Women In Medicine Shout #MeToo About Sexual Harassment At Work

KFF Health News, March 20, 2018

While the health care field overall has far more women than men, in many stations of power the top of the pyramid is overwhelmingly male, with women occupying the vast base.

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

By Christina Jewett, Kaiser Health News

Annette Katz didn’t expect to be part of a major social movement. She didn’t set out to take on a major health organization. But that all began to change when a co-worker saw her fighting back tears and joined Katz to report to her union what amounted to a criminal sexual offense at a Cleveland Veterans Affairs Medical Center in 2012 and 2013.

Four years later, Katz, a licensed practical nurse at the hospital, testified in a court deposition that a male nursing assistant had shoved her into a linen closet and groped her and subjected her to an onslaught of lewd comments.

In speaking out and taking legal action, Katz joined a growing group of women who are combating sexual harassment in the medical field at every level, from patients’ bedsides to the executive boardroom.

Much as the #MeToo moment has raised awareness of sexual harassment in business, politics, media and Hollywood, it is prompting women in medicine to take on a health system where workers have traditionally been discouraged from making waves and where hierarchies are ever-present and all-commanding. While the health care field overall has far more women than men, in many stations of power the top of the pyramid is overwhelmingly male, with women occupying the vast base.

In a recent survey, 30 percent of women on medical faculties reported experiencing sexual harassment at work within the past two years, said Dr. Reshma Jagsi, who conducted the poll. That share is comparable to results in other sectors and, as elsewhere, in medicine it had been mostly taboo to discuss before last year.

“We know harassment is more common in fields where there are strong power differentials,” said Jagsi, who is director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. “And we know medicine is very hierarchical.”

Workers in the health care and social assistance field reported 4,738 cases of sexual harassment from fiscal 2005 through 2015, eclipsed only by fields such as hospitality and manufacturing, where men make up a greater proportion of the workforce, according to data gathered by the Equal Employment Opportunity Commission.

A Kaiser Health News review of dozens of legal cases across the U.S. shows similar patterns in the waves of harassment cases that have cropped up in other fields, from entertainment to sports to journalism: The harassers are typically male. The alleged harasser supervises or outranks the alleged victim. There are slaps on the butt, lewd comments and requests for sex. When superiors are confronted with reports of bad behavior, the victims, mostly women, are disbelieved, demoted or fired.

But recently, physicians have taken to Twitter using the #MeTooMedicine tag, sharing anecdotes and linking to blogs that chronicle powerful doctors harassing them or disrobing at professional conferences.

Women who work in cardiology recently told the cardiology trade publication TCDMD that they felt the problem was particularly widespread in their specialty, where females account for 14 percent of the physicians. A Los Angeles anesthesiologist made waves in a blog post urging “prettier” women to adopt a “professional-looking, even severe, hair style” to be taken seriously and to consider self-defense classes.

Among those speaking out is Dr. Jennifer Gunter, a San Francisco obstetrician-gynecologist, who recently wrote a blog post about being groped in 2014 by a prominent colleague at a medical conference — even naming him.

“I think nothing will change unless people are able to name people and institutions are held accountable,” she said in an interview. “I don’t think without massive public discourse and exposure that things will change.”

Lawsuits, many settled or still making their way through the courts, describe encounters.

A Florida nurse claimed that in 2014, a surgeon made lewd comments about her breasts, asking her in a room full of people if he should “refer to her as ‘JJ’ or ‘Jugs,’” the nurse’s lawsuit says. The nurse said she “responded that she wished to be called by her name.”

In other cases: A phlebotomist in New York alleged in a lawsuit that a doctor in her medical practice gave her a box of Valentine’s Day candy and moved in for an unwanted kiss on the mouth. A Florida medical resident alleged that a supervising doctor told her she looked like a “slutty whore.” A Nebraska nurse claimed that a doctor she traveled with to a professional conference offered to buy her a bikini, if he could see her in it, and an extra night in a hotel, if they could share the room. She declined.

A Pennsylvania nurse described the unsatisfying response she got after reporting that a colleague had pressed his pelvis against her and flipped through her phone for “naked pictures.” A supervisor to whom she reported the conduct expressed exasperation, saying “I can’t deal with this” and “What do you want?”

Dr. Kayla Behbahani, chief psychiatry resident at University of Massachusetts Memorial Medical Center, did not file a lawsuit but recently wrote about sexual harassment by a subordinate. In an interview, she said her instincts were to pity the man, and also to follow a dictate that’s drilled into medical students: Don’t make waves. So, she disclosed the harassment only after another woman’s complaint launched an investigation.

“As a professional, I come from a culture where you go with the flow,” Behbahani said. “You deal with what you’re dealt. In that regard, it was a dilemma for me.”

Annette Katz, the Veterans Affairs nurse, initially didn’t complain about the harassment. A single mother with two children, she needed her job. Her attacker, MD Garrett, was also a nursing assistant but had more seniority, was a veteran and was friends with her boss.

“I really did feel that I would lose my job,” Katz said in an interview. “I would be that troublemaker.”

But as the abuse escalated, she went to the VA inspector general and the Cleveland police.

She estimated that five times Garrett pushed her into a closet where he would ask for sex. She would “tell him ‘no’ and fight my way out of [his] grip,” her statement said. He shoved her into an unconscious patient’s bathroom and would “try to restrain me, but I eventually could break free.”

After one such assault, a colleague noticed tears in Katz’s eyes. The co-worker shared with Katz that she, too, had been a target of Garrett’s lewd behavior.

Katz and the colleague filed complaints in March 2013 with their union, the police and with their managers. That July, Garrett was indicted by a grand jury and later pleaded guilty to three counts of sexual imposition and one count of unlawful restraint. He was also dismissed from his job.

Reached by phone, Garrett said he agreed to the plea because he was facing multiple felonies and didn’t know what a jury would do. He said that even though he pleaded guilty to four misdemeanors, he did not commit the crimes of which he was accused. “There was no harassment; she and I were friends,” he said.

Speaking quietly, going to HR — if that worked, we wouldn’t be here.

Dr. Jennifer Gunter

In 2013, Katz sued the VA, alleging that it failed to protect her from harassment and retaliated against her by refusing to give her a job-site transfer before firing her for not showing up to work.

The VA attorneys argued that the department had no direct knowledge of harassing behavior before Katz reported it, and that once it was informed, immediate action was taken. Veterans Affairs deputy press secretary Lydia Blaha said in an email that anyone engaged in sexual harassment is swiftly held accountable.

The U.S. Department of Veterans Affairs agreed in February to pay $161,500 to settle Katz’s lawsuit.

Katz said it was costly and emotional to press on with her legal case but hopes it helps other women see that seeking justice is worthwhile. “I do think there are a lot of women who just suffer in silence,” she said.

Gunter, the San Francisco physician-blogger, said that needed change will come only when people who are more established across all professions stand up for those who are more junior. “Speaking quietly, going to HR — if that worked, we wouldn’t be here,” she said.

It’s ironic, she said, that as a gynecologist she’s trained to believe patients’ claims about sexual assault. In the workplace, though, it’s well-known that raising such matters can backfire. She added: “Physicians should be setting a standard on this.”

Congress Tackles The Opioid Epidemic. But How Much Will It Help?

KFF Health News, March 20, 2018

Advocates say what they need most is money, which would most likely come through the government spending bill that's due March 23. But they aren't holding their breath.

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

By Shefali Luthra

The nation’s opioid epidemic has been called today’s version of the 1980s AIDS crisis.

In a speech Monday, President Donald Trump pushed for a tougher federal response, emphasizing a tough-on-crime approach for drug dealers and more funding for treatment. And Congress is upping the ante, via a series of hearings — including one scheduled to last Wednesday through Thursday — to study legislation that might tackle the unyielding scourge, which has cost an estimated $1 trillion in premature deaths, health care costs and lost wages since 2001.

Dr. Leana Wen, an emergency physician by training and the health commissioner for hard-hit Baltimore, said Capitol Hill has to help communities at risk of becoming overwhelmed.

