Liquid Gold: Pain Doctors Soak Up Profits By Screening Urine For Drugs

KFF Health News, November 7, 2017

Spending on urine screens and related genetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year.

This article first appeared November 06, 2017 on Kaiser Health News.

By Fred Schulte and Elizabeth Lucas

The cups of urine travel by express mail to the Comprehensive Pain Specialists lab in an industrial park in Brentwood, Tenn., not far from Nashville. Most days bring more than 700 of the little sealed cups from clinics across 10 states, wrapped in red-tagged waste bags. The network treats about 48,000 people each month, and many will be tested for drugs.

Gloved lab techs keep busy inside the cavernous facility, piping smaller urine samples into tubes. First there are tests to detect opiates that patients have been prescribed by CPS doctors. A second set identifies a wide range of drugs, both legal and illegal, in the urine. The doctors’ orders are displayed on computer screens and tracked by electronic medical records. Test results go back to the clinics in four to five days. The urine ends up stored for a month inside a massive walk-in refrigerator.

The high-tech testing lab’s raw material has become liquid gold for the doctors who own Comprehensive Pain Specialists. This testing process, driven by the nation’s epidemic of painkiller addiction, generates profits across the doctor-owned network of 54 clinics, the largest pain-treatment practice in the Southeast. Medicare paid the company at least $11 million for urine and related tests in 2014, when five of its professionals stood among the nation’s top billers. One nurse practitioner at the company’s clinic in Cleveland, Tenn., single-handedly generated $1.1 million in Medicare billings for urine tests that year, according to Medicare records.

Dr. Peter Kroll, one of the founders of CPS and its medical director, billed Medicare $1.8 million for these drug tests in 2015. He said the costly tests are medically justified to monitor patients on pain pills against risks of addiction or even selling of pills on the black market. “I have to know the medicine is safe and you’re taking it,” Kroll, 46, said in an interview. Kroll said that several states in which CPS is active have high rates of opioid use, which requires more urine testing.

A sign hangs in the lobby of the Comprehensive Pain Specialists clinic in Hendersonville, Tenn., advising patients about urine drug screening. (Heidi de Marco/KHN)

Kaiser Health News, with assistance from researchers at the Mayo Clinic, analyzed available billing data from Medicare and private insurance billing nationwide, and found that spending on urine screens and related genetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year — more than the entire budget of the Environmental Protection Agency. The federal government paid providers more to conduct urine drug tests in 2014 than it spent on the four most recommended cancer screenings combined.

Yet there are virtually no national standards regarding who gets tested, for which drugs and how often. Medicare has spent tens of millions of dollars on tests to detect drugs that presented minimal abuse danger for most patients, according to arguments made by government lawyers in court cases that challenge the standing orders to test patients for drugs. Payments have surged for urine tests for street drugs such as cocaine, PCP and ecstasy, which seldom have been detected in tests done on pain patients. In fact, court records show some of those tests showed up positive just 1 percent of the time.

Urine drug testing has become particularly lucrative for doctors who operate their own labs. (Heidi de Marco/KHN)

Urine testing has become particularly lucrative for doctors who operate their own labs. In 2014 and 2015, Medicare paid $1 million or more for drug-related tests billed by health professionals at more than 50 pain management practices across the U.S. At a dozen practices, Medicare billings were twice that high.

Thirty-one pain practitioners received 80 percent or more of their Medicare income just from urine testing, which a federal official called a “red flag” that may signal overuse and could lead to a federal investigation.

“We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”

‘It Was Almost A License To Steal’

As alarm spread about opioid deaths and overdoses in the past decade, doctors who prescribed the pills were looking for ways to prevent abuse and avert liability. Entrepreneurs saw a lucrative business model: persuade doctors that testing would keep them out of trouble with licensing boards or law enforcement and protect their patients from harm. Some companies offered doctors technical help opening up their own labs.

A 2011 whistleblower lawsuit against one of the nation’s top billers for urine tests, a San Diego-based laboratory owned by Millennium Health LLC, underscores the potential for profit. “Doctor,” one lab representative said during sales calls, according to an affidavit, “drug testing is not about medicine but about making money, and I am going to show you how to make a lot of money.”

Millennium Health, billing records show, took in more than $166 million from Medicare in 2014 despite being the target of at least eight whistleblower cases alleging fraud over the past decade. A Millennium sales manager involved in a 2012 case in Massachusetts reported earning $700,000 in salary and sales commissions in the previous year.

Millennium encouraged doctors to order more tests both as a way to lower patients’ risks and to shield the physicians against possible investigations by law enforcement or medical licensing boards, according to court filings. Millennium denied the allegations in the whistleblower suits and settled all of them with the Justice Department in 2015 by agreeing to pay $256 million; its parent company, Millennium Lab Holdings II, declared bankruptcy.

(Garth Superville for KHN)

Tests to detect drugs in urine can be basic and cheap. Doctors have long used testing cups with strips that change color when drugs are present. The cups cost less than $10 each, and a strip can detect 10 types of drugs or more at once and display the results in minutes.

After noticing that some labs were levying huge charges for these simple urine screens, the Centers for Medicare & Medicaid Services moved in April 2010 to limit these billings. To circumvent the new rules, some doctors scrapped cup testing in favor of specialized — and much costlier — tests performed on machines they installed in their facilities. These machines had one major advantage over the cups: Each test for each drug could be billed individually under Medicare rules.

“It was almost a license to steal. You had such a lucrative possibility, it was very tempting to sell as many [tests] as you can,” said Charles Root, a longtime lab industry consultant whose company, CodeMap, has tracked the rise of testing labs in doctors’ offices.

Voluminous Drug Tests

The CPS testing lab in Tennessee opened in 2013, not long before a pain specialist named William Wagner moved from New Mexico to open a CPS clinic in Anderson, S.C. He was lured by the promise of $30,000 a month in salary, which would grow as the clinic added patients and revenue, along with other benefits. His contract said he could be on-site for as little as 20 percent of the clinic’s operating hours.

A sign for responsible opioid treatment is displayed in an exam room of the Comprehensive Pain Specialists clinic in Hendersonville, Tenn. (Heidi de Marco/KHN)

When the company recruited him, Wagner said, he was told the job offered “potential to earn a great deal of money” from bonuses he would receive from services he generated, including a share of collections from lab services for urine tests done at the new Tennessee facility.

