or chemicals. That would be a step above the current requirements for high-level disinfection, which involves manual scrubbing and automated washing. A shift to sterilization would likely require significant changes in equipment design and major investments by hospitals and clinics.

In their current form, many endoscopes aren’t built to withstand repeated sterilization. Some also have long, narrow channels where blood, tissue and other debris can get trapped inside.

In some cases, disposable, single-use scopes are an option, and new products are starting to gain acceptance. In other instances, certain parts of a scope might be disposable or removable to aid cleaning.

The Joint Commission, which accredits many U.S. hospitals and surgery centers, issued a safety alert last year about disinfection and sterilization of medical devices in response to a growing rate of noncompliance. In 2016, the Joint Commission cited 60 percent of accredited hospitals for noncompliance and 74 percent of all “immediate threat to life” citations from surveyors related to improperly sterilized or disinfected equipment.

Michelle Alfa, a professor in the department of medical microbiology at the University of Manitoba, said accreditors may need to conduct more frequent inspections and endoscopy labs should be shut down “if they don’t get their act together. These results are totally unacceptable.”

Calif. Leads Nation In Pushing Back Against Trump Administration Health Policies

KFF Health News, April 20, 2018

While other states are making efforts to preserve the ACA and expand coverage, California stands out by virtue of its ambition and size, economic clout, massive immigrant population and liberal bent.

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

By Ana B. Ibarra

These days, when the federal government turns in one direction, California veers in the other — and in the case of health care, it’s a sharp swerve.

In the nation’s most populous state, lawmakers and other policymakers seemingly are not content simply to resist Republican efforts to dismantle the Affordable Care Act. They are fighting to expand health coverage with a series of steps they hope will culminate in universal coverage for all Californians — regardless of immigration status and despite potentially monumental price tags.

The Golden State embraced the health care law early and eagerly, and has more to lose than any other state if the ACA is dismantled: About 1.5 million Californians purchase coverage through the state’s Obamacare exchange, Covered California, and 3.8 million have signed up for Medicaid as a result of the program’s expansion under the law.

While other states are making efforts to preserve the ACA and expand coverage, California stands out by virtue of its ambition and size, economic clout, massive immigrant population and liberal bent.

Its health care resistance movement is broad and includes Attorney General Xavier Becerra, who has made a sport of suing the Trump administration. He is currently leading a coalition of 15 states, plus the District of Columbia, against a Texas-based lawsuit that seeks to strike down the ACA.

Even Covered California, the ACA marketplace, has jabbed at the feds. During the most recent enrollment period, which ended in January, it preserved its three-month sign-up window while the federal government cut the enrollment period in half for states that rely on the healthcare.gov exchange. Covered California also deployed a monster advertising budget of $45 million to encourage enrollment, while the federal government slashed its ad dollars to $10 million.

California’s activism could be contagious, said Linda Blumberg, a fellow at the nonprofit research institution the Urban Institute.

“California has been in the forefront” on a lot of health policy issues, she said. To the extent that it is successful, she said, “that helps not only the state of California itself but other states as well.”

Since last year, the federal government has allowed some states to impose work requirements on Medicaid recipients; promoted temporary health plans that have fewer consumer protections than Obamacare insurance; and, most recently, adopted a rule allowing states to lower the percentage of premium dollars that insurers are required to spend on medical care.

In response, California lawmakers are debating bills that would prohibit work requirements in Medi-Cal, the state’s version of Medicaid; ban the sale of short-term plans in the state; and increase the percentage of insurance premiums that must go toward consumers’ care.

“Look at what we’ve done in women’s issues, climate change, protecting immigrants. … That’s just the kind of thing we do. Health is no different,” said state Sen. Ed Hernandez (D-West Covina), the head of the Senate Health Committee and author of several proposals.

Four pending bills in California would provide some consumers with state-funded financial help to supplement federal subsidies created by Obamacare. One such proposal could cost the state about $500 million initially.

“We continue to move forward and push the envelope, now more than ever,” state Sen. Ricardo Lara (D-Bell Gardens) told a room full of physicians recently in Sacramento. Lara, a candidate for state insurance commissioner, is carrying a bill that would offer full Medicaid benefits to a group that’s never been covered before: adults who are in the country illegally.