“We haven’t seen the peak of the epidemic. We are seeing the numbers climb year after year,” she said.

Provisional data from the Centers for Disease Control and Prevention suggest that almost 45,000 Americans died from opioid overdoses in the 12-month period ending July 2017, up from about 38,000 in the previous cycle. (Those data are likely to change, since many death certificates have not yet been reported to the CDC.)

“It’s not going to get any better unless we take dramatic action,” Wen said.

And the time for most meaningful change could be dwindling. Advocates say what they need most is money, which would most likely come through the government spending bill that’s due March 23. But they aren’t holding their breath.

Show Me The Money

The federal budget deal, which was signed into law in early February, promised $6 billion over two years for initiatives to fight opioid abuse. Congress is still figuring out how to divvy up those funds. The blueprint is expected to be included in the spending bill this week.

Last month, a bipartisan group of senators introduced a bill that would add another $1 billion in funding to support expanded treatment and also limit clinicians to prescribing no more than three days’ worth of opioids at a time.

That legislation is likely to have wide support in the Senate, but its path through the House is less certain.

This cash infusion is still not going to be enough, predicted Daniel Raymond, policy director for the Harm Reduction Coalition, a national organization that works on overdose prevention.

“It’s not clear whether there’s a real appetite to go as far as we need to see Congress go,” he said. “To have a fighting chance, we need a long-term commitment of at least $10 billion per year.” Academic experts said that assessment sounded on target.

The figure is more than three times what’s allocated in the budget and 10 times what even the new Senate bill would provide, and far beyond the spending levels put forth by any previous packages to fight the opioid epidemic.

The difficulty in getting funding — and a key reason why the bipartisan Senate bill might stall in the House — in part goes to the heart of Republicans’ philosophy about budgeting.

The GOP, which controls both chambers of Congress, has “always been very focused on pay-fors,” said a Republican aide to the House Energy and Commerce Committee, explaining that new funding is generally expected to be accompanied by cuts in current expenditures so that overall government spending doesn’t rise. And that could limit how much money lawmakers are ultimately willing to commit to fight opioid abuse.

Some observers worry this notion is pound-foolish.

“We have an enormous set of costs ahead of us if we don’t invest now,” said Dr. Traci Green, an associate professor of emergency medicine and community health science at Boston University, who has extensively researched the epidemic.

Ahead In Congress

Meanwhile, the House could take up its version of a separate Senate-passed proposal designed to, in certain cases, make more prominent any opioid history in a patient’s medical record. The idea is to prevent doctors from prescribing opioids to at-risk patients.

In addition, the House’s Energy and Commerce Committee in late February held a hearing focused on “enforcement” — discussing, for instance, giving the federal Drug Enforcement Administration more power in drug trafficking, and whether to treat fentanyl, a particularly potent synthetic opioid, as a controlled substance. This week’s hearings will tackle a slew of public health-oriented bills, such as making sure overdose patients in the emergency room get appropriate medication and treatment upon discharge, or expanding access to buprenorphine, which is used to treat addiction.

And the House Ways and Means Committee, which has jurisdiction over Medicare — the federal insurance plan for seniors and disabled people — is working to develop strategies that limit access to opioids and make treatment more available.

These are some promising ideas, Raymond said, but it’s still “playing catch-up. … The big gap is the money, and the broader vision.”

This flurry of activity comes after Congress in 2016 passed two laws directly dealing with addiction and substance abuse disorders, the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act. CARA promised $181 million — although it didn’t appropriate those dollars — while the Cures Act provided $1 billion over two years.

It’s playing out against the backdrop of steady policy tensions.

The Trump administration, which in October declared the opioid epidemic a public health crisis, has repeatedly pushed a more punitive approach, such as harsher sentences for drug trafficking, including the death penalty and establishing mandatory minimum sentences. That emphasis, experts said, detracts from other parts of the plan that might highlight, say, addiction treatment.

Instead, those experts emphasized treatment and prevention as well as “harm reduction” ideas such as providing more overdose-antidote medication and funding programs like syringe exchanges.

They say focusing on punishment has been ineffective in the past and neglects the heart of the issue.

Certainly, curbing the flow of illegal drugs is important, Wen said. But it’s insufficient by itself. And the size of the problem means lawmakers need to provide quicker, more direct aid — not just proposals that tinker “around the edges.”

“We would never refuse any funding, because we need it desperately,” she said. “But ask us what we need.”

Paying Hospitals To Keep People Out Of Hospitals? It Works In Maryland.

KFF Health News, March 19, 2018

Analysts often describe the change as the most far-reaching attempt in the nation to control the medical costs driving up insurance premiums and government spending.

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

By Jay Hancock

Saturdays at Mercy Medical Center used to be perversely lucrative. The dialysis clinic across the street was closed on weekends.

That meant the downtown Baltimore hospital would see patients with failing kidneys who should have gone to the dialysis center. So Mercy admitted them, collecting as much as $30,000 for treatment that typically costs hundreds of dollars.

“That’s how the system worked,” said Mercy CEO Thomas Mullen. Instead of finding less expensive alternatives, he said, “our financial people were saying, ‘We need to admit them.’”

Maryland’s ambitious hospital-payment overhaul, put in place in 2014, has changed such crass calculations, which are still business as usual for most of American health care. A modification of a long-standing state regulation that would be hard to replicate elsewhere, the system is nevertheless attracting national attention, analysts say.

As soon as Mercy started being penalized rather than rewarded for such avoidable admissions, it persuaded the dialysis facility to open on weekends, saving government insurance programs and other payers close to $1 million annually.

In the four years since Maryland implemented a statewide system of pushing hospitals to lower admissions, such savings are adding up to hundreds of millions of dollars for the taxpayers, employers and others who ultimately pay the bills, a new report shows.

Maryland essentially pays hospitals to keep people out of the hospital. Analysts often describe the change as the most far-reaching attempt in the nation to control the medical costs driving up insurance premiums and government spending.

Like a giant health maintenance organization, the state caps hospitals’ revenue each year, letting them keep the difference if they reduce inpatient and outpatient treatment while maintaining care quality. Such “global budgets,” which have attracted rare, bipartisan support during a time of rancor over health care, are supposed to make hospitals work harder to keep patients healthy outside their walls.

Maryland’s system, which evolved from a decades-old effort to oversee hospitals as if they were public utilities, regulates all hospital payments by every private and government insurer. That makes it radically different from piecemeal attempts to lasso health spending, such as creating accountable care organizations, which seek savings among smaller groups of patients.

From the program’s launch in 2014 through 2016, per capita hospital spending by all insurers grew by less than 2 percent a year in Maryland. That’s below the economic growth rate, according to new results from the state’s hospital regulator and the federal Department of Health and Human Services.

Keeping hospital spending below economic growth — defined four years ago as 3.58 percent annually — is a key goal for the program and something that rarely happened.

Counting The Savings

The state plan saved the Medicare program for seniors and the disabled about half a billion dollars over three years and achieved “substantial reductions in hospitalization and especially improvements in quality of care,” said a Medicare spokesman.

In the three years measured so far, he added, “the state has already exceeded the required performance for the full five years of the model.”

As high costs for hospital care have been growing more slowly nationwide, Maryland hospital costs over that period rose even less.

“It looks like it has very strong results,” said John McDonough, a Harvard health policy professor who helped craft the federal Affordable Care Act.

What Maryland is doing, he said, “is pretty bold and it’s pretty thoughtfully done and has generated a huge amount of interest around the country.”

Comprehensive results through 2016 are the most recent available from Maryland and HHS, although savings continued last year, Maryland officials said. Independent researchers found mixed results for savings in the earlier years of Maryland’s system.

Maryland’s global budgets saved Medicare $293 million — 1.8 percent of total Medicare spending — in 2014 and 2015, research firm RTI International reported in August.

A separate paper from a team led by Eric Roberts at the University of Pittsburgh found that Maryland’s program in those years couldn’t be clearly credited for reducing hospital use.