That did not happen, according to Wagner. He is suing CPS, saying that it failed to collect bills for services he rendered and then closed the clinic. CPS refutes Wagner’s claims and says it fulfilled its obligations under the contract. In a counterclaim, CPS argues that Wagner owes it $190,000.

“All of their money was being made off of urine drug screens. They weren’t doing anything else properly,” Wagner said. The lawsuit is pending in federal court in Nashville.

Former CPS chief executive John Davis, in an interview, described the urine-testing lab as part of a “strategic expansion initiative” in which the company invested $6 million to $10 million in computerized equipment and swiftly acquired new clinics. Kroll, one of the owners of CPS, said the idea was to “take the company to the next level.”

Davis, who led the initiative before leaving the company in June, would not discuss the private company’s finances other than to say CPS is profitable and that lab profits “to a great degree” drove the expansion. “Urine screening isn’t the reason why we decided to grow our company. We wanted to help people in need,” Davis said.

Kroll acknowledged that urine tests are profit-makers, but stressed that verifying that patients aren’t abusing drugs gives him a “whole different level of confidence that I’m doing something right for the patients’ condition.”

He said his doctors try to be “judicious” in ordering urine tests. Kroll said some of his doctors and nurses treat “high-risk” patients who require more frequent testing. The company said that its Medicare billing practices, including urine screens, had withstood a “very in-depth” government audit. The audit initially called for repayment of $25 million but was settled in 2016 for less than $7,000, according to the company. Medicare officials had no comment.

Kroll’s orthopedic career took a sharp turn more than a decade ago after watching his brother suffer through multiple surgeries for muscular dystrophy, along with bone fractures, stiffness and pain. His brother died at age 25, and Kroll decided to switch to anesthesiology and become a pain specialist.

“It sensitized me to the plight of people with chronic conditions that we have no medical answer for,” Kroll said. His brother “battled for his whole life.”

Kroll’s career change coincided with a national movement to establish pain management as a vital medical specialty, with its own accrediting societies and lobbying and political arm to advance its interests and those of patients.

Joined by three other doctors, he formed Comprehensive Pain Specialists at a storefront in suburban Hendersonville, Tenn. It quickly gained a foothold on referrals from local doctors unsure, or uneasy, about treating unyielding pain with heavy narcotics such as oxycodone, morphine and methadone.

In 2014, when CPS was among Medicare’s major urine-test billers, Tennessee led the nation in Medicare spending on urine drug tests run by doctors with in-house labs, according to federal billing records.

A urine specimen is prepared for shipment to the CPS lab to be tested. (Heidi de Marco/KHN)

How Much Is Too Much?

There is wide disagreement among legislators, medical trade associations and the state boards that license doctors over the best approach to urine testing. One association of pain specialists argued in 2008 that urine testing could be done as often as weekly, while others have balked at that frequency.

Indiana’s medical board ordered mandatory urine tests for all pain patients in late 2013, only to face a lawsuit from the American Civil Liberties Union, which argued that the policy was unconstitutional and an unlawful search. Officials backed down the next year, and current policy states that testing can be done “at any time the physician determines that it is medically necessary.”

The federal Centers for Disease Control and Prevention, wary of both cost and privacy concerns, declined to set a definitive national standard despite years of debate. In long-awaited guidelines issued in March 2016, the CDC called for testing at the start of opioid therapy and once a year for long-term users. Beyond that, it said, testing should be “left up to the discretion” of the medical professional.

Doctors who receive the lion’s share of their Medicare funds from urine drug testing would certainly raise a red flag.

Donald White, spokesman for the Department of Health and Human Services’ Office of the Inspector General

There is likewise little scientific justification for many of these new types of drug testing that have made their way onto doctors’ order sheets and laboratory menus.

Many pain patients on opioids are routinely tested for phencyclidine, an illegal, hallucinogenic drug also known as PCP, or angel dust, Medicare records show. Yet urine tests have rarely detected the drug. Millennium, the San Diego-based company that once topped Medicare billings for urine tests, found PCP in fewer than 1 percent of all patient samples, according to federal court filings.

In a tour of the CPS lab, Chief Operations Officer Jeff Hurst, who has more than two decades of experience working for commercial labs, rattled off a list of drugs ranging from cocaine to heroin and methamphetamine, which he said was “really big in East Tennessee.”

How often urine tests reveal serious drug abuse — or suggest patients might be selling some of their medications instead of taking them — is tough to pin down. Asked during a tour of the laboratory in Tennessee if CPS could provide such data, Hurst said he did not have it; Kroll said he didn’t either.

Hurst said the lab often ends up doing a “long list of tests” because CPS doctors are prescribing dangerous drugs that may be deadly if abused and “need to know what patients are taking.” Prescribed drugs, such as opiates and tranquilizers, are also measured at the CPS lab.

Government officials have criticized the explosive growth in testing for some prescription drugs, notably a class of tranquilizers known as tricyclic antidepressants. Medicare paid more than $45 million in 2014 for more than 200,000 people to be tested for tricyclic drugs, often multiple times. Medicare was billed for 644,495 tests for one tricyclic drug, amitriptyline, up from 6,173 tests five years earlier.

The Department of Justice argued in a 2012 whistleblower case that these tests often couldn’t be justified because of “low abuse potential” of the drugs and a “lack of abuse history for the vast majority of patients.”

Income Breakdown Raises ‘Red Flag’

When told that drug screens accounted for most of the Medicare income for dozens of pain doctors, federal officials said that was troubling.

“Doctors who receive the lion’s share of their Medicare funds from urine drug testing would certainly raise a red flag,” said Donald White, a spokesman for the Department of Health and Human Services’ Office of the Inspector General. “Confirmation of fraud would require federal investigation and a formal judicial proceeding.”

In a report released last fall, the watchdog office said some uptick in testing might be justified by the drug abuse epidemic, but noted that the situation also “could provide cover for labs that might seek to fraudulently bill Medicare for unnecessary drug testing.”

