With federal officials seemingly unwilling or unable to come up with legislation to control skyrocketing drug prices, that task is increasingly moving to the states. But so is pharma muscle and money opposing the measures.

This article first appeared February 01, 2018 on Kaiser Health News.

By Jay Hancock and Shefali Luthra

It was expected to be a perfunctory statehouse meeting — three lobbyists and a legislator discussing a proposal to educate Louisiana doctors about the price of drugs they prescribe.

The bill seemed like a no-brainer in a country where even decades-old medicines can cost thousands and consumers are urged to make smart choices in buying health care. The legislation simply required pharmaceutical sales reps promoting medicines at doctors’ offices to also reveal a price.

No one expected the industry scrum that materialized.

About 10 pharma lobbyists flooded the room in Baton Rouge’s art deco state Capitol, some of them hired guns — lobbyists who’d never represented drug companies before, remembers Jeff Drozda, an insurance lobbyist at the 2016 meeting.

“The message was: We’re going to bring everything at you against these bills,” he said.

They did. Pharmaceutical Research and Manufacturers of America, the powerful trade group known as PhRMA, donated directly to more lawmakers in Louisiana than in any other state in 2016, a new IRS filing shows. When discussion of the measure reached its peak last year, the industry hired a lobbyist for every two legislators.

PhRMA spent thousands entertaining lawmakers at Baton Rouge venues such as Mike Anderson’s Seafood, specializing in shrimp-and-crab gumbo, and the Mestizo Restaurant, home of the Daredevil Margarita, lobbying records show.

“I’ve been in the legislature 10 years. I’ve never in my life seen that kind of effort,” said Kirk Talbot, a Republican who sponsored the bill in the Louisiana House.

With federal officials seemingly unwilling or unable to come up with legislation to control skyrocketing drug prices, that task is increasingly moving to the states. But so is pharma muscle and money opposing the measures, regulatory disclosures and corporate filings from the last two years show.

State lawmakers are likely to consider drug-price transparency bills this year in Connecticut, Michigan, Oregon, Washington and New Jersey, to name just a few. Many of the measures are similar to a new California law that requires drugmakers to justify big price increases. (To fight that law, the industry hired 45 lobbying firms.)

Meanwhile, activists who backed a 2017 law enabling Maryland officials to challenge “unconscionable” price increases for generic drugs now advocate price regulation for all expensive pharmaceuticals. Policymakers in New Mexico, Massachusetts and Arizona are talking about limiting drug coverage or negotiating drug prices under Medicaid.

In Washington, D.C., PhRMA, is widely credited with stalling federal drug-price measures for years, with lobbying, advertising and political contributions.

Now states are getting a dose of the same medicine.

PhRMA set the stage in 2016 by establishing a group that ultimately spent $110 million to defeat a high-profile California ballot initiative requiring state agencies to pay no more for drugs than does the federal Department of Veterans Affairs. A PhRMA-linked group spent more than $50 million to defeat a similar ballot measure last year in Ohio.

Traditionally well represented in statehouses, PhRMA wrote checks to hundreds of legislative candidates and political action committees in dozens of states in 2016, newly available IRS filings show. So did many of its member companies, according to new data published by the Center for Political Accountability, a nonprofit that works to shed light on corporate political spending.

Merck, maker of a hepatitis C drug called Zepatier that costs $54,600 according to Truven Health Analytics, gave $19 million to PhRMA in 2016 but also gave about $500,000 to candidates and political committees in some two dozen states, sometimes in checks as small as $100, according to the CPA data, compiled from voluntary disclosures on corporate websites.

Amgen, maker of leukemia drug Blincyto, which costs $173,000 for an average treatment, according to the company, donated to more than 100 statehouse candidates in about a dozen states for the 2016 elections. Johnson & Johnson, Pfizer, Bristol-Myers Squibb and Allergan also directly or indirectly supported state candidates in 2016, CPA data show.

Pharma companies “definitely have not seen that kind of activity aimed at them at the state level before and have raised their presence to address that,” said Leanne Gassaway, top state lobbyist for America’s Health Insurance Plans, a major insurance trade group.

Few states got as much pharma attention the past two years as Louisiana, though the money spent there fell short of the tens of millions invested in swaying referenda in California and Ohio. It’s cheaper to influence scores of lawmakers than millions of voters.