The system’s advocates say several years of results are needed to show it’s working.

“These are not fake savings,” said Joseph Antos, an economist at the conservative-leaning American Enterprise Institute who sits on Maryland’s hospital-payment commission. “It didn’t happen instantaneously. It’s taken this number of years to achieve the kinds of savings that you see” for 2016 and beyond.

Even boosters such as Joshua Sharfstein, the former Maryland health secretary who got approval for global budgets from the Obama administration, say the system is far from perfect or finalized.

“There is a range of responses. Some hospitals have been able to do more than others,” said Sharfstein, now an associate dean at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “Change in health care is notoriously slow.”

Hospitals have lagged in delivering primary, preventive care to people with chronic conditions such as asthma, diabetes and heart failure, especially in low-income neighborhoods.

Maryland’s system does little to control soaring costs of drugs or nursing home care, doctors’ office treatments and other care not connected to hospitals, although policymakers are working on proposals to do both.

Even so, “what Maryland has done is just so far ahead of many of these other models” to try to control costs, said Dan D’Orazio, a management consultant who has worked with hospitals across the country. One Maryland hospital CEO told him: “This has fundamentally changed how we wake up and do business every day,” D’Orazio said.

Seeing A Difference

At Mercy, described by policymakers as more aggressive than many hospitals in watching costs, about a third of the patients now leave the hospital with medications in hand, said Dr. Wilma Rowe, the hospital’s chief medical officer. That bypasses the tendency for patients to skip a follow-up pharmacy visit and risk landing back in the emergency room.

A statewide data network notifies Mercy and other hospitals when one of their patients ends up in an emergency room somewhere else. That helps coordinate care.

Greater Baltimore Medical Center, north of the city, has hired dozens of primary care doctors to track around 1,000 people with diabetes — staying in touch, advising on diets and keeping them on insulin so they avoid the hospital.

Often clinicians visit elderly patients’ homes to prevent what might turn into an ambulance call and admission, said the hospital’s CEO, Dr. John Chessare.

Before global budgets, “I’d look at the waiting room in the [emergency department], and if it wasn’t full I’d get scared,” he said.

Now he worries it might be full of people who could be better treated elsewhere — including Gilchrist, a GBMC affiliate delivering hospice care for those at the end of life.

These days, he said, “we consider it a defect if someone with chronic disease dies in the hospital.”

Docs Worry There's 'Nowhere To Send' New And Expectant Moms With Depression

KFF Health News, March 19, 2018

Depression affects up to 1 in 7 women during or after pregnancy. Among those who screen positive, 78 percent don't get mental health treatment.

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

By April Dembosky, KQED

Lawmakers in California will begin debate next month on a bill that would require doctors to screen new moms for mental health problems — once while they’re pregnant and again after they give birth.

But many obstetricians and pediatricians bristle at the idea, saying they are afraid to screen new moms for depression and anxiety.

“What are you going to do with those people who screen positive?” said Dr. Laura Sirott, an OB-GYN who practices in Pasadena. “Some providers have nowhere to send them.”

Nationally, depression affects up to 1 in 7 women during or after pregnancy, according to the American Psychological Association.

And of women who screen positive for the condition, 78 percent don’t get mental health treatment, according to a 2015 research review published in the journal Obstetrics & Gynecology.

Sirott said her patients give a range of reasons why they don’t take her up on a referral to a psychologist: “‘Oh, they don’t take my insurance.’ Or ‘my insurance pays for three visits.’ ‘I can’t take time off work to go to those visits.’ ‘It’s a three-month wait to get in to that person.'”

She said it’s also hard to find a psychiatrist who is trained in the complexities of prescribing medications to pregnant or breastfeeding women, and who is willing to treat them, especially in rural areas.

“So it’s very frustrating,” Sirott said, “to ask patients about a problem and then not have any way to solve that problem.”

Moms are frustrated, too. After the baby comes, no one asks about the baby’s mother anymore.

Wendy Root Askew struggled for years to get pregnant, and when she finally did, her anxiety got worse. She couldn’t stop worrying that something would go wrong.

“And then, after I had my son, I would have these dreams where someone would come to the door and they would say, ‘Well, you know, we’re just going to wait two weeks to see if you get to keep your baby or not,'” Root Askew said. “And it really impacted my ability to bond with him.”

Wendy and Dominick Root Askew with their son. When the little boy (now 6) was born, Wendy struggled with postpartum depression. (Courtesy of Wendy Root Askew)

She likes California’s bill, AB 2193, because it goes beyond mandated screening. It would require health insurance companies to set up case management programs to help moms find a therapist, and connect obstetricians or pediatricians to a psychiatric specialist.

“Just like we have case management programs for patients who have diabetes or sleep issues or back pain, a case management program requires the insurance company to take some ownership of making sure their patients are getting the treatment they need to be healthy,” said Root Askew, who is now advocating for the bill on behalf of the group 2020 Mom.

Health insurance companies haven’t taken a position on the legislation. It’s unclear how much it would cost them to comply, because some already have infrastructure in place for case management programs, and some do not. But there is consensus among insurers and health advocates that such programs save money in the long run.

“The sooner that you can get good treatment for a mom, the less expensive that condition will be to manage over the course of the woman’s life and over the course of that child’s life,” Root Askew said.

Some doctors still have their objections. Under the bill, they could be disciplined for not screening. Some have said they worry about how much time it would take.

The health care system, and the incentives, aren’t set up for this sort of screening, Sirott said.

“Currently, I get $6 for screening a patient,” she said. “By the time I put it on a piece of paper and print it, it’s not worth it.”

It’s not clear whether the direct and indirect costs of screening would be worth it to the patients, either. Four other states — Illinois, Massachusetts, New Jersey and West Virginia — have tried mandated screening, and it did not result in more women getting treatment, according to a study published in Psychiatric Services in 2015.

Even with California’s extra requirement that insurance companies facilitate care, women could still face high copays or limits on the number of therapy sessions. Or, the new mothers might be so overwhelmed with their care for a newborn, that it would be difficult to add anything to their busy schedules.

What does seem to work, according to the study of mandated screening in other states, is when nurses or mental health providers visit new moms at home.

“Despite abundant goodwill, there is no evidence that state policies are addressing this great need,” the study’s authors report.

Supporters of California’s proposed bill, however, say doctors need to start somewhere. Screening is the first step in recognizing the full scope of the problem, said Dr. Nirmaljit Dhami, a Mountain View, Calif., psychiatrist. Women should be screened on an ongoing basis throughout pregnancy and for a year after birth, Dhami said, not just once or twice as the bill requires.

“I often tell doctors that if you don’t know that somebody is suicidal it doesn’t mean that their suicidality will go away,” she said. “If you don’t ask, the risk is the same.”

The Other Opioid Crisis: Hospital Shortages Lead To Patient Pain, Medical Errors

KFF Health News, March 16, 2018

Hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently.

This article first appeared March 16, 2018 on Kaiser Health News.

By Pauline Bartolone

Even as opioids flood American communities and fuel widespread addiction, hospitals are facing a dangerous shortage of the powerful painkillers needed by patients in acute pain, according to doctors, pharmacists and a coalition of health groups.

The shortage, though more significant in some places than others, has left many hospitals and surgical centers scrambling to find enough injectable morphine, Dilaudid and fentanyl — drugs given to patients undergoing surgery, fighting cancer or suffering traumatic injuries. The shortfall, which has intensified since last summer, was triggered by manufacturing setbacks and a government effort to reduce addiction by restricting drug production.

As a result, hospital pharmacists are working long hours to find alternatives, forcing nurses to administer second-choice drugs or deliver standard drugs differently. That raises the risk of mistakes — and already has led to at least a few instances in which patients received potentially harmful doses, according to the nonprofit Institute for Safe Medication Practices, which works with health care providers to promote patient safety.