(Heidi de Marco/KHN)

Medicare pays only for services it considers “medically necessary.” While that sometimes can be a judgment call, pain clinics that adopt a “one-size-fits-all” approach to urine testing may find themselves under suspicion, said Mehta, the assistant U.S. attorney in Florida.

Mehta’s office investigated a network of Florida clinics called Coastal Spine & Pain Center for alleged over-testing, including routinely billing for a second round of expensive tests simply to confirm earlier findings. In a press release in August 2016, the government argued that these tests were “medically unnecessary.” The company paid $7.4 million last year to settle the False Claims Act case. Coastal Spine & Pain, which did not admit fault, had no comment.

Four Coastal Spine & Pain doctors were among the top 50 Medicare billers during 2014, when they charged nearly $6 million for drug tests, according to Medicare billing data analyzed by KHN.

Starting in 2016, Medicare began to crack down on urine billings as part of a federal law that is supposed to reset lab fees for the first time in three decades. Now tougher scrutiny of urine testing, and cuts in reimbursements, may be threatening CPS — or at least its profits.

CPS closed nine clinics last year and told its doctors that urine-testing revenue had dropped off 32 percent in the first quarter of the year, according to a letter then-CEO Davis sent its physician partners.

Davis said the company had to “make some changes” because of cuts in Medicare reimbursements for urine tests and other medical services. A company spokeswoman told KHN that the drop in urine revenue worsened through 2016 but has bounced back somewhat this year.

Despite the cuts, privately held CPS plans to open new clinics this year. Urine testing will remain a key service — for keeping patients safe, it said. CPS is just playing by the rules of the game. “Tell us how often to test,” said Hurst, the operations officer, “and we’ll be happy to follow it.”

KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

‘Liquid Gold’ Investigation: Sifting Through The Data

Kaiser Health News relied on payment data from Medicare’s fee-for-service program, available from the Centers for Medicare & Medicaid Services to analyze the prevalence and cost of urine drug testing and related genetic testing. Doctors and laboratories bill Medicare using standard codes. KHN consulted with several billing experts in the field and used government documents to identify relevant billing codes for this analysis.

Medicare reimburses providers for each code they bill based on a standard amount that allows for some geographic variation. Each code represents a type of test, and multiple tests can be done on a single urine sample; therefore, the amount that providers bill for a single sample of urine varies greatly.

Medicare’s Part B payment data is publicly available only for the years 2012 through 2015. KHN acquired historical data from the consulting firm CodeMap going back to 2005 to analyze trends in billing.

KHN also teamed up with researchers at the Mayo Clinic to analyze claims data for private insurers and Medicare Advantage to estimate the total cost per year, which in 2014 was roughly $8.5 billion for private plus government payers. Mayo Clinic researchers accessed data from the OptumLabs Data Warehouse, which includes health insurance claims that cover about 20 million patients per year. The analysis included claims from physicians and independent labs, and excluded any facility (hospital or outpatient) fees. To estimate the yearly cost, KHN took the total cost per enrollee from the Mayo Clinic data analysis and applied it to the estimated populations for both private insurance (from the Current Population Survey) and Medicare Advantage (from CMS’ Beneficiary Public Use File). This is a rough estimate because the OptumLabs claims might not reflect some variations in medical care costs and health conditions across the country.

Health Companies Race To Catch UnitedHealth As Amazon Laces Up

KFF Health News, November 6, 2017

UnitedHeath is admired on Wall Street for its dependable results and diverse stable of businesses. But the prospect of further industry consolidation alarms some consumer advocates and health policy experts.

This article first appeared November 08, 2017 on Kaiser Health News.

By Chad Terhune

Pedestrians pass in front of a CVS Health Corp. store in downtown Los Angeles on Oct. 27. (Christopher Lee/Bloomberg via Getty Images)

As soon as news surfaced last week about the potential merger of CVS Health and Aetna, all eyes turned to the looming threat from Amazon.

The online retailer’s flirtation with the pharmacy business is a factor, no doubt. But many industry experts say CVS and Aetna have another huge competitor on their minds: UnitedHealth Group.

UnitedHealth is best known as the nation’s largest health insurer, with more than 45 million members in the U.S. But behind the scenes, it has extended its reach deep into America’s medicine cabinets, operating rooms and doctor offices.

Its Optum unit fills more than 100 million prescriptions per month as a pharmacy benefit manager, poaching big customers from rivals CVS and Express Scripts. UnitedHealth owns more than 400 surgery centers and urgent-care clinics and runs medical practices for about 22,000 physicians across the country.

“People have gotten carried away with Amazon,” said Ana Gupte, a health care analyst at Leerink Partners. “CVS and Aetna is an Optum wannabe. UnitedHealth is the winning business model, and Optum is showing the way.”

UnitedHealth’s expansion into dispensing prescription drugs and treating patients has put the company on track to reach $200 billion in annual revenue this year and profits for the first nine months of 2017 already topped $7 billion.

UnitedHeath is admired on Wall Street for its dependable results and diverse stable of businesses, which helps insulate it from rough patches in the insurance sector. However, the prospect of further industry consolidation alarms some consumer advocates and health policy experts. And they say UnitedHealth hasn’t always been a good role model.

In 2009, U.S. Senate investigators said the company built an industrywide database that deliberately understated what insurers should pay for out-of-network care, exposing consumers nationwide to hundreds of millions of dollars in extra charges.

More recently, patients have accused the company’s prescription drug business, OptumRx, of overcharging for routine medications in order to pocket a pharmacy “clawback” that boosts profits. The company has denied any wrongdoing in response to lawsuits over the drug pricing.

Employers, lawmakers and consumer groups accuse the three largest pharmacy middlemen — Express Scripts, CVS and UnitedHealth — of keeping drug prices high and pocketing too many of the discounts they negotiate with pharmaceutical companies.

Consumer advocates also are concerned about the prospect of companies mining a vast supply of consumer data to maximize profits rather than improve care.

“It is hard to find instances where these very large companies used their market power for the good of consumers, rather than for their shareholders,” said Lynn Quincy, a consumer advocate and director of the Healthcare Value Hub at the Altarum Institute, a nonprofit think tank. “The lack of transparency at these really large companies is appalling. That’s why we’re skeptical it will make things better.”