“We not only play defense, but we want to make sure we’re more proactive,” he said.

California’s efforts to cover unauthorized immigrants under Medi-Cal predate the Trump administration. Achieving it now would represent not only a significant expansion of coverage within the state, but also a direct challenge to the federal government, which has made a point of cracking down on immigrants.

Critics point out that this spirit of defiance does not represent all Californians.

“We have some crazy things happening here,” said Sally Pipes, president of the conservative Pacific Research Institute. “Nobody talks about how to pay for these. Well, you pay for it in increased taxes.”

Sara Rosenbaum, a professor at the Milken Institute School of Public Health at George Washington University, said it’s no secret that President Donald Trump doesn’t like California — and that the feeling is mutual.

While she believes his administration might try to punish the state for its defiance, California will nonetheless persist in its campaign to defend the ACA and expand coverage.

“I’m sure [federal officials] can try to do a million things to make the state’s life miserable,” she said. “They can jerk it around on the federal Medicaid payments. … But I just think this, too, shall pass.”

It’s not clear whether the pending legislative proposals will succeed. Assuming any of the bills make it through the legislature, their fate lies with Gov. Jerry Brown, a Democrat known for fiscal conservatism.

“If the past is any indication, it seems unlikely that bills with sizable and uncertain ongoing costs will move forward,” said Shannon McConville, a researcher at the Public Policy Institute of California.

California is not alone in resisting health care policies put forth by the Trump administration. Other states, including Maryland and New Jersey, may establish state-based penalties for not having insurance — a response to Congress’ decision to kill the federal Obamacare penalty starting in 2019.

But California’s approach, characteristically, is different.

“Rather than use the stick, use the carrot,” said Hernandez. His bill would target $500 million from the state’s general fund to help some income-eligible Californians pay their premiums or out-of-pocket medical costs. This assistance would supplement the federal financial aid for those on the Covered California exchange.

The Senate Health Committee approved the bill last week.

The Congressional Budget Office estimates that about 4 million people nationwide will become uninsured when the tax penalty for not having insurance goes away. In California, the number would be about 378,000, according to a recent Harvard University study.

Three other bills would offer state-based financial aid to different groups of consumers, including those who make too much money to qualify for federal tax credits but still struggle to pay their premiums.

The biggest potential budget-buster of them all is a proposal to establish a single-payer health system, which was pulled from consideration last year, largely because of its eye-popping price tag: $400 billion annually.

Advocates for universal health care aren’t giving up, though some have shifted their strategy to moving piecemeal toward universal health care in lieu of a massive single-payer bill.

“There are individual steps that we can still take to expand coverage to various populations that are falling through the cracks,” said Gerald Kominski, director of the UCLA Center for Health Policy Research.

One of those populations, and a large one, is immigrants living without authorization in the country.

Lara is not the only legislator with a proposal to extend full Medi-Cal coverage to income-eligible adult immigrants without legal status. State Assemblyman Joaquin Arambula (D-Fresno) has introduced a separate bill that would do the same. Arambula’s measure made it through the Assembly Health Committee on Tuesday, and Lara’s bill passed the Senate Health Committee earlier this month.

Of the nearly 3 million Californians without insurance, about 58 percent are currently ineligible for full Medi-Cal benefits or Covered California insurance because they’re not in the country legally.

California must “lead the nation in bold and inclusive polices” that support the health of all communities, said Arambula, who is an emergency room doctor.

In 2016, the state extended full Medi-Cal benefits to all children, and now more than 200,000 undocumented kids are enrolled. It’s not clear how much it would cost to cover undocumented adults, but last year, the state budgeted $279.5 million for the children. Adults are generally more expensive to cover.

All of these measures, successful or not, add up to a campaign of defiance.

“It’s a signal that California is willing to fight very hard, on multiple fronts … to protect certain values and policies,” McConville said. “This shows we’re not willing to go backwards on that.”

New Medicare Perk For Diabetes Prevention Stumbles At Rollout

KFF Health News, April 19, 2018

In all but a few locations, Medicare's new prevention program isn't up and running yet. And there's no easy way (no phone number or website) to learn where it's available.