In the institute’s survey of hospital pharmacists last year, one provider reported that a patient received five times the appropriate amount of morphine when a smaller-dose vial was out of stock. In another case, a patient was mistakenly given too much sufentanil, which can be up to 10 times more powerful than fentanyl, the ideal medication for that situation.

In response to the shortages, doctors in states as far-flung as California, Illinois and Alabama are improvising the best they can. Some patients are receiving less potent medications like acetaminophen or muscle relaxants as hospitals direct their scant supplies to higher-priority cases. Other patients are languishing in pain because preferred, more powerful medications aren’t available, or because they have to wait for substitute oral drugs to kick in.

The American Society of Anesthesiologists confirmed that some elective surgeries, which can include gall bladder removal and hernia repair, have been postponed.

In a Feb. 27 letter to the U.S. Drug Enforcement Administration, a coalition of professional medical groups — including the American Hospital Association, the American Society of Clinical Oncology and the American Society of Health-System Pharmacists — said the shortages “increase the risk of medical errors” and are “potentially life-threatening.”

In addition, “having diminished supply of these critical drugs, or no supply at all, can cause suboptimal pain control or sedation for patients,” the group wrote.

The shortages involve prefilled syringes of these drugs, as well as small ampules and vials of liquid medication that can be added to bags of intravenous fluids.

Drug shortages are common, especially of certain injectable drugs, because few companies make them. But experts say opioid shortages carry a higher risk than other medications.

Giving the wrong dose of morphine, for example, “can lead to severe harm or fatalities,” explained Mike Ganio, a medication safety expert at the American Society of Health-System Pharmacists.

Calculating dosages can be difficult and seemingly small mistakes by pharmacists, doctors or nurses can make a big difference, experts said.

Marchelle Bernell, a nurse at St. Louis University Hospital in Missouri, said it would be easy for medical mistakes to occur during a shortage. For instance, in a fast-paced environment, a nurse could forget to program an electronic pump for the appropriate dose when given a mix of intravenous fluids and medication to which she was unaccustomed.

“The system has been set up safely for the drugs and the care processes that we ordinarily use,” said Dr. Beverly Philip, a Harvard University professor of anesthesiology who practices at Brigham and Women’s Hospital in Boston. “You change those drugs, and you change those care processes, and the safety that we had built in is just not there anymore.”

Chicago-based Marti Smith, a nurse and spokeswoman for the National Nurses United union, offered an example.

“If your drug comes in a prefilled syringe and at 1 milligram, and you need to give 1 milligram, it’s easy,” she said. “But if you have to pull it out of a 25-milligram vial, you know, it’s not that we’re not smart enough to figure it out, it just adds another layer of possible error.”

During the last major opioid shortage in 2010, two patients died from overdoses when a more powerful opioid was mistakenly prescribed, according to the institute. Other patients had to be revived after receiving inaccurate doses.

The shortage of the three medications, which is being tracked by the FDA, became critical last year as a result of manufacturing problems at Pfizer, which controls at least 60 percent of the market of injectable opioids, said Erin Fox, a drug shortage expert at the University of Utah.

A Pfizer spokesman, Steve Danehy, said its shortage started in June 2017 when the company cut back production while upgrading its plant in McPherson, Kan. The company is not currently distributing prefilled syringes “to ensure patient safety,” it said, because of problems with a third-party supplier it declined to name.

That followed a February 2017 report by the U.S. Food and Drug Administration that found significant violations at the McPherson plant. The agency cited “visible particulates” floating in the liquid medications and a “significant loss of control in your manufacturing process [that] represents a severe risk of harm to patients.” Pfizer said, however, that the FDA report wasn’t the impetus for the factory upgrades.

Other liquid-opioid manufacturers, including West-Ward Pharmaceuticals and Fresenius Kabi, are deluged with back orders, Fox said. Importing these heavily regulated narcotics from other countries is unprecedented and unlikely, she added, in part because it would require federal approval.

At the same time, in an attempt to reduce the misuse of opioid painkillers, the Drug Enforcement Administration called for a 25 percent reduction of all opioid manufacturing last year, and an additional 20 percent this year.

“DEA must balance the production of what is needed for legitimate use against the production of an excessive amount of these potentially harmful substances,” the agency said in August.

When the coalition of health groups penned its letter to the DEA last month, it asked the agency to loosen the restrictions for liquid opioids to ease the strain on hospitals.

The shortages are not being felt evenly across all hospitals. Dr. Melissa Dillmon, medical oncologist at the Harbin Clinic in Rome, Ga., said that by shopping around for other suppliers and using pill forms of the painkillers, her cancer patients are getting the pain relief they need.

Dr. Shalini Shah, the head of pain medicine at the University of California-Irvine health system, pulled together a team of 20 people in January to figure out how to meet patients’ needs. The group meets for an hour twice a week.

The group has established workarounds, such as giving tablet forms of the opioids to patients who can swallow, using local anesthetics like nerve blocks and substituting opiates with acetaminophen, ketamine and muscle relaxants.

“We essentially have to ration to patients that are most vulnerable,” Shah said.

Two other California hospital systems, Kaiser Permanente and Dignity Health in Sacramento, confirmed they’re experiencing shortages, and that staff are being judicious with their supplies and using alternative medications when necessary. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

At Helen Keller Hospital’s emergency department in Sheffield, Ala., earlier this month, a 20-year-old showed up with second-degree burns. Dr. Hamad Husainy said he didn’t have what he needed to keep her out of pain.

Sometime in January, the hospital ran out of Dilaudid, a drug seven times more potent than morphine, and has been low on other injectable opioids, he said.

Because Husainy’s patient was a former opioid user, she had a higher tolerance to the drugs. She needed something strong like Dilaudid to keep her out of pain during a two-hour ride to a burn center, he said.

“It really posed a problem,” said Husainy, who was certain she was in pain even after giving her several doses of the less potent morphine. “We did what we could, the best that we could,” he said.

Bernell, the St. Louis nurse, said some trauma patients have had to wait 30 minutes before getting pain relief because of the shortages.

“That’s too long,” said Bernell, a former intensive care nurse who now works in radiology.

Dr. Howie Mell, an emergency physician in Chicago, said his large hospital system, which he declined to name, hasn’t had Dilaudid since January. Morphine is being set aside for patients who need surgery, he said, and the facility has about a week’s supply of fentanyl.

Mell, who is also a spokesman for the American College of Emergency Physicians, said some emergency departments are considering using nitrous oxide, or “laughing gas,” to manage patient pain, he said.

When Mell first heard about the shortage six months ago, he thought a nationwide scarcity of the widely used drugs would force policymakers to “come up with a solution” before it became dire.

“But they didn’t,” he said.

For Aspiring Doctors With Disabilities, Many Medical Schools Come Up Short

KFF Health News, March 15, 2018

For Aspiring Doctors With Disabilities, Many Medical Schools Come Up Short

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

By Elana Gordon, WHYY

Being a medical student or resident is hard enough, but what if you have a disability that adds to the challenge?

One medical resident with a physical disability was about a year and a half into training when the health care institution finally installed an automatic door he needed. Another student faced frustrations when arranging accommodations for taking tests, with it seeming like the medical school was “making up rules along the way.” When another resident first sought support, the disability representative for the school was allegedly unfamiliar with the Americans With Disabilities Act.

These firsthand experiences are documented in a report issued Tuesday by the Association of American of Medical Colleges and the University of California-San Francisco about the accessibility and inclusion of students and doctors with disabilities in the medical field. The culture and the environment surrounding disabilities varies widely, it found, with some places doing far better than others.

About 1,500 medical students in the U.S. have disclosed a disability and receive formal accommodations. That’s about 2.7 percent of students, according to the report, and represents a lower percentage than undergraduate programs, in which about 11 percent of students, on average, disclose a disability. The report found that in medicine especially, many students hide their disability out of a “fear of judgment, bias, and skewed perception of ability.”

Medicine is an incredibly tough and competitive field where, historically, doctors have been viewed as superhumans, operating at the highest physical and mental capacity at all hours of the day and night, performing miracles and saving lives. There’s an expectation of perfection.