In a statement, UnitedHealth said it’s committed to “helping people live healthier lives” and its Optum unit is trying to make the entire health system work better.

In the past, company executives have said they’re fighting on behalf of employers and consumers against high costs, as well as poor outcomes and mind-boggling complexity. Before the merger news, executives at Aetna and CVS had already hinted at working together to tackle many of the same issues through the retailer’s vast network of stores.

Last week, The Wall Street Journal broke the news about the potential merger between CVS and Aetna, which could be worth more than $66 billion. CVS and Aetna say they won’t comment on market rumors or speculation.

In general, these companies are trying to address problems familiar to most Americans: poor coordination of care. Doctors rarely talk to each other. It’s incredibly hard to share medical records among providers or even with patients. Despite a lot of talk about linking pay to performance, a surprising amount of medical care is still reimbursed under the old-fashioned fee-for-service model that rewards quantity over quality.

For some experts, CVS and Aetna are well-positioned to fix many of those issues and that might make their deal more likely to pass muster with antitrust officials.

UnitedHealth, which has reached into everything from home health care to billing technology, has won praise for some of its efforts. One 2015 study published in Health Affairs found that the company’s use of house calls helped reduce costly hospital admissions for Medicare patients by 14 percent.

“One of the big failures of the U.S. health care system has been fragmentation, and these vertical mergers are trying to cure that problem,” said Thomas Greaney, a former federal antitrust lawyer and now a professor at the University of California’s Hastings College of the Law in San Francisco.

“You want to encourage efficiencies and integration that helps promote better care and lower costs. But you don’t want that to turn into a local monopoly,” he added.

Farzad Mostashari, a former official in the Obama administration who has studied health care competition, said it’s too soon to tell whether a CVS-Aetna deal would be good or bad for consumers. But Mostashari, who now heads Aledade, a tech start-up that works with doctors, said it warrants intense scrutiny of the more subtle ways it could put rivals at a disadvantage.

“These vertical mergers can create competitive challenges where you use your dominant market position to tip the ball to yourself in another area,” he said.

Big Gains In Latino Coverage Poised To Slip During Chaotic Enrollment Season

KFF Health News, October 30, 2017

The uninsured rate among Latinos dropped from 43% in 2010 to less than 25% in 2016. This year's shorter enrollment season and cutbacks in federal funding could allow Latino enrollment to falter.

This article first appeared October 30, 2017 on Kaiser Health News.

By Paula Andalo

Latinos, who just a year ago were highly sought customers for the Affordable Care Act’s marketplace plans may not get the same hard sell this year.

The Trump administration’s laissez-faire approach toward the upcoming enrollment period for the health law’s insurance marketplaces could reverse advances made in the number of Latinos with coverage, fear navigators and community activists.

Enrollment outreach efforts during the Obama administration targeted Latinos, both because they have a high uninsured rate and because a large proportion of the community is young and fairly healthy, criteria prized by insurers to help balance older, sicker customers, who are more likely to sign up.

Nearly a million people who identify themselves as Latino or Hispanic enrolled in marketplace plans this year, making up a tenth of customers. The uninsured rate among Latinos dropped from 43 percent in 2010 to under 25 percent in 2016. Still, millions are eligible and remain uninsured.

A shorter enrollment season and cutbacks in federal funding for marketing and navigator groups have the potential to allow Latino enrollment to slip, the advocates say.

Enrollment for the 39 states using the federal website begins Nov. 1 and ends Dec. 15, about a month and a half less than in the previous year. Some states running their own exchanges have extended that period into January.

Claudia Maldonado, program director for the Keogh Health Connection in Phoenix, an organization that connects underserved people with health services, said uncertainty is what dominates these days. "We're getting ready, because we know it's going to be a difficult open enrollment period."

The Spanish-language enrollment website, cuidadodesalud.gov, will be operating again this year, federal officials said, but it will face the same scheduled maintenance shutdowns as its Anglo sibling, healthcare.gov.

The Centers for Medicare & Medicaid Services (CMS), which manages the federal online insurance marketplaces, announced last month that the sites would be "closed for maintenance" for half the day on Sundays during the open enrollment period. The states that run their own marketplaces, such as California and New York, will not be affected by the shutdowns.

In Darkness

It's unfortunate the service disruption of cuidadodesalud.gov will happen on Sundays, said Daniel Bouton, director of health services for the Community Council of Greater Dallas, a nonprofit that helps Latinos sign up for health care. "The day that Hispanic families go to church, where they are all together and where we have been enrolling them in previous years."

“People want to have the issue of their health coverage resolved,” said Anne Packham, director of the insurance marketplace project at Covering Central Florida, an Orlando-based organization. “And all the announcements about Obamacare frustrate them.”

Enrolling a consumer on the exchanges is not a 10-minute process. A family can purchase a health plan there and also learn if they are eligible for Medicaid or CHIP, the federal-state insurance program for children in low-income families that earn too much to qualify for Medicaid. It can take up to an hour and a half and often requires more than one session with the navigator, who are the certified insurance market experts who have helped enroll millions of Latinos across the country.

Many Hispanics prefer to sign up for coverage in person with a trained navigator, said several people with experience helping consumers.

In an email, CMS said that scheduled website outages would not affect the enrollment flow and that the federal call center where consumers can get help with enrollment questions "will continue to assist callers."

"It is important to note that the duration of the potential Sunday outages are the maximum amount of time allowed for the maintenance; actual outage times could be shorter," the email added.

An Alternative Website

The Spanish-language website had a rough start when Obamacare plans launched in 2013, not coming online until two months after the English version. Still, navigators say that cuidadodesalud.gov often serves as a "last resort" for consumers, both Latinos and others, when they have technical problems with the English version.

"In past registrations, many times when healthcare.gov was down, the Spanish site was not," said Bouton.

"Navigators are bilingual and generally use the site in English, but when it is not working well, they end the registration process in cuidadodesalud.gov, which often worked better [than healthcare.gov] in previous years," said Julia Holloway, director of program development and navigator services for Affiliated Service Providers of Indiana, in Indianapolis. Her program has been told by federal officials that it will get 82 percent less money for navigators during the open season this fall.