I’ve been in the legislature 10 years. I’ve never in my life seen that kind of effort.

Drug prices are “something that’s completely out of control,” Talbot said, adding that he gets constituent requests to rein in prescription medicine prices.

Neither Talbot, chairman of the House insurance committee, nor many others in the conservative state are moving to regulate drug prices. But he and other lawmakers saw promise in an idea from Blue Cross and Blue Shield of Louisiana, a big insurer whose premiums have been driven up partly by rising drug expenses.

The proposal, which got little news coverage even in Louisiana, would have required sales reps promoting their latest, greatest medicines to give doctors the wholesale prices at the same time. Physicians, who are largely unaware of prescription costs, might think twice about ordering $500 worth of brand-name pills when a $30 generic could deliver the same benefit, the thinking went.

The measure died in committee after the pharma lobby staged its flash mob at the 2016 meeting. When the idea came up again last spring, this time with backing from Talbot and Sen. Fred Mills, Republican chairman of the Senate health committee, the industry shifted into high gear.

Mills got “a tremendous amount of calls” on his cellphone from pharma lobbyists as well as emails and texts almost immediately after his bill landed on a legislative website, he recalled. First in line was Pete Martinez, PhRMA’s top Louisiana operative.

“I’ve had this volume” of special-interest pressure “but not the speed,” said Mills, a small-pharmacy owner from St. Martin Parish who said he sees the rising price of pills firsthand. Mills recalled phone calls from “top government affairs people” at Pfizer, “telling me the problems with this bill.”

No fewer than 84 lobbyists representing pill companies blanketed Baton Rouge at the height of the legislative session last year, state records show — the most in at least nine years.

In 2016, PhRMA gave directly to about 80 Louisiana state politicians, more than those in any other state, the IRS filing shows. PhRMA and individual drug companies have made more than $600,000 in contributions to Louisiana state and local political races in the past three years, according to campaign finance files.

Martinez did not respond to requests for an interview. At hearings in Louisiana, PhRMA argued that informing doctors of wholesale drug prices is irrelevant to patients. What matters is consumers’ out-of-pocket payment, not the rest of the cost that’s often picked up by insurance, they said.

“We are committed to engaging with lawmakers, patients and others to find solutions that actually help patients,” a PhRMA spokesman said in a statement for this article.

Proponents countered that rising total drug costs are an increasingly painful burden on taxpayers, employers, workers and everybody else who pays them indirectly through insurance plans and government programs.

PhRMA’s opposition had an effect.

Instead of making salespeople disclose prices, the legislation that lawmakers eventually passed and that Gov. John Bel Edwards signed in June requires the Louisiana Board of Pharmacy to host a website listing the information. Rather than ordering drug reps to tell doctors about the site, the act says they “may” give prescribers the internet address if they choose.

The law “is quite watered-down and basically meaningless,” said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School who follows pharma laws.

Talbot says he may have lost this battle but will continue the war.

“I’m going to take another stab at it” this year, he said. “We’re on the front wave of this thing. All the states are jumping on this bandwagon.”

For more than 50 years, the program for the poor and sick has been required to ferry certain clients to and from medical appointments. But a few states have sought - and received - waivers to that rule.

This article first appeared January 29, 2018 on Kaiser Health News.

By JoNel Aleccia
Photos by Heidi de Marco

EVERETT, Wash. — Unable to walk or talk, barely able to see or hear, 5-year-old Maddie Holt waits in her wheelchair for a ride to the hospital.

The 27-pound girl is dressed in polka-dot pants and a flowered shirt for the trip, plus a red headband with a sparkly bow, two wispy blond ponytails poking out on top.

Her parents can’t drive her. They both have disabling vision problems; and, besides, they can’t afford a car. When Maddie was born in 2012 with the rare and usually fatal genetic condition called Zellweger syndrome, Meagan and Brandon Holt, then in their early 20s, were plunged into a world of overwhelming need — and profound poverty.

“We lost everything when Maddie got sick,” said Meagan Holt, now 27.

Multiple times each month, Maddie sees a team of specialists at Seattle Children’s Hospital who treat her for the condition that has left her nearly blind and deaf, with frequent seizures and life-threatening liver problems.