This article first appeared April 19, 2018 on Kaiser Health News.

By Judith Graham

Several weeks ago, Medicare launched an initiative to prevent seniors and people with serious disabilities from developing Type 2 diabetes, one of the most common and costly medical conditions in the U.S.

But the April 1 rollout of the Medicare Diabetes Prevention Program, a major new benefit that could help millions of people, is getting off to a rocky start, according to interviews with nearly a dozen experts.

In all but a few locations, experts said, Medicare’s new prevention program — a yearlong series of classes about healthy eating, physical activity and behavioral change for people at high risk of developing diabetes — isn’t up and running yet. And there’s no easy way (no phone number or website) to learn where it’s available.

A Medicare spokesman declined to indicate where the diabetes program is currently available, saying only that officials had approved three providers to date.

In a first for Medicare, community organizations such as YMCAs and senior centers will run the program, not doctors and hospitals. But many sites are struggling with Medicare’s contracting requirements and are hesitant to assume demanding administrative responsibilities, said Brenda Schmidt, acting president of the Council for Diabetes Prevention and chief executive officer of Solera Health, a company that assembles provider networks.

Medicare Advantage plans, an alternative to traditional Medicare run by private insurance companies, are now required to offer the Medicare Diabetes Prevention Program to millions of eligible members. But they aren’t doing active outreach because there are so few program sites available.

It’s “too early” to discuss how Medicare Advantage plans will handle implementation given uncertainty about the program’s accessibility, Cathryn Donaldson, director of communications for America’s Health Insurance Plans, said in an email.

Supporters urge patience. While Medicare’s embrace of diabetes prevention is “transformational,” building an infrastructure of community organizations to deliver these services “hasn’t been done before. It’s going to take time,” said Ann Albright, director of the Division of Diabetes Translation at the U.S. Centers for Disease Control and Prevention.

In a written comment, a spokesman for the Centers for Medicare & Medicaid Services said about 50 of more than 400 eligible programs are in the process of submitting applications. An online resource identifying approved programs is under development, and outreach to people with Medicare coverage is “planned for the coming months,” the statement said.

For those who want more timely information, here’s a look at the Medicare Diabetes Prevention Program and why it’s worth waiting for, even if takes awhile for a program to become available near you.

Diabetes and older adults. According to the CDC, at least 23 million people age 65 and older have “prediabetes” — elevated blood sugar levels that put them at heightened risk of developing Type 2 diabetes.

In five years, without intervention, up to one-third of this group will develop Type 2 diabetes — a leading cause of blindness, amputation and kidney disease in older adults, associated with a heightened risk of heart disease, stroke and dementia.

Program eligibility. The Medicare Diabetes Prevention Program is available to older adults and people with serious disabilities with Medicare Part B coverage who have prediabetes — and it’s free for those who qualify.

Once the program becomes available in your area, your doctor can refer you or you can sign up on your own, so long as you have a body mass index of at least 25 (or a BMI of 23, if you’re Asian), you haven’t been previously diagnosed with diabetes, and your blood sugar levels are consistent with prediabetes.

This benefit is available only once to each qualified Medicare beneficiary, so it behooves you to make sure you’re ready for the commitment it entails.

“The purpose of this should be to improve your health and quality of life, long term, not to lose vanity pounds,” said Marlayna Bollinger, executive director of San Diego’s Skinny Gene Project, which works with people at risk of developing diabetes.

Evidence of effectiveness. Medicare is tweaking the National Diabetes Prevention Program, launched by the CDC in 2010. In a much-cited 2002 study published in the New England Journal of Medicine, researchers found that participants in an early version of the CDC program were 58 percent less likely to develop diabetes than a placebo group. For people 60 and older, the reduced risk of developing diabetes was even more striking — 71 percent.

James Combs, 66, weighed 273 pounds when he enrolled in a program offered by Baptist Health in Lexington, Ky., in January 2016. Today, he weighs 210 pounds, no longer takes medication for high blood pressure, and reported “feeling fantastic.” (Combs enrolled before becoming eligible for Medicare, and his private insurance paid for the program.)