The lower flow of consumers on cuidadodesalud.gov has made the Spanish version technologically more stable than the English version.

From Nov. 1, 2015, to Jan. 2, 2016, nearly 20 million people used healthcare.gov, compared with 953,708 who navigated cuidadodesalud.gov.

Fear Of Deportations

Edgar Aguilar, program manager with Community Health Initiative, a network of grass-roots organizations in California that assist people signing up for insurance, said even though California does not face some of the same challenges as states using the federal marketplace, enrollment this year will be challenging.

He is in charge of the operation in Kern County, in the Central Valley, which has a high population of Latino farmers.

"We were successful signing up Latinos in the past, there are less than 8 percent of Latinos without insurance in the county, but the confusion about what is happening with Obamacare and the fear of immigration problems make people think twice before renewing a health plan or [signing] up their kids for Medicaid or CHIP", he said.

Navigators surveyed for this article said they feel more tension this year in the days leading up to the start of enrollment.

Hispanic members of Congress sent a letter to the Department of Health and Human Services in August seeking reassurance that enrollment outreach would continue for Latinos. A spokesperson for the caucus said an HHS representative promised to set up a meeting on the issue, but it never happened.

One hurdle to enrollment is the fear of deportations. Undocumented immigrants do not have the right to buy health insurance through the ACA markets, but there are thousands of families with mixed immigration status, and advocates fear they may be hesitant to buy insurance or apply for subsidies to help pay for coverage.

"Since the new government took office, when raids increased and the legal status of ‘Dreamers’ [young people brought to the U.S. while children] was in jeopardy, people started canceling their appointments with the navigators, and stopped enrolling their children in Medicaid or CHIP," said Bouton.

However, navigators said they aren’t giving up. "We keep making calls. We have the same goal of registering more people," said Maldonado. Her organization is operating with a 30 percent lower budget for navigators. In her state, Cover Arizona, a network of nonprofit organizations, continues to organize events, hand out leaflets and make calls to encourage enrollment.

"We had to cut the budget for marketing, but another organization that did not have that cut helps us and distributes our brochures," said Bouton. More than ever, navigators say, the focus is on teamwork.

"We are passionate about what we do, and we will try to enroll as many people as possible," said Holloway.

Millennials Embrace Nursing Profession - Just In Time To Replace Baby Boomers

KFF Health News, October 27, 2017

The trend could be associated with economic factors. Millennials came of age during a period of deep economic uncertainty. Nursing generally offers stable earnings and low unemployment.

This article first appeared October 27, 2017 on Kaiser Health News.

By Michelle Andrews

The days are long past when the only career doors that readily opened to young women were those marked teacher, secretary or nurse. Yet young adults who are part of the millennial generation are nearly twice as likely as baby boomers were to choose the nursing profession, according to a recent study.

These young people, born between 1982 and 2000, are also 60 percent more likely to become registered nurses than the Gen X’ers who were born between 1965 and 1981.

What gives?

“There’s no perfect answer,” said David Auerbach, an external adjunct faculty member at Montana State University’s College of Nursing and the lead author of the study, which was published this month in Health Affairs. The trend could be associated with economic factors, he said. Millennials came of age during a period of deep economic uncertainty with the Great Recession, which began in 2007, and the nursing profession generally offers stable earnings and low unemployment.

In addition, researchers have teased out generational characteristics that might make nursing more attractive to millennials.

“These people are looking for more meaningful work and work that they care about,” Auerbach said.

One thing that hasn’t changed since the 1950s: Nursing is still dominated by women. In 2017, women made up at least 83 percent of registered nurses and licensed practical nurses, according to data from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

For the study, researchers analyzed Census Bureau data on 429,585 registered nurses from 1979 to 2015. The study excluded data on advanced practice nurses.

The study found that the number of new entrants into the field has plateaued in recent years. Still, the millennial generation’s embrace of the nursing profession should nearly compensate for the retirement of baby boomer nurses over the next dozen years and may help avert shortages, according to the researchers.

Many factors will influence whether the supply of nurses is adequate in coming years. The health care needs of an aging population is only one of them.

“The growth in accountable care organizations and alternative payment models is probably the biggest factor,” Auerbach said. For example, as hospitals move away from fee-for-service medicine toward models that pay based on quality and cost effectiveness, nurses’ roles may shift, and fewer of them may be needed in hospital settings as inpatient care declines.

Federal Judge Denies Bid To Force Feds To Resume ACA Subsidies

KFF Health News, October 26, 2017

U.S. District Judge Vince Chhabria wrote that 'the emergency relief sought by the states would be counterproductive.'

California Attorney General Xavier Becerra led the lawsuit, filed by 18 states and the District of Columbia, seeking an emergency restraining order compelling the Trump administration to resume the Obamacare payments. (Bill Clark/CQ Roll Call)

This article first appeared October 25, 2017 on Kaiser Health News.

By Ngoc Nguyen

SAN FRANCISCO — A federal judge Wednesday denied a petition to immediately reinstate Affordable Care Act subsidies that President Donald Trump suspended earlier this month.

The ruling came in a lawsuit filed by 18 states and the District of Columbia, led by California Attorney General Xavier Becerra. It sought an emergency restraining order compelling the Trump administration to resume the Obamacare payments, which would have totaled $7 billion this year.

In his ruling, U.S. District Judge Vince Chhabria wrote that "the emergency relief sought by the states would be counterproductive." He said the vast majority of states have already prepared for the termination of the payments and already "devised responses that give millions of lower-income people better health coverage options than they would otherwise have had."

Earlier this month, the Trump administration ended the so-called cost-sharing subsidies that compensate insurers for discounts given to low-income consumers to help cover their out-of-pocket expenses under policies sold on the ACA marketplaces. Officials argued that the subsidies are illegal because they have not been approved by Congress.

These subsidies are different from the tax credits many consumers get, depending on their income, to pay Obamacare premiums.

Chhabria said whether the funds were properly appropriated remains an open question as the lawsuit continues. His decision dealt only with the restraining order.

Becerra vowed to continue the legal battle to reinstate the payments.

"The fight for affordable healthcare moves forward," Becerra said in a statement. "The actions by the Trump Administration undermine critical payments that keep costs of healthcare affordable for working families. The judge made clear in his ruling that the ACA is the law of the land. Without an emergency order halting the Trump action, swift action in this litigation becomes even more compelling."