But doctors are human, too.

A lack of understanding about disabilities can create big challenges for otherwise qualified and talented future doctors, said Lisa Meeks, co-author of the report and a disabilities expert at the University of Michigan Medical School. Yet some schools may not even be aware of what they could be doing to foster a more inclusive environment.

“I don’t know of a school that doesn’t want to do the best practice,” said Meeks, who is also co-founder of the Coalition for Disability Access in Health Science and Medical Education, adding that schools might just not have the tools.

For Dr. Geoffrey Young, AAMC’s senior director for student affairs and programs, the nearly 100-page report is a much-needed blueprint for medical institutions to better serve students with disabilities, whether those disabilities be the easily identifiable physical kind or invisible ones.

“I think we have to do a better job of educating those in the field about what the potential is for those with disabilities, versus what is consumed or assumed to be an automatic inability,” Young said, adding that the culture is shifting in medicine. “We are having this conversation in a very open way.”

The report identifies very clear barriers and considerations schools can take in response. That includes everything from the way disabilities are discussed in the admissions process to having a person within the institution who is well-versed in both disability access issues and medical school requirements, to help future doctors better navigate their training.

For Dr. Lina Mehta, associate dean for admissions at Case Western Reserve University School of Medicine in Cleveland, improvements start with changing attitudes and approaches at the onset. Case was cited in the report as a positive example for the disabilities language it has adopted in its materials.

“In admissions, we sort of dictate the face and function of what medicine is going to look like by virtue of who we bring in,” Mehta said. Having a more diverse future physician population, one that includes people with disabilities, improves the field’s ability to understand and care for patients, she said. “It’s critical we bring in a group of learners and future practitioners who will mirror patient populations that they’re taking care of.”

This story is part of a partnership that includes WHYY’s The Pulse, NPR and Kaiser Health News.

Opioid Maker Funds Efforts To Fight Addiction: Is It 'Blood Money' Or Charity?

KFF Health News, March 14, 2018

While patient groups and communities have been quick to accept money for programs they could otherwise not afford, families who have lost loved ones to opioids are not easily placated.

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

By Jenny Gold

A program to give naloxone overdose-antidote kits and training to front-line officers. Funding for pill disposal boxes in pharmacies, clinics and police stations across North Carolina. A radio campaign in Connecticut warning of the dangers of opioid abuse. A new medicine to treat opioid-induced constipation.

The money behind these efforts to combat the opioid epidemic and its side effects comes from a perhaps unlikely sponsor: Purdue Pharma, the company that makes the top-selling opioid, OxyContin.

After years of aggressively promoting OxyContin as a safe and effective way to combat pain, the company is — equally aggressively — recasting itself as a fundamental player in the response to a crisis that many experts say it helped to create. Such efforts come amid hundreds of lawsuits claiming that Purdue fueled the opioid epidemic by deceptively marketing OxyContin, as well as new government efforts to regulate opioids.

In February, Purdue announced that it would stop promoting its opioid drugs to physicians. At the same time, Purdue is looking to partner with other companies and expand its portfolio into areas such as oncology and sleep medicine. OxyContin accounted for more than 94 percent of Purdue’s sales in 2012 and was still over 82 percent as of last year, according to Symphony Health.

While patient groups and communities have been quick to accept money for programs they could otherwise not afford, families who have lost loved ones to opioids are not easily placated.

When Sue Kruczek heard the Purdue-sponsored radio ad on her local station, warning of the dangers of opioid addiction, she was so appalled that she said she “almost had to pull over.”

“It’s sickening. It makes me feel sick. I hold Purdue personally responsible for this epidemic,” said Kruczek, who lost her son Nick to an opioid overdose in 2013, just a week shy of his 21st birthday. “It’s blood money at this point.”

Kruczek said she was also unimpressed by the full-page ads Purdue placed in major newspapers in December, touting its “abuse-deterrent” OxyContin formulation and support for the Centers for Disease Control and Prevention guidelines for safe prescribing.

Greg Williams, executive vice president of Facing Addiction, a nonprofit group that advocates for people struggling with addiction, noted that the ads were published just months after a coalition of 41 states’ attorneys general subpoenaed records from major opioid manufacturers, including Purdue. “The timing of this recent blitz is not an accident — they were quiet for a long time,” he said of the ads and donations, calling them a tactic to avoid paying more later. “They’re spending millions of dollars to do this when they owe billions,” he said.

Purdue said it is wrong to blame the company for the opioid crisis, which resulted in 42,000 overdose deaths in 2016. The Council of Economic Advisers estimated that the crisis cost $504 billion in 2015, or 2.8 percent of GDP.

“Pointing fingers isn’t a way to get the resolution we need,” Robert Josephson, a spokesman for Purdue, said in an interview. “Pointing to one company and one product that never constituted more than 3.6 percent of total prescriptions really misses the mark.” The advertisements all end with the phrase: “We want everyone engaged to know you have a partner in Purdue Pharma. This is our fight, too.”

Some programs that have benefited from Purdue’s donations say they were unaware that the drugmaker had provided the funding — though in the midst of a crisis they were nonetheless grateful.

As part of Purdue’s partnership with the National Sheriffs’ Association, the sheriff’s department in rural Wood County, Ohio, received about 60 doses of naloxone for officers to carry. So far, the department has used about seven doses to revive people experiencing an overdose.

Sheriff Mark Wasylyshyn said that when he received the kits he was not aware that Purdue had provided the funds. But, he said, it would not have affected his decision to accept them. “I think whoever wants to do it, it’s wonderful,” he said. “If they wouldn’t have done it, I wouldn’t have had it to save those seven lives.”

Fred Wells Brason II, president and CEO of Project Lazarus in North Carolina, which partnered with Purdue to install pill disposal boxes across the state, said the organization had received little pushback for accepting the donation. The drug companies “are not going to go away. We need them, and patients need them. We just want to make sure prescribing is safe and responsible,” he said.

OxyContin sales have been dropping in recent years, from $2.8 billion in 2012 to $1.7 billion in 2017, in part because of competition from generics. Unlike other opioid manufacturers such as Johnson & Johnson, which makes hundreds of products, Purdue is known almost exclusively for its opioid drugs.

That is partly why it is soliciting business partnerships to diversity its portfolio. But one of the first of the new products feels to some like an affront: Acquired through a partnership with Japanese company Shionogi Inc. and approved last year, Symproic is a pill to treat opioid-induced constipation — a common malady of people taking the pain meds. It costs about $350 per month.

Purdue’s recent promise to cut half of its sales staff and stop marketing OxyContin to physicians altogether is unlikely to have much of an impact, especially since there are already generic versions of the drug, said Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University.

“Once drug companies have generic competition, they often stop promoting anyway,” he said, adding that OxyContin is still being marketed aggressively in other countries through Purdue’s international arm, called Mundipharma. Although OxyContin is still protected by a Purdue patent, it is available in multiple generic equivalent forms, sold by generic drug companies with Purdue’s permission.

The company’s approach is nothing new, said Mike Moore, a former attorney general of Mississippi who is currently consulting on several major cases against Purdue. “They have had a history of tiny half-steps every time someone begins looking at them,” said Moore. In 2002 for example, Moore recalled, Purdue gave Florida $2 million for education and prevention programs to combat opioid abuse. “That’s like pennies in a coffee can. It doesn’t do anything,” said Moore.

Any global settlement with Purdue and other opioid manufacturers would need to be at least $100 billion to seriously address the opioid crisis, Moore said.

Even as Purdue has cut back its sales force and has been spending on harm reduction, it continues to promote prescribing of opioids.

From 2012 to 2017, for example, Purdue gave $4.15 million in funding to patient advocacy organizations and professional societies such as the Academy of Integrative Pain Management and the American Academy of Pain Medicine, a recent U.S. Senate investigation found. Many of the groups, in turn, issued statements and guidelines that minimized the risk of long-term use of opioids to treat chronic pain, according to the Senate’s report.