The only way Maddie can make the trip, more than an hour each way, is through a service provided by Medicaid, the nation’s health insurance program started more than 50 years ago as a safety net for the poor.

Called non-emergency medical transportation, or NEMT, the benefit is as old as Medicaid itself. From its inception, in 1966, Medicaid has been required to transport people to and from such medical services as mental health counseling sessions, substance abuse treatment, dialysis, physical therapy, adult day care and, in Maddie’s case, visits to specialists.

“This is so important,” said Holt. “Now that she’s older and more disabled, it’s crucial.”

More than 1 in 5 Americans — about 74 million people — now rely on Medicaid to pay for their health care. The numbers have grown dramatically since the program expanded in 32 states plus the District of Columbia to cover prescription drugs, health screening for children, breast and cervical cancer treatment and nursing home care.

With a Republican administration vowing to trim Medicaid, 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’s role in transportation is a telling example. Included in the NEMT coverage are nearly 104 million trips each year at a cost of nearly $3 billion, according to a 2013 estimate, the most recent, by Texas researchers.

Citing runaway costs and a focus on patients taking responsibility for their health, Republicans have vowed to roll back the benefits, cut federal funding and give states more power to eliminate services they consider unaffordable.

Already, states have wide leeway in how to provide and pay for the transportation.

Proponents of limiting NEMT say the strategy will cut escalating costs and more closely mirror private insurance benefits, which typically don’t include transportation.

They also contend that changes will help curb what government investigators in 2016 warned is “a high risk for fraud and abuse” in the program. In recent years, the Centers for Medicare & Medicaid Services (CMS) reported that a Massachusetts NEMT provider was jailed and fined more than $475,000 for billing for rides attributed to dead people. Two ambulance programs in Connecticut paid almost $600,000 to settle claims that they provided transportation for dialysis patients who didn’t have medical needs for ambulance transportation. And the mother of a Medicaid patient who was authorized to transport her child for treatment billed Medicaid for trips that didn’t take place. She was sentenced to 30 days in jail and ordered to pay $21,500.

Last March, Rep. Susan Brooks, an Indiana Republican, introduced a resolution that would have revoked the federal requirement to provide NEMT in an effort to provide states with “flexibility.” That effort stalled.

Another Republican proposal in 2017 would have reversed the Affordable Care Act’s Medicaid expansion and reduced federal funding for the NEMT program. It failed, but other efforts by individual states still stand.

Former Health and Human Services Secretary Tom Price and CMS Administrator Seema Verma encouraged the nation’s governors to consider NEMT waivers, among other actions, in a March letter to them.

“We wish to empower all states to advance the next wave of innovative solutions to Medicaid challenges,” they wrote. The Trump administration has used state waivers to bypass or unravel a number of the Obama administration’s more expansive health policies, and has granted some states’ requests.

At least three states, Iowa, Indiana and Kentucky, have received federal waivers — and extensions —allowing them to cut Medicaid transportation services. Massachusetts has a waiver pending.

Critics of the cuts worry the trend will accelerate, leaving poor and sick patients with no way to get to medical appointments.

“I wouldn’t be surprised to see more of these waivers in the pipeline,” said Joan Alker, executive director of the Georgetown University Center for Children and Families.

Because medical transportation isn’t typically covered by the commercial insurance plans most Americans use, it’s unfamiliar to many people and could be seen as unnecessary, said Eliot Fishman, senior director of health policy for Families USA, a nonprofit, nonpartisan consumer health advocacy group.

Formerly a Medicaid official in the federal government, Fishman called the transportation program “vital” not only for children with severe disabilities, but also for non-elderly, low-income adults.

CMS released results of a 2014 survey of Medicaid users, which found that lack of transportation was the third-greatest barrier to care for adults with disabilities, with 12.2 percent of those patients reporting they couldn’t get a ride to a doctor’s office.

“This is not something to be trifled with lightly,” Fishman said. “We’re talking about a lifesaving aspect of the Medicaid program.”

About 3.6 million Americans miss or delay non-emergency medical care each year because of transportation problems, according to a 2005 study published by the National Academy of Sciences.

That same study analyzed costs for providing NEMT to patients facing 12 common medical conditions and found that providing additional transportation is cost-effective. For four of those conditions — prenatal care, asthma, heart disease and diabetes — medical transportation saved money when the total costs for both transportation and health care were tallied.

Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation, whether that’s taxis, vans or public transit.

Most states rely on NEMT brokers or managed-care organizations to administer the transportation services. Other states run the service directly, paying providers on a per-ride basis, while some use local ride services and pay independent taxi firms to shuttle patients.

Proponents of revamping NEMT note that disabled children like Maddie and other people with serious disabilities are in little danger of losing services. In Iowa and Indiana, Medicaid transportation remains available to several groups of patients, including those classified as “medically frail,” though the definition of who qualifies can vary widely.

In addition, one managed-care provider, Anthem, continues to transport Indiana Medicaid patients, despite the waiver that was first enacted in 2007.

Still, Medicaid clients like Fallon Kunz, 29, of Mishawaka, Ind., are often stuck. Kunz, who has cerebral palsy, migraine headaches and chronic pain, uses a power wheelchair. When she was a child, she qualified for door-to-door service to medical appointments, she said.

Today, she lives with her father, whose home is outside the route of a Medicaid transit van. Getting to and from medical appointments for her chronic condition is a constant struggle, she said. Taxis are too expensive: $35 each way for a wheelchair-enabled cab.

We’re talking about a lifesaving aspect of the Medicaid program.

“The only way I can get rides to and from my doctor’s appointment is to ride the 2 miles in my wheelchair, despite all kinds of weather, from my home, across the bridge, to the grocery store,” she said. “Right outside the grocery store is the bus stop. I can catch the regular bus there.”

Sometimes, she’s in too much pain or the Indiana weather — warm and humid in the summer, frigid and windy in the winter — is too much to battle and she skips the appointment.

“Today I didn’t go because it was too cold and my legs hurt too much,” she said on a December Tuesday. “I didn’t feel like getting blown off the sidewalk.”

In Maddie Holt’s case, she was shuttled to Seattle Children’s on a rainy Tuesday morning in a medical van driven by Donavan Dunn, a 47-year-old former big-rig trucker. He works for Northwest Transport, one of several regional brokers that manage NEMT services for Washington state.

Dunn said he received special training to transport patients like Maddie, who is loaded onto a motorized platform, wheelchair and all, into the van and then carefully strapped in.

“I have to drive different,” said Dunn. “I have to watch my corners, watch my starts, watch my stops. It’s always in the back of my mind that I have somebody on board that’s fragile.”

The transportation service can be used only for medical visits to the specialists who treat Maddie’s condition, which is caused by mutations in any one of at least 12 genes. If Meagan Holt needs to pick up prescriptions or get groceries, she leaves Maddie and a second daughter, Olivia, 3, at home with their dad and takes the bus or walks to her destinations.

Caring for a severely disabled child is not the life she expected, Meagan Holt said, but she cherishes time with Maddie, who has learned to communicate through tactile sign language spelled into her hand.

“She knows about 100 words. She knows the alphabet,” Meagan said. “She likes Disney princesses. She loves ‘Frozen.’”

Maddie is one of hundreds of NEMT-eligible children transported to Seattle Children’s each month. Last September, for instance, more than 1,300 clients made more than 3,600 trips at a cost of more than $203,000, according to the Washington Health Care Authority, which oversees the state’s Medicaid program called Apple Health.

The need is so great, in fact, that the hospital created a transportation will-call desk to help organize the comings and goings.

“When we realized how much transportation is a barrier to getting to your appointment, we decided to do something about it,” said Julie Povick, manager of international exchanges and guest services at Seattle Children’s.

“The majority of our patients are in survival mode,” Povick added. “You need a lot of handholding.”

But Verma, the architect of Indiana’s Medicaid overhaul plan, has suggested that too much handholding might be “counterproductive” for patients — and bad for the country.

In a 2016 Health Affairs essay, Verma noted that early analysis of the effects of curtailing NEMT in Indiana showed that more Medicaid patients with access to the program said transportation was a primary reason for missed appointments than did members without access.

“Moreover, 90 percent of [Healthy Indiana Plan] members report having their own transportation or the ability to rely on family and friends for transportation to health care appointments,” she wrote.

But Marsha Simon, a Washington, D.C., health policy consultant who has tracked NEMT for years, said Medicaid is the option of last resort. People who are able to get rides on their own already do.