The ruling was expected. Chhabria expressed skepticism Monday that Trump's decision to halt the subsidies would cause consumers immediate harm, as California and many other states claimed in the suit.

Since assuming office in January, Trump has repeatedly threatened to stop the cost-sharing subsidies. But he held off while Republicans in Congress were working to replace the ACA.

Responding to the uncertainty, a number of states have allowed insurers to raise their premiums. California earlier this month ordered insurers to add a surcharge to some policies next year, to offset the potential loss in federal funding and keep the individual insurance market stable. The 12.4 percent surcharge was added to silver plans only, the second-least-expensive tier.

"California is doing a really good job in responding to the termination of [cost-sharing reduction] payments in a way that is avoiding harm for people and actually benefiting people," said Judge Chhabria.

He said that the vast majority of states have "seen the writing on the wall" and chosen to respond by increasing premiums for silver plans. That, in turn, will force the federal government to give higher tax credits to most consumers, so they won't feel any financial pinch.

Under intense questioning by the judge, California Deputy Attorney General Gregory Brown acknowledged that California has done a lot to mitigate the harm to consumers. But he said the administration's actions are destabilizing the exchanges and the individual insurance market, and causing chaos for states and consumers just eight days before enrollment begins Nov. 1.

Some experts and states are concerned jumpy insurers will bolt from the market and leave some regions with minimal or no choices for coverage. However, a bipartisan bill in Congress would restore the cost-sharing subsidies and aims to stabilize the insurance markets. But it's not clear the bill will muster the support it needs to pass both the Senate and House or whether Trump would sign it.

In California, 1.4 million people buy their own coverage through the state marketplace, and 90 percent receive federal subsidies that reduce what they pay.

During the hearing, Chhabria read from a Covered California press release that predicts how the changes will affect consumers in 2018. It notes that even though silver plan premiums will rise as a result of the surcharge, the federal tax credits will also increase to cover the rise in premiums. That would leave 4 out of 5 consumers with monthly premiums that stay the same or decrease.

The judge also said ruling in favor of the restraining order would mean insurance companies could essentially "double collect" — benefiting from both the premium increases from the surcharge on silver plans and the cost-sharing subsidies.

Brown said a restraining order to resume the cost-sharing payments would bring back the status quo. If insurance companies double collect, the state would compensate by reducing rates down the line, he said.

"We're not looking to give insurance companies a windfall … but the stability is important to insurance companies," he said.

So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients' Ills

KFF Health News, October 23, 2017

Despite added cost an inconvenience, the longer of two treatment options is given to more than half of eligible breast cancer patients, highlighting concerns of possible overtreatment.

This article first appeared October 23, 2017 on Kaiser Health News.

By Liz Szabo

After Kathi Kolb was diagnosed with breast cancer, her doctor recommended seven weeks of daily radiation treatments. She persuaded him to shorten treatment to three weeks, based on clinical trials showing that the condensed course works just as well. (Katye Martens Brier for KHN)

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

“You’re terrified out of your mind” after a diagnosis of cancer, said Dennison, 55, a retired psychologist from Orange County, Calif.

In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 — six years before her diagnosis — showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology, which writes medical guidelines, endorsed the shorter course.

In 2013, the society went further and specifically told doctors not to begin radiation on women like Dennison — who was over 50, with a small cancer that hadn’t spread — without considering the shorter therapy.

“It’s disturbing to think that I might have been overtreated,” Dennison said. “I would like to make sure that other women and men know this is an option.”

Dennison’s oncologist, Dr. David Khan of El Segundo, Calif., notes that there are good reasons to prescribe a longer course of radiation for some women.

Khan, an assistant clinical professor at UCLA, said he was worried that the shorter course of radiation would increase the risk of side effects, given that Dennison had undergone chemotherapy as part of her breast cancer treatment. The latest radiation guidelines, issued in 2011, don’t include patients who’ve had chemo.

Yet many patients still aren’t told about their choices.

An exclusive analysis for Kaiser Health News found that only 48 percent of eligible breast cancer patients today get the shorter regimen, in spite of the additional costs and inconvenience of the longer type.

The analysis was completed by eviCore healthcare, a South Carolina-based medical benefit management company, which analyzed records of 4,225 breast cancer patients treated in the first half of 2017. The women were covered by several commercial insurers. All were over age 50 with early-stage disease.

The data “reflect how hard it is to change practice,” said Dr. Justin Bekelman, associate professor of radiation oncology at the University of Pennsylvania Perelman School of Medicine.

A growing number of patients and doctors are concerned about overtreatment, which is rampant across the health care system, argues Dr. Martin Makary, a professor of surgery and health policy at the Johns Hopkins University School of Medicine in Baltimore.

From duplicate blood tests to unnecessary knee replacements, millions of patients are being bombarded with screenings, scans and treatments that offer little or no benefit, Makary said. Doctors estimated that 21 percent of medical care is unnecessary, according to a survey Makary published in September in Plos One.

Unnecessary medical services cost the health care system at least $210 billion a year, according to a 2009 report by the National Academy of Medicine, a prestigious science advisory group.

Those procedures aren’t only expensive. Some clearly harm patients.

Overzealous screening for cancers of the thyroid, prostate, breast and skin, for example, leads many older people to undergo treatments unlikely to extend their lives, but which can cause needless pain and suffering, said Dr. Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice.

“It’s just bad care,” said Dr. Rebecca Smith-Bindman, a professor at the University of California-San Francisco, whose research has highlighted the risk of radiation from unnecessary CT scans and other imaging.

Annie Dennison said doctors offered just one option after her breast cancer diagnosis last year: six weeks of radiation treatment. (Courtesy of Annie Dennison)

Outdated Treatments

All eligible breast cancer patients should be offered a shorter course of radiation, said Dr. Benjamin Smith, an associate professor of radiation oncology at the University of Texas MD Anderson Cancer Center.

Studies show that side effects from the shorter regimen are the same or even milder than traditional therapy, Smith said.

“Any center that offers antiquated, longer courses of radiation can offer these shorter courses,” said Smith, lead author of the radiation oncology society’s 2011 guidelines.