In 2007, Purdue pleaded guilty in federal court to misleading doctors and patients about OxyContin’s risk of addiction and potential for abuse, and agreed to pay $600 million in fines. The period under investigation, however, ended in mid-2001. Since then, Josephson said, Purdue has learned from its past mistakes and has an excellent track record. “We as a company have been addressing prescription drug abuse for 15 years,” said Josephson.

Thus far, critics note, Purdue’s efforts have not included methods that would significantly reduce or limit sales of OxyContin, the company’s blockbuster high-dose opioid drug. In statements about opioid misuse, for example, Purdue avoids the use of the term “addiction” and instead focuses on “abuse” of drugs.

“There’s a real sense that they’re saying, ‘We’re not the drivers of the problem, the addicts are the drivers of the problem. We're going to try to help, but really it’s the addicts and the people trafficking in this illegally that are the problem,’” said W. Timothy Coombs, a professor of crisis communications at Texas A&M University.

Said Adriane Fugh-Berman, who studies pharmaceutical marketing practices at the Georgetown University Medical Center: “If they were really sincere, they would be looking for ways to sell fewer opioids. We’re not seeing that.”

Patients Overpay For Prescriptions 23% Of The Time, Analysis Shows

KFF Health News, March 14, 2018

The practice of charging a copay that is higher than the full cost of a drug is called a 'clawback' because the middlemen that handle drug claims for insurance companies essentially 'claw back' the extra dollars from the pharmacy.

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

By Sydney Lupkin

[UPDATED at 6:45 p.m. ET on March 13]

As a health economist, Karen Van Nuys had heard that it’s sometimes cheaper to pay cash at the pharmacy counter than to put down your insurance card and pay a copay.

So one day, she asked her pharmacist how much her prescription would cost if she didn’t use her health coverage and paid cash.

“And sure enough, it was [several dollars] below my copay,” Van Nuys said.

Van Nuys and her colleagues at the University of Southern California Schaeffer Center for Health Policy & Economics decided to launch a first-of-its-kind study to see how often this happens. They found that customers overpaid for their prescriptions 23 percent of the time, with an average overpayment of $7.69 on those transactions.

The USC study, released Tuesday, analyzed the prices that 1.6 million people paid for 9.5 million prescriptions in the first half of 2013, based on data from Optum Clinformatics, an organization that sells anonymized claims data for analysis, and National Average Retail Price (NARP) data, which contained drug prices paid by insurers and was based on a national survey of pharmacists.

It showed that the overpayments totaled $135 million during that six-month period.

The practice of charging a copay that is higher than the full cost of a drug is called a “clawback” because the middlemen that handle drug claims for insurance companies essentially “claw back” the extra dollars from the pharmacy. (The middlemen, known as pharmacy benefit managers, include Express Scripts, CVS Caremark and OptumRx. Express Scripts and CVS Caremark say they don’t use clawbacks. OptumRx declined immediately to comment.)

Here’s how it works: After taking your insurance card, your pharmacist says you owe a $10 copay, which you pay, assuming that the drug costs more than $10 and your insurance is covering the rest. But unbeknownst to you, the drug actually cost only $7, and the PBM claws back the extra $3. Had you paid out-of-pocket, you would have gotten a better deal.

Until Van Nuys and her colleagues went digging, no one knew how common the practice was.

“Clearly this is going on [at a] much higher frequency than most people imagine,” said Geoffrey Joyce, who directs health policy at the center and was a coauthor on the study. “You’re penalizing people for having insurance.”

See Kaiser Health News chart at this link.

The findings cover only a small portion of the population over a short time span, so they might not be perfectly reflective of what’s going on nationally, Joyce said. But they debunk the perception that clawbacks are rare.

Steve Hoffart, who owns Magnolia Pharmacy, an independent compounding and retail pharmacy in Magnolia, Texas, said clawbacks are still happening — even though Texas legislators passed a law to prohibit them. Hoffart said he collects and sends $1,100 or $1,200 a month in clawbacks to the PBMs.

The National Community Pharmacists Association, of which Hoffart is a member, said the new research “is illustrative of just one of many ways that PBMs’ lack of transparency disadvantages pharmacy patients. … If you want to reduce prescription drug costs, policymakers must demand greater transparency from PBMs.”

The trade group for the PBMs, the Pharmaceutical Care Management Association, said that overall the PBMs bring down the total cost of prescription drugs, lowering costs for patients and insurers.

“We support the patient paying the lowest price available at the pharmacy counter,” the group said in a statement.

The USC researchers found that brand-name drugs had the highest clawbacks — an average overpayment of $13.46 per prescription. Clawbacks on generic drugs were $7.32, on average. The drug with the most frequent clawbacks was zolpidem tartrate — generic Ambien, a drug used to treat insomnia.

Although the research team was able to obtain copay data, it didn’t have data on what the PBMs paid for the drugs, said Van Nuys, the lead study author and executive director of the Schaeffer Center’s life sciences innovation project. As a stand-in, the reserachers used the National Average Retail Price data, which existed for a short period in 2013. They included clawbacks only of $2 or more.

Sometimes, the clawbacks are stunning. The day before Hoffart testified in favor of Texas’s new anti-clawback law, a patient was charged a $42.60 copay for a generic version of simvastatin, a statin drug. The patient could have paid $18.59 out-of-pocket, and the clawback was $39.64, Hoffart said, adding that the clawback made him lose money on the transaction.

Patients often aren’t told they could pay less without using insurance unless they ask.

“If they don’t ask, they’re not going to get the information they need,” Hoffart noted.

But even then, some insurance plans prohibit pharmacists from telling patients due to gag clauses. Six states have prohibited the gag clauses and 20 more are considering similar legislation, according to the National Conference of State Legislatures.

A Battered Doctor, A Slain Patient And A Family's Quest For Answers

KFF Health News, March 13, 2018

A Battered Doctor, A Slain Patient And A Family’s Quest For Answers

By Brian Rinker

BAKERSFIELD, Calif. — The police report is all David Cole Lang’s family has to describe his last moments on Earth.

Fifty pages of officer narratives and witness interviews filled with grisly detail, it lacks any explanation for his death. Ten months later, Lang’s widow, Monique, says she still has no clue as to why the 33-year-old combat veteran and father who struggled with opioid addiction ended up fatally shot by a doctor whom — as far as Monique knew — he hadn’t seen in over a year.

“I didn’t understand why he was there,” she said. “I still don’t.”

On that April evening last year, according to interviews in the report, Lang yelled and cussed at the addiction and pain treatment doctor, Edwin Zong, in his office, and leapt across a desk to punch him repeatedly. Hearing the doctor scream for help, the last patient waiting to see Zong that day ran to open the door. He told police he found Lang standing over Zong, curled in a fetal position on the floor, his face covered in blood and “the fear of a child in his eyes.”

“Hey!” the patient yelled.

When Lang turned toward the doorway, Zong told police, the doctor opened a desk drawer and grabbed a handgun. He fired three or four times. One bullet tore through the blood vessels in Lang’s neck. He staggered outside, collapsed in a parking lot and died.

Local authorities concluded that Zong had acted in self-defense, and he faced no charges. In an email to Kaiser Health News, the doctor declined a request for an interview but said he believes he was targeted for robbery. “I was lucky I wasn’t killed,” he wrote. “Treating addiction is a very tough job, many doctors won’t do it.”

The tragedy that played out in Zong’s office speaks to a dangerous trend: In many parts of the United States, the number of people addicted to opioids far exceeds the capacity of doctors willing and authorized to treat them. That is particularly true when it comes to professionals like Zong who dispense Suboxone or Subutex, both formulations of buprenorphine — widely considered the optimal addiction treatment because it all but erases opioid withdrawal symptoms without creating a significant high.

With tens of thousands of Americans dying annually from opioid overdoses, the Food and Drug Administration recently signaled that it is open to expanding the number of drugs available to ease withdrawal and reduce cravings, but access to prescribers remains a problem even for the drugs that already exist.