“If 90 percent can and 10 percent can’t, what about the 10 percent?” Simon said.

It’s a question that haunts Kunz every day.

“I’m a college student, I have a cat,” said Kunz, who is studying psychology online at Southern New Hampshire University. “I’m just a regular human trying to do things, and the inaccessibility in this area is ridiculous.”

Hampered by political ideology from the White House that has spurred a focus on overhauling Medicaid benefits, for instance, Medicaid's former CMO says CMS is 'ill-equipped' right now to handle the opioid epidemic.

This article first appeared January 29, 2018 on Kaiser Health News.

By Emmarie Huetteman

Andrey Ostrovsky’s family did not discuss what killed his uncle. He was young, not quite two weeks past his 45th birthday, when he died, and he had lost touch with loved ones in his final months. Ostrovsky speculated he had committed suicide.

Almost two years later, Ostrovsky was Medicaid’s chief medical officer, grappling with an opioid crisis that kills about 115 Americans each day, when he learned the truth: His uncle died of a drug overdose.

His family knew the uncle’s life had been turbulent for a while before his death, watching as he divorced his wife and became estranged from his 4-year-old daughter and eventually lost his job as a furniture store manager. But Ostrovsky wanted to understand what happened to his uncle, his stepfather’s younger brother. So, last fall when he found himself in southeastern Florida, where his uncle died in 2015, he contacted one of his uncle’s friends for what he thought would be a quick cup of coffee.

Instead the friend “let loose,” revealing that they had been experimenting with a variety of drugs the night his uncle died — the tragic culmination of more than a decade of substance abuse much of his family knew nothing about. An autopsy showed there were opiates and cocaine in his system, Ostrovsky later learned.

The revelation shook Ostrovsky, a pediatrician appointed to the Centers for Medicare & Medicaid Services in 2016. He had championed better drug treatment programs for the 74 million people on Medicaid — an increasingly uphill battle after Republicans signaled they would trim the program under President Donald Trump.

Within his own agency, Ostrovsky already felt that he was something of a pariah. After he’d posted a tweet against a Republican plan to repeal and replace the Affordable Care Act, he was reprimanded and removed from his major projects. A conservative group known as America Rising filed a Freedom of Information Act request for his email correspondence, a move seen as an attempt to intimidate Ostrovsky.

But that revelation over coffee in Florida made the drug crisis deeply personal for Ostrovsky and his family, prompting him to act. He realized that solutions were not just about money, but also about combating stigma, that stain he says prevented his uncle from getting help. So, he quit his government job last month and is speaking publicly about his family’s experience, to remove the shame of drug addiction.

“It’s not what killed him,” Ostrovsky says, referring to the stigma. “But that’s what killed him.”

Last fall, the Trump administration declared the opioid crisis a public health emergency, stopping short of allocating more funding for an “epidemic” that killed more than 42,000 in 2016 — more than any year on record, according to the Centers for Disease Control and Prevention. That declaration was extended last week. Early data indicate 2017 may have outpaced 2016 in drug deaths.

In one of the latest attempts to manage the crisis, Democratic Gov. Tom Wolf of Pennsylvania recently declared the opioid epidemic a statewide disaster emergency. For the first time, Pennsylvania officials will direct emergency resources toward a public health crisis in the same way they would a natural disaster.

The uncle’s story offers an intimate look at a crisis that has vexed officials on the local, state and national level, strained public health resources — and infiltrated not just America’s streets and drug dens, but also workplaces and successful middle-class families like Ostrovsky’s. KHN agreed not to disclose the uncle’s name out of respect for his family’s privacy.

The uncle immigrated to the United States from Azerbaijan when he was 16, seeking a brighter future than the one stretched before him in the crumbling Soviet Union, Ostrovsky recalled. His family settled in Baltimore, where he married and started his own family. When he wasn’t working, he grilled lamb kebabs and danced to music from his home country. He was a warm, welcoming host, insisting guests have at least a cup of tea.

“Even when he had nothing, he would take that last piece of bread and offer it to you,” Ostrovsky says.