Smith, who is currently updating the expert guidelines, said there’s no evidence that women who’ve had chemo have more side effects if they undergo the condensed radiation course.

“There is no evidence in the literature to suggest that patients who receive chemotherapy will have a better outcome if they receive six weeks of radiation,” Smith said.

Shorter courses save money, too. Bekelman’s 2014 study in JAMA, the journal of the American Medical Association, found that women given the longer regimen faced nearly $2,900 more in medical costs in the year after diagnosis.

The high rate of overtreatment in breast cancer is “shocking and appalling and unacceptable,” said Karuna Jaggar, executive director of Breast Cancer Action, a San Francisco-based advocacy group. “It’s an example of how our profit-driven health system puts financial interests above women’s health and well-being.”

Just getting to the hospital for treatment imposes a burden on many women, especially those in rural areas, Jaggar said. Rural breast cancer patients are more likely than urban women to choose a mastectomy, which removes the entire breast but typically doesn’t require follow-up radiation.

Too Many Tests

Meg Reeves, 60, believes much of her treatment for early breast cancer in 2009 was unnecessary. Looking back, she feels as if she was treated “with a sledgehammer.”

At the time, Reeves lived in a small town in Wisconsin and had to travel 30 miles each way for radiation therapy. After she completed her course of treatment, doctors monitored her for eight years with a battery of annual blood tests and MRIs. The blood tests include screenings for tumor markers, which aim to detect relapses before they cause symptoms.

Yet cancer specialists have repeatedly rejected these kinds of expensive blood tests and advanced imaging since 1997.

For survivors of early breast cancer like Reeves — who had no signs of symptoms of relapse — “these tests aren’t helpful and can be hurtful,” said Dr. Gary Lyman, a breast cancer oncologist and health economist at the Fred Hutchinson Cancer Research Center. Reeves’ primary doctor declined to comment.

In 2012, the American Society for Clinical Oncology, the leading medical group for cancer specialists, explicitly told doctors not to order the tumor marker tests and advanced imaging — such as CT, PET and bone scans — for survivors of early-stage breast cancer.

Yet these tests remain common.

Thirty-seven percent of breast cancer survivors underwent screening for tumor markers between 2007 and 2015, according to a study presented in June at the American Society of Clinical Oncology’s annual meeting and published in the society’s journal online.

Sixteen percent of these survivors underwent advanced imaging. None of these women had symptoms of a recurrence, such as a breast lump, Lyman said.

Beyond wasted time and worry for women, these scans also expose them to unnecessary radiation, a known carcinogen, Lyman said. A National Cancer Institute study estimated that 2 percent of all cancers in the United States could be caused by medical imaging.

Paying The Price

Health care costs per breast cancer patients monitored with advanced imaging averaged nearly $30,000 in the year after treatment ended. That was about $11,600 more than for women who didn’t get such follow-up tests, according to Lyman’s study. Women monitored with biomarkers had nearly $6,000 in additional health costs.

Reeves knows the costs of cancer treatment all too well. Although she had health insurance from her employer, she says she had to sell her house to pay her medical bills. “It was financially devastating,” Reeves said.

“It’s the worst kind of financial toxicity, because you’re incurring costs for something with no benefit,” said Dr. Scott Ramsey, director of the Hutchinson Institute for Cancer Outcomes Research.

Even simple blood tests take a toll, Reeves said.

Repeated needle sticks — including those from unnecessary annual blood tests — have scarred the veins in her left arm, the only one from which nurses can draw blood, she says. Nurses avoid drawing blood on her right side — the side of her breast surgery — because it could injure that arm, increasing the risk of a complication called lymphedema, which causes painful arm swelling.

Reeves worries about the side effects of so many scans.

After treatment ended, her doctor also screened her with yearly MRI scans using a dye called gadolinium. The Food and Drug Administration is investigating the safety of the dye, which leaves metal deposits in organs such as the brain. After suffering so much during cancer treatment, she doesn’t want any more bad news about her health.

Becoming An Advocate

Kathi Kolb, 63, was staring at 35 radiation treatments over seven weeks in 2008 for her early breast cancer. But she was determined to educate herself and find another option.

“I had bills to pay, no trust fund, no partner with a big salary,” said Kolb, a physical therapist from South Kingstown, R.I. “I needed to get back to work as soon as I could.”

Kolb asked her doctor about a 2008 Canadian study, which was later published in the influential New England Journal of Medicine, showing that three weeks of radiation was safe. He agreed to try it.

Kolb, a Rhode Island physical therapist, says she’s frustrated that fewer than half of eligible breast cancer patients receive a shorter course of radiation, even though studies proved it was safe nearly 10 years ago. (Katye Martens Brier for KHN)

Even the short course left her with painful skin burns, blisters, swelling, respiratory infections and fatigue. She fears these symptoms would have been twice as bad if she had been subjected to the full seven weeks.

“I saved myself another month of torture and being out of work,” Kolb said. “By the time I started to feel the effects of being zapped [day] after day, I was almost done.”

A growing number of medical and consumer groups are working to educate patients, so they can become their own advocates.

The Choosing Wisely campaign, launched in 2012 by the American Board of Internal Medicine (ABIM) Foundation, aims to raise awareness about overtreatment. The effort, which has been joined by 80 medical societies, has listed 500 practices to avoid. It advises doctors not to provide more radiation for cancer than necessary, and to avoid screening for tumor markers after early breast cancer.

“Patients used to feel like ‘more is better,’” said Daniel Wolfson, executive vice president of the ABIM Foundation. “But sometimes less is more. Changing that mindset is a major victory.”

Yet Wolfson acknowledges that simply highlighting the problem isn’t enough.

Many doctors cling to outdated practices out of habit, said Dr. Bruce Landon, a professor of health care policy at Harvard Medical School.

Meg Reeves believes that much of the treatment she received for breast cancer was unnecessary. (Courtesy of Meg Reeves)

“We tend in the health care system to be pretty slow in abandoning technology,” Landon said. “People say, ‘I’ve always treated it this way throughout my career. Why should I stop now?’”