Medicare’s model. Small groups of about eight to 20 people meet weekly, for about an hour, 16 times over a six-month period, then once or twice a month for the next six months. Nutritionists, diabetes educators or other coaches use a structured CDC-approved curriculum and foster group discussion and problem-solving.

Participants check their weight at each session and keep daily logs of what they’re eating and their physical activity. The goal is to have participants lose at least 5 percent of their body weight and get 150 minutes of physical activity weekly.

“The objectives are very realistic and that increases the likelihood of success,” said Kathleen Stanley, Baptist Health’s coordinator for diabetes education and prevention.

A four-year pilot program involving nearly 8,000 seniors in 315 locations, sponsored by Medicare and coordinated by YMCA of the USA, found that savings were significant: an estimated $2,650 over the course of 15 months for each participant.

Medicare has also added a second year of monthly sessions, designed to reinforce lessons learned in the first year, for people who meet weight loss targets and regularly attend classes. (Those who don’t aren’t allowed to attend these sessions.)

Medicare will pay up to $670 per participant for the two-year period if programs meet performance standards relating to weight loss and attendance. If not, payments are lower.

For the moment, Medicare doesn’t plan to work with companies such as Omada Health Inc. or Canary Health that offer online versions of CDC’s Diabetes Prevention Program. But advocacy groups are pressing for this alternative to in-person classes.

“Virtual delivery of the diabetes prevention program would be a great option, particularly for seniors in underserved areas,” said Meghan Riley, vice president of federal government affairs for the American Diabetes Association.

Next steps. YMCA of the USA is among several organizations that plan to participate in the Medicare Diabetes Prevention program but are adopting a cautious approach.

“We’re still digging through Medicare rules and regulations and trying to make sure we understand the implications,” said Heather Hodges, the Y’s senior director of evidence-based health interventions.

She said 25 of the Y’s 840 associations were in the process of applying for Medicare certification and that as many as 50 might be offering the Medicare Diabetes Prevention Program by the end of the year. (Each Y association encompasses multiple locations.)

Albright said the CDC was asking state health departments and 10 national organizations, including the American Diabetes Association, the National Alliance for Hispanic Health and Black Women’s Health Imperative, to promote the new Medicare benefit. Once Medicare publishes a list of programs that its officials have approved, CDC will highlight this online, she said.

Angela Forfia, senior manager of prevention at the American Association of Diabetes Educators, suggested that older adults contact their local Area Agency on Aging, local health departments and senior centers in their area and express interest in the Medicare Diabetes Prevention Program.

“If Medicare recipients start to demand and ask for this, you’ll have more organizations step up and sign on to become Medicare suppliers,” she suggested.

Meanwhile, seniors might want to learn if they have prediabetes. (About 9 out of 10 people who do don’t know it.) “Take our risk test and see where you stand,” Albright advised (available at www.doihaveprediabetes.org). “It’s a good conversation starter with your health care professional, who may want to follow up by ordering a blood test.”

In A Puerto Rican Mountain Town, Hope Ebbs And Health Suffers

KFF Health News, April 19, 2018

Villagers are not standing still. They are working hard to recover. But their resilience is withering.

This article first appeared April 19, 2018 on Kaiser Health News.

By Sarah Varney

CASTAÑER, Puerto Rico — Helicopters from the power company buzz across the skies of this picturesque valley, ferrying electrical poles on long wires to workers standing on steep hillsides.

The people of Castañer, an isolated village in Puerto Rico’s central mountains, watch warily. Crews have come and gone, and people living along the mountain roads don’t expect to get power until late summer, if ever. Power finally started flowing to the center of town last month, but the electrical grid remains unstable — an island-wide blackout Wednesday disrupted progress — and the hospital continues to use its own generator.

More than six months after Hurricane Maria, daily life in Castañer is nowhere close to normal. Children attend school half the day; another nearby school is closed for at least two years, and families who lost their homes have set up beds and couches in its classrooms.

The deadly storm made landfall on the island’s southeastern coast on Sept. 20 and stayed over the island for nearly eight hours with sustained winds of 155 mph. Across Puerto Rico, it killed as many as a thousand people, wiped away homes and farms and crippled the electrical grid.

The federal government has committed about $18 billion to rebuild Puerto Rico, and in towns like this the task looks immense.