One reason for the shortage of providers is that doctors must take eight hours of training to prescribe the medication and apply for a waiver from the federal Drug Enforcement Administration, because the medicine is itself an opiate. Few doctors are willing to check all those boxes and take on the sometimes difficult patients who seek the drug.

Patients addicted to heroin or prescription opioids like oxycodone or fentanyl suffer severe withdrawal — sweats, tremors, anxiety — and are often desperate for medication-based treatment to wean them from the drugs or at least quell their symptoms. For the cash-strapped patients, the cheaper the better.

Doctors who accept these patients, whether motivated by profit or compassion, can become overwhelmed, seeing far more than their offices can handle, opening the door to chaos and lawlessness. More problematic is that some clinics, like Zong’s, offer a mix of services — treatment for both opiate addiction and pain. Patients being prescribed potentially dangerous narcotics are mixed in the waiting area with those struggling to kick addiction.

Several years ago in Vermont, which pioneered buprenorphine treatment, some small practices rapidly swelled to 600 or 700 patients each, said Dr. Richard Rawson, an experienced addiction researcher at the University of Vermont. Doctors sometimes prescribed more than their authorized limit, failed to test patients for drug abuse and — wittingly or not — fostered illegal sales, Rawson said.

“We know that when you have those types of practices where you bring large numbers of addicted individuals together it produces a mess,” he said. “People are selling drugs in the parking lot and all kinds of wacky stuff like that.”

Inevitably, some patients relapse. Some become angry if they don’t get what they came for. A solo practitioner like Zong — who by many accounts had few employees, a tendency to work late on his own and a high cash intake — faces security risks.

Zong was concerned enough to stow a gun in his desk drawer.  “I keep a gun in my office for self-protection,” he said in his email.

Long Lines, Short Appointments

In California, demand for buprenorphine has only grown with the opioid epidemic and recent changes to Medi-Cal, the state’s Medicaid program, which have made it easier and quicker for low-income people to get the drug. The program was expanded under the Affordable Care Act to cover more adults (3.8 million) and more drug treatment.

In addition, beginning in June 2015, doctors were no longer required to get prior approval from the Medicaid program each time they prescribed buprenorphine.

Within seven months, claims jumped 100 percent, according to the state.

Zong, an osteopathic physician who had trained in internal medicine in New York, opened his Bakersfield practice in 2007. Situated next to a marijuana dispensary, it was a one-stop shop for pain management, addiction treatment and acupuncture. Though Zong’s medical training didn’t focus on those areas, he had the necessary DEA waiver to prescribe buprenorphine by 2010, records show.

Zong had a reputation for writing scripts, cheap and fast, according to numerous interviews with former patients, drug treatment professionals and pharmacy employees in the area. Lines of sometimes-agitated patients stretched from the waiting room into the parking lot, the street and the dirt lot across the road, patients and neighbors said.

If the wait was lengthy, the appointments weren’t, the patients said.

“When I walked in the first time,” said Brian Adams, a former patient, “[Zong] said, ‘What’s going on?’ I said, I’m a heroin addict. I need help. He said ‘OK, I’ll write you a prescription for Suboxone.’”

No intake. No drug testing. No counseling. “I was in and out in five minutes,” Adams said.

The price for the visit ranged from $80 to $100 cash to secure the medicine, patients said — far cheaper than anywhere nearby.

Federal regulators say buprenorphine should be “part of a comprehensive treatment plan that includes counseling and participation in social support programs.”

There was an option like that within a few miles of Zong’s office: Aegis Treatment Centers, which runs opioid treatment clinics closely regulated by the government. The clinics required services including intake, urine testing and counseling for opioid treatment.

From a hard-up patient’s perspective, Aegis had another downside: It had not yet been approved to accept Medi-Cal for buprenorphine, which was dispensed on-site as take-home pills. The range of services and medication costs nearly $700 for those without insurance, although a limited number of discounts are available to the poor.

Zong’s Medi-Cal patients had it easier: Their freshly issued scripts were covered at local pharmacies.

Anger And Suspicion

Zong had good reasons to be concerned about security. He’d had a handful of break-ins at the clinic, his vehicle and home — one recently, according to the police report.

At some point, he became licensed to carry and conceal a firearm. Adams said he once saw him pull it out when Adams got confrontational.

Angry that Zong wouldn’t prescribe him an anti-anxiety medication, “I stood up and was like ‘Man, [expletive] you,’” Adams said. Zong pulled out his gun and placed it on the table in front of him, Adams said, and he quickly sat back down.

Patients and pharmacists said Zong sometimes did add addictive anti-anxiety drugs like Xanax to buprenorphine prescriptions for people presumably seeking to escape addiction. Besides creating the potential for further drug abuse, the combination can be deadly, experts say.

Records of Medi-Cal claims obtained by Kaiser Health News show that, in addition to treating patients with buprenorphine, Zong prescribed significant amounts of highly addictive opioids, including oxycodone and hydrocodone, as well as habit-forming anti-anxiety medications. They do not show what combinations of drugs were offered each patient.

Staffers at three pharmacies in the area said they were concerned about peculiarities in Zong’s prescriptions or drug-seeking behavior among his patients.

Myron Chang, a pharmacist at the Walgreens at H Street and Planz Road in Bakersfield, said Zong’s prescriptions “were suspicious.” Staffers noticed odd quantities of pills prescribed — 43, 46, he said. Usually, doctors call for 30 or 60 to match a daily dose for a 30-day month, Chang said.

Chang added that Zong’s scripts sometimes included a potentially dangerous cocktail of sleeping pills, narcotics and anti-anxiety medications. He showed a reporter one of Zong’s 2013 prescriptions for Subutex and Xanax.

“We just stopped taking his scripts,” Chang said.

Not The Same Man

After the killing, police found a ski mask, a black hoodie and a recently used meth pipe in Lang’s car, according to their report. Witnesses reported to police that Lang came into the offices saying “something about money” or that he was “waiting on his money.”

Court records show he had pleaded no contest for misdemeanor burglary in 2014 and served three days in jail.

Lang’s family is skeptical that Lang was trying to rob Zong. They acknowledge, however, that he was not the man he used to be.

When Monique met Cole, as he was called, she was still in high school. He was an outgoing and funny 19-year-old, with beautiful green eyes and a sharp wit. In short order, they married and he shipped out to Iraq. Then came two more tours, in Iraq and Afghanistan. One explosion, then another, nearly killed him.

When he came home to his wife and baby daughter, he “was a lot different, especially around family functions,” said Monique Lang. He wouldn’t want to go, and if he did, he was quiet and remote. “I was like, ‘This isn’t you. What is going on?’ He never would say.”

In 2009, after Monique discovered money missing from the couple’s bank account, her husband came clean: He was hooked on opioids. From then on, it was a roller coaster of pills, heroin and rehab. In the middle of it all, they had a son, now 4.

Lang’s family said the former Marine was in constant pain, physically and mentally. He had a severe back injury. He screamed in his sleep. His daughter, now 10, would sleep on the couch downstairs, to escape the sound.

He secretly wrote suicide notes to his wife and kids.

Zong told reporters the day after the shooting that he did not remember seeing Lang before. But the family told police he was seen on occasion between 2012 and 2015, according to their report, and that he received Suboxone for opioid addiction.

In an interview, Monique Lang said she once accompanied Cole to an appointment. She didn’t like the atmosphere, she said, and didn’t understand how taking a medication with no other services would help her husband.

But that was history — or so the family thought. By last April, they believed Lang was sober, getting the support he needed at Aegis.

Another Clinic ‘Overwhelmed’

Zong told police he performed one final task on his clinic’s last day, with Cole Lang dying outside on the asphalt and squad cars en route: He wiped the blood from his battered face and agreed to write his remaining patient a prescription.

Although Zong — who also goes by the name Yon Yarn — remains licensed to practice with an unblemished osteopathic board record, he says he will not reopen his practice.

His departure created chaos as desperate people dependent on his prescriptions struggled to get help elsewhere.