To Ostrovsky, he was the “cool uncle,” always bringing his nephew trinkets from his travels. When Ostrovsky was in seventh grade, his uncle returned from Jamaica with a shirt that read: “See no evil, hear no evil, speak no evil, s— happens mon.” Ostrovsky wore it to school — and happily suffered the inevitable punishment. “I love him for that and was proud to get in trouble,” he wrote in an email.

Sometime around the early 2000s, the uncle and his wife divorced. He began drinking more, a vice Ostrovsky attributed in part to his cultural heritage but that he suspects grew into alcoholism.

It is unclear to the family when, exactly, drugs came into his life, though his problems seem to have escalated in his 30s. His drug of choice was cocaine, Ostrovsky learned from his uncle’s friend, who frequently took drugs with him over the years.

His inability to function at work and other financial strains eventually drove him to crack cocaine, an especially addictive, cheaper form that produces an instant, intense high when smoked. Months before his death, he lost his job and grew depressed. He began using more heavily and trying new drugs. He dabbled in benzodiazepines, a class of psychoactive drugs like Xanax and Valium, and opioids.

Opioids, which broadly include both illegal drugs like heroin and prescription painkillers like OxyContin, are particularly perilous when misused because they suppress the ability to breathe. Those who use opioids also build up a tolerance over time, encouraging them to use more to achieve a high. These facts are especially problematic considering street drugs are often cut with more powerful opioids — such as fentanyl, a fast-acting painkiller — to create a more intense high.

Eventually, Ostrovsky’s uncle began living with his drug dealer. On the night of his death, he and his friend went through the dealer’s stash when he was out, trying pills and other drugs. When the dealer returned, after the friend had left, the uncle didn’t answer the door.

They found him on the couch, looking “at peace,” his friend recounted to Ostrovsky. They tried to resuscitate him and called for help. Sitting on the curb outside, his friend watched the paramedics carry him away.

The friend says he quit using drugs and is enrolled in a methadone program, a treatment option that uses another opioid to reduce withdrawal symptoms.

Hampered by political ideology from the White House that has spurred a focus on overhauling Medicaid benefits, for instance, Ostrovsky says his former agency, CMS, is “ill-equipped” right now to handle this problem. So, for now, he’s working outside the government.

This month, Ostrovsky announced he is joining Concerted Care Group, an addiction treatment program based in Baltimore whose patients are mostly covered by Medicaid, where he will serve as CEO as the organization looks to expand.

Ostrovsky first noticed Concerted Care Group when it was part of a CMS pilot program, a standout because it eschewed the surreptitious-feeling grab-and-go approach of most outpatient addiction centers. “This can’t be a methadone clinic,” Ostrovsky thought when he first heard about it.

It offered patients private spaces to take their medicine; security guards to ensure their safety; even coffee while they wait, preserving at least a modicum of patient dignity. In the same spirit, Ostrovsky hopes that sharing his personal story about his uncle will combat the stigma that makes patients and their loved ones ashamed to reach out for help.

“I think this is really important, that people hear about his story and talk,” he says, “and get over that feeling of not wanting to have that uncomfortable conversation with my family member who needs help.”

An unusual number of calamities plagued America's hospitals in 2017: fires in California; hurricanes in Texas, Florida, and Puerto Rico; the deadliest mass shooting in modern history; and even attacks within hospital walls.

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

By Ana B. Ibarra

It was 3:35 a.m. and flames from a massive Northern California wildfire licked at the back of a Santa Rosa hospital.

Within three hours, staffers evacuated 122 patients to other facilities — something they’d never come close to doing before. Ambulances sped off with some of the sickest patients; city buses picked up many of the rest.

With phone lines charred and communication restricted, doctors and nurses struggled to figure out who was sent where — forced to keep their wits even as some of their own homes burned and their families fled.

This was not exactly covered in their meticulously executed drills and disaster-preparedness videos.

“You never know how you’ll react until it comes your way … until fate taps you on the shoulder,” said Dr. Josh Weil, an emergency medicine physician at Kaiser Permanente in Santa Rosa who led the hospital evacuation operation on Oct. 9.

America’s hospitals were beset by an unusual number of calamities in 2017: The fires that raged in Northern and Southern California; hurricanes that displaced thousands in Houston, Florida and Puerto Rico; the deadliest mass shooting in modern history that killed 58 people and wounded more than 500 others in Las Vegas; and the attack at a Bronx hospital in which a doctor turned a gun on his former colleagues, killing one and injuring six.