Here in Puerto Rico’s "Coffee Belt," the hurricane winds snapped banana trees and ripped up acres of coffee plants. Flash flooding and mudslides from the heavy rain also wreaked havoc on agricultural crops.

With no harvest this spring, idle men now spend hours on the plaza or in the town bar.

From his office at Castañer General Hospital, Domingo Monroig, the chief executive, looks out onto that bar on Castañer’s main street. In the months since the storm, the hospital has been the town’s organizing center.

"I don’t know if the phrase is unhappy, but we call it como triste in Spanish, because it is not the same," said Monroig.

"For example, when they have light they are playing la cancha [in] the basketball area or they are in the plaza. But if we don’t have light, everybody stays in their home and they say, ‘I don’t know what to do. It’s every day, every day, the same, the same.’"

Many residents here continue to experience acute stress and anxiety attacks, said Dr. Javier Portalatin, a clinical psychologist and director general for mental health at the hospital. "Hurricane Georges was in the nighttime, and we only heard the sounds of it," he said, referring to a devastating 1998 storm that hit the island. "This hurricane, we saw in the daytime in this region. We could actually see what was happening through the windows. I have patients who saw their pets being killed and their neighbors’ houses destroyed right next to them. These memories spur their anxiety attacks."

Up a winding mountain road, one of Portalatin’s patients, Johanna Garcia Mercado, lives in near constant fear. Just 10 feet in front of her tiny, dark home, the hillside collapsed during the hurricane. Since then, she feels panic rising in her chest and often cries uncontrollably.

"When it rains and thunders," said Mercado, "I’m afraid the steep hillside behind the house will collapse and bury my daughters in mud."

The 37-year-old mother lifts up her T-shirt to reveal fresh scars from surgery on her pancreas, caused from the prolonged stress, said her social worker.

Mercado said she has thought of moving, but this piece of land is all the family owns. Her husband worked on the coffee farm across the road, but with no harvest this year, he is digging up yautia roots, which are similar to turnips, and selling them in San Sebastián, an hour away.

The villagers of Castañer are not standing still — they are working hard to recover.

But their resilience is withering, even for people like Mariela Miranda, a devoted do-gooder who has taken it upon herself to bring food and water to her bedridden neighbors. She delivers hot rice and turkey stew to a family that is caring for a 59-year-old man in the final throes of cancer.

They rely on a small inverter to power the ventilator keeping him alive. They have a generator, too, but today it isn’t working.

"It’s been really hard, because they need a generator because his machine has to be on 24 hours for the oxygen," said Miranda.

Miranda gets back in the car and heads to her next stop.

She is a walking catalog of Hurricane Maria’s relentless torment: the neighbor sucking for air because he couldn’t plug in his nebulizer; the diabetics who can’t refrigerate their insulin.

She even helps a 109-year-old bedridden woman with Alzheimer’s who had terrible bedsores after lying for four months on a medical air mattress — not inflated, because her home had no power.

"They’re getting sick mentally," Miranda said. "You can see they’re not the same. You can see the frustration."

Even after the power comes back on, Miranda said, her elderly and bedridden neighbors will never fully recover. "If the light comes back, they will still have the mental damage, like they were like abandoned," she said.

"This gets to you," she continued. "It drains you. You get so frustrated sometimes. Because there are people that will die." She recalls an elderly man she used to visit who died a month ago. "He died because he had [sleep] apnea and he didn’t have the power. So every night he would sleep at the macasina, in the driveway. He would sleep in the driveway sitting on the couch because he was scared to die if he fell asleep."

When asked who should lead the effort to restore daily life to Castañer, Miranda grew exasperated. "We hear the help is getting here," she said, "but those of us who visit the houses? We don’t see it."

At the Mission La Santa Cruz church, the Rev. Edwin Orlando Velez Castro was preparing for Friday night services. Most of the townspeople, he said, were baptized here.

Standing in the darkened chapel — there is no power here either — he said that singing is like a prayer to God to change life and make it new.

"Most of the hymns we sing in this time give people faith that God will help us rebuild ourselves and our town," he said. "That is part of our mission — to be light in this darkness."

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