“We were overwhelmed,” said Javier Moreno, regional clinic manager at Aegis. “We probably fielded a hundred, 200 calls from patients who were panicking — ‘I’m worried about relapse.’ ‘I don’t know what to do.’ ‘My prescription is expiring.’”

Even months after Cole Lang’s death, neighbors said patients still showed up at Zong’s door, with the scrawled “Closed” sign on it, hoping to find that the doctor was in.

Medicaid Is Rural America's Financial Midwife

KFF Health News, March 12, 2018

Medicaid payments allow struggling hospitals to maintain vital costly services such as maternity care.

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

By Shefali Luthra

ZANESVILLE, Ohio — Brianna Foster, 23, lives minutes away from Genesis Hospital, the main source of health care and the only hospital with maternity services in southeastern Ohio’s rural Muskingum County.

Proximity proved potentially lifesaving last fall when Foster, pregnant with her second child, Holden, felt contractions at 31 weeks — about seven weeks too soon. Genesis was equipped to handle the situation — giving Foster medication and an injection to stave off delivery. After his birth four weeks later – still about a month early, at 5 pounds 12 ounces — Holden was sent to the hospital’s special care nursery for monitoring.

Mother and son went home after a few days. “He was pretty small — but he’s picking up weight fast,” said Foster of Holden, now almost 4 months old.

Medicaid, the federal-state health insurance program for low-income people — including Foster, who most recently worked as a preschool teacher’s aide — is responsible for much of her good fortune.

Started in 1965, the program today is part of the financial bedrock of rural hospitals like Genesis. As treatments have become increasingly sophisticated — and expensive — health care has become inextricably linked to Medicaid in rural areas, which are often home to lower-income and more medically needy people.

Kaiser Health News is examining how the U.S. has evolved into a “Medicaid Nation,” where millions of Americans rely on the program, directly and indirectly, often unknowingly.

Medicaid covers nearly 24 percent of rural, nonelderly residents and offers some financial stability to rural facilities by reducing uncompensated care costs at hospitals that would otherwise be in dire straits. In some cases, it enables them to provide costly but vital services, such as high-risk maternity care.

Medicaid pays the tab for close to 45 percent of all U.S. births annually, and about 51 percent of rural births, according to research. In Ohio, Medicaid pays for about 52 percent of births, according to 2016 state data, the most recent available.

But efforts to control Medicaid costs are consistently high on Republicans’ to-do list. The Trump administration has encouraged states to introduce work requirements and other changes to Medicaid — changes that would almost certainly reduce the number of people it covers and the money rural hospitals receive. Ohio lawmakers have recently signaled they intend to require that Medicaid enrollees also be employed.

Matthew Perry, Genesis’ CEO, who identifies as conservative and finds plenty of fault in Obamacare, is concerned about high government spending. But he acknowledges that cuts to Medicaid would be deeply problematic for his hospital, affecting what services it can afford to provide. Perry keeps a map in his office to track local options for medical care, and the next-closest OB ward is an hour away in Columbus. What happens, hypothetically, if you take Genesis Hospital off the map?

“That’s a huge problem,” he said.

Squeezed Hospitals, Cutting Costs

Like many rural hospitals Genesis is this area’s health care hub, the access point for primary care as well as mental health care, routine surgeries and other medical needs.

It is also central to the local economy.

Here in Zanesville, population 25,000, it seems as if almost everybody knows someone employed by the hospital.

Main Street is quiet — a stretch of scattered restaurants and pubs, county buildings and churches. Ten minutes away, across the river, Genesis anchors a stretch that would otherwise claim little more than fast-food chains, used car dealerships and cellphone shops.

This hospital, the flagship of a larger Ohio health system, is the product of a 2015 merger of two older town hospitals: Bethesda and Good Samaritan. Its 300 beds are the main source of health care across six counties — a quarter million people — and it delivers 1,500 babies per year.

Ask a woman in town where she would plan to deliver, and the answer is practically a given: Genesis, of course. Locals say it’s hard to conceive of a reality in which the hospital didn’t deliver babies.

In recent years, it’s also doubled down on other services, like cancer care, neurosurgery and open-heart surgery — which experts say can cushion a rural hospital’s bottom line, even if need isn’t as great.

Still, hospitals like Genesis often struggle with tight budgets and regular debates about whether cash flow can continue to support certain types of services. Rural hospitals have seen a sharp decline in the past decade. Nationally, 80 have closed since 2010 and the trend is expected to continue.

“When rural hospitals are squeezed, they have to look at what fixed costs they can shed,” said Katy Kozhimannil, an associate professor at the University of Minnesota School of Public Health, who studies obstetrics access. “The fixed costs of providing obstetrics services are very clear, and very distinct.”

Obstetrics requires pricey specialists, expensive malpractice insurance and, in the 21st century, the capacity to deal with extreme preemies and high-risk deliveries. At the same time, Medicaid reimburses hospitals less for this service— often below the cost of the care — than any other insurance program, making it a balance-sheet loss.

Already, about 45 percent of rural communities do not have a hospital with dedicated maternity care. From 2004 to 2014, almost 1 in 10 rural counties lost their hospital-based obstetrics programs, suggests research published last fall.

In Ohio, nine rural hospitals have dropped obstetrics since 2007 — including one that closed. The state currently has 73 small and rural hospitals in operation.

“We’ve seen a slow erosion of obstetrics in rural areas,” said Michael Topchik, national leader of the Chartis Center for Rural Health, an analytics and consulting firm. “And I’m afraid that further [Medicaid] cuts would exacerbate that trend.”

That scenario is part of the reason why rural health advocates have fiercely criticized GOP efforts at the federal and state level to cut Medicaid or to eliminate the Affordable Care Act’s option for states to expand eligibility for the program.

Research suggests that states’ expansion of Medicaid eligibility led to greater financial stability for rural hospitals. Also, more generous Medicaid coverage increases the odds that rural areas have any kind of obstetrics program.

Potential cutbacks offer a complicated calculation in this conservative town, with practical considerations bumping into politics.

“Things like trauma and obstetrics and behavioral medicine … they’ve got to be subsidized by other, more profitable things,” said Perry, the hospital CEO. “You can’t repeal the laws of economics.”

Still, Muskingum County backed Donald Trump over Hillary Clinton by more than 2-to-1. Its most recent congressional representative, Republican Pat Tiberi, was a vocal Obamacare critic who, until an early retirement this past January, consistently voted to repeal the ACA and pushed efforts to reduce Medicaid’s size and scope.

A Public Health Concern

When pregnant women are geographically farther from health care, they and their babies are more likely to have poor outcomes, like lower birth weights, research suggests.

Foster said that if she had to travel to Columbus, she likely would not have made as many prenatal appointments. Each visit means scrounging up gas money and finding someone to watch her older son for at least three hours.

“It’s obvious that better prenatal care means better outcomes,” said Bijan Goodarzi, an OB-GYN at Muskingum Valley Health Center, a Genesis affiliate about a five-minute drive from the hospital.

And without an operational delivery unit, hospitals are unlikely to keep on staff obstetricians who are experienced in complicated births, experts said.

Keeping rural maternity services open with Medicaid funding also engages new mothers with the local health system in regions with high rates of chronic illness, drug addiction and smoking. The national opioid epidemic is acute in this corner of Ohio.

“What we see is someone who comes in with no teeth, or all rotted teeth or can’t eat. And she’s not complaining about dental work. She’s here worried about her pregnancy,” Goodarzi said.

Even as Obamacare repeal appears on pause, Medicaid remains vulnerable. In Ohio, many state lawmakers are pushing a cap on the state’s expanded Medicaid program — a controversial move that would almost certainly squeeze hospital revenue. Nationally, Republican leaders are weighing cuts to Medicaid, Medicare and other safety-net programs.

“If you pull too many of those foundational blocks out of the system that support the safety net … it can crumble,” said Perry, who worries about the effect of such cuts. “People can assume something’s always going to be there, when in reality, that assumption is not always true.”

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