Across the country, natural disasters have become more frequent and more deadly; the carnage from mass shootings resembles that on a battlefield. In some cases, these crises are more severe and elaborate than most hospitals — particularly smaller ones — are prepared for, and experts say it is time to bring facilities up to speed.

“The probability that any individual hospital will be involved in an unusual event is increasing,” said Dr. Carl Schultz, professor emeritus of emergency medicine and public health at the University of California-Irvine. “All hospitals are potentially vulnerable,” he said, and “there is more pressure for hospitals to be prepared.”

That’s the case, he added, even though hospitals often lack the resources and funding to upgrade their disaster plans.

In the new year, hospitals that responded to outsized tragedies in 2017 are reassessing their plans in light of their painful experiences. Below are some instructive examples:

Keeping Track Of Patients

In Northern California, staffers from the Kaiser hospital in Santa Rosa rushed to clear out their wards as the ferocious Tubbs Fire approached. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

The original plan was to jot down details from each displaced patient’s identification bracelet so that the hospital could later confirm that patients arrived at other hospitals safely. But with the fire coming fast upon them, it became clear this would take too long, Weil said.

On the fly, one staffer suggested taking photos of patient wristbands with smartphones, he said.

“That was a brilliant idea that really saved us,” Weil said.

The hospital is now considering whether smartphones might be of greater use in future emergencies, or if there’s a more efficient way to track patients who must be rapidly whisked away.

Eight days earlier, another tracking issue surfaced at Sunrise Hospital & Medical Center in Las Vegas — this one concerning incoming patients. The facility was suddenly inundated by people shot or otherwise injured during the tragedy at the outdoor country music festival; 212 patients were admitted in a two-hour window, 124 of them with gunshot wounds.

Of those, 92 had no official photo identification on them.

Families dashed desperately from one hospital to another searching for their loved ones, said Alan Keesee, the hospital’s chief operations officer. Without IDs for patients, it was a challenge to confirm whether they were at the hospital, let alone whether they would be OK.

Enterprising staffers listed their unidentified patients’ physical traits and unique features, such as tattoos, to help match people with the descriptions family members provided. In turn, many relatives pulled up social media profile photos of their loved ones to give the hospital something to go by.

The chaotic process of patient identification exposed a desperate need for a centralized data hub where descriptions of unidentified patients in a massive emergency could be uploaded and accessed by all area hospitals, Keesee said.

And indeed, he said, his hospital is working with the Nevada Hospital Association and other local health agencies to determine whether the hub can be created.

Communication And Coordination

Last June, a former doctor stormed Bronx-Lebanon Hospital armed with a semiautomatic rifle.

Staff members had trained for just this kind of incident. But they had not anticipated how restricted their movements would be once police took over, said Dr. Sridhar Chilimuri, the physician-in-chief that day.

“Shooting victims need blood transfusions, so you need to get from the blood bank to the operating rooms quickly,” Chilimuri said.

But the hospital lockdown blocked access to elevators. Doctors and nurses also had to fetch surgical instruments and move patients, he added, but they couldn’t do so without approval from police.

Because it was an internal shooting, police had to clear staffers of suspicion before they could return to work — even the doctors needed for lifesaving operations.

The hospital has since updated its drills to include an accelerated process of police screening — targeting the medical staff most urgently needed — and its training videos now show an attacker armed with an assault weapon rather than a small handgun.

“Hopefully that will help us cut down on the time we are crippled,” Chilimuri said.

Running Low On Supplies

When Hurricane Irma barreled into South Florida in September, the 10 Tenet Health hospitals in the region felt ready.

They had beefed up their disaster plans after Hurricane Matthew landed a year earlier, said Cathy Philpott, a director of nursing practice and clinical operation for the hospital system. They also brought in staff from other states and rolled in backup generators, she said.

Even so, they faced an unexpected challenge: a shortage of platelets, cells that help the body form clots to stop bleeding.

Until sister hospitals in Boston could airlift platelets in, the hospitals had to work with local blood banks to conserve the supply and prioritize their use for trauma patients. When hurricanes are forecast in the future, the hospitals will reach out to local blood banks and host platelet drives as the storms approach, Philpott said.

“That’s the lesson learned,” she said.