Many doctors say they feel pressured to order unnecessary tests out of fear of being sued for doing too little. Others say patients demand the services. In surveys, some doctors blame overtreatment on financial incentives that reward physicians and hospitals for doing more.

Because insurers pay doctors for each radiation session, for example, those who prescribe longer treatments earn more money, said Dr. Peter Bach, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes in New York.

“Reimbursement drives everything,” said economist Jean Mitchell, a professor at Georgetown University’s McCourt School of Public Policy. “It drives the whole health care system.”

Smith-Bindman, the UC-San Francisco professor, said the causes of overtreatment aren’t so simple. The use of expensive imaging tests also has increased in managed care organizations in which doctors don’t profit from ordering tests, her research shows.

“I don’t think it’s money,” Smith-Bindman said. “I think we have a really poor system in place to make sure people get care that they’re supposed to be getting. The system is broken in a whole lot of places.”

Dennison said she hopes to educate friends and others in the breast cancer community about new treatment options and encourage them to speak up. She said, “Patients need to be able to say ‘I’d like to do it this way because it’s my body.’”

Despite GOP Efforts To Corral Medicaid Spending, States Expand Benefits

KFF Health News, October 19, 2017

States generally add benefits to Medicaid - one of the largest programs in state budgets - during strong economic times.

This article first appeared October 19, 2017 on Kaiser Health News.

By Phil Galewitz

While congressional Republicans and President Donald Trump have been seeking major cuts in federal funding of Medicaid, 26 states this year expanded or enhanced benefits and at least 17 plan to do so next year, according to a report released Thursday.

The increased benefits were largely for mental health and substance abuse treatment, but states also added telemedicine and dental care, according to the report by the Kaiser Family Foundation and the National Association of Medicaid Directors. (Kaiser Health News is an editorially independent program of the foundation.)

The number of states adding benefits was the highest in at least a decade, according to the 50-state survey. Last year, 21 states expanded benefits.

Just six states moved to cut Medicaid benefits in fiscal 2016.

Oregon last year became the first state to provide coverage for oral contraceptives prescribed by a pharmacist, rather than a doctor, with its Medicaid program, the report said.

Four states — Louisiana, Virginia, South Dakota and New York — added cancer screening benefits such as paying for genetic testing for the BRCA breast cancer gene mutation.

Medicaid, the state-federal health insurance program for the poor, covers nearly 75 million people and is one of the largest programs in state budgets. States generally add benefits to Medicaid during strong economic times.

States added the benefits while Congress debated making significant changes to the program, including ending the open-ended federal spending that has been a staple of the program since its beginning in 1966. The Republican efforts, including bills to replace the Affordable Care Act, have withered after stiff opposition from advocates and Democrats and three moderate Republicans in the Senate.

Medicaid also faces uncertainty as the Trump administration weighs whether to allow states for the first time to require non-disabled, adult enrollees to work in order to qualify for benefits. At least six states have such a request pending with the Centers for Medicare & Medicaid Services, and a decision is expected before end of the year.

Robin Rudowitz, associate director for the Kaiser Family Foundation's Program on Medicaid and the Uninsured, said states are adding benefits to respond to the national opioid abuse problem as well as to continue the trend to give enrollees who are elderly or have serious health problems the ability to remain in their homes longer instead of going to nursing homes. She said more states have been expanding benefits for several years coming out of the Great Recession, which ended in 2009.

"We are seeing the delayed effects of the improving economy — enrollment growth is going down … and states are increasing provider [reimbursement] rates and restoring and adding benefits," she said.

Even while Maine, Indiana, Kentucky and other states want to add an adult work requirement to Medicaid, which will make it harder for some people to qualify, some of these same states and others are enhancing benefits, she said.

"All of this is happening against a backdrop of major uncertainty about what is going to happen at the federal level," Rudowitz said.

After three years of supersized enrollment growth that peaked in 2015 as a result of most states expanding coverage under the ACA, Medicaid enrollment growth slowed to 2.7 percent nationally in fiscal year 2017, which ended Sept. 30, down from 3.9 percent the year before, according to a second Kaiser report also released Thursday.

Overall Medicaid spending increased 3.9 percent in 2017, up from 3.5 percent in 2016. States reported that increase reflected higher spending on such things as prescription drugs and long-term care services.

The states' share of Medicaid spending grew by 3.5 percent also in 2017 but is expected to go up 6 percent in 2018. That increase is mostly a result of states starting to pay 5 percent of the cost of new enrollees covered under the ACA expansion. The federal government paid the full costs for those enrollees through 2016.

The survey was prepared by Health Management Associates.

Chasing Millions In Medicaid Dollars, Hospitals Buy Up Nursing Homes

KFF Health News, October 18, 2017

As many rural hospitals nationwide face serious financial difficulties, the funding enhancements pioneered in Indiana have been a key factor in helping to keep city and county hospitals economically viable, advocates say.

This article first appeared October 18, 2017 on Kaiser Health News.

By Phil Galewitz

The common area of the nursing home at Westminster Village North in Indianapolis, which has benefited from additional federal Medicaid funding. (Courtesy of Westminster Village North)

Westminster Village North, a nursing home and retirement community in Indianapolis, recently added 25 beds and two kitchens to speed food delivery to residents. It also redesigned patient rooms to ease wheelchair use and added Wi-Fi and flat-screen televisions. This fall, it’s opening a new assisted living unit.

“We have seen amazing changes and created a more home-like environment for our residents,” said Shelley Rauch, executive director of the home.

The nursing home can afford these multimillion-dollar improvements partly because it has, for the past five years, been collecting significantly higher reimbursement rates from Medicaid, the state-federal health insurance program for the poor. About half of its residents are covered by the program.

In 2012, the nursing facility was leased to Hancock Regional Hospital, a county-owned hospital 15 miles away. The lease lets it take advantage of a wrinkle in Medicaid’s complex funding formula that gives Indiana nursing homes owned or leased by city or county governments a funding boost. For Indiana, that translates to 30 percent more federal dollars per Medicaid resident. But that money is sent to the hospitals, which negotiate with the nursing homes on how to divide the funding.

Nearly 90 percent of the state’s 554 nursing homes have been leased or sold to county hospitals, state records show, bringing in hundreds of millions in extra federal payments to the state.

Even though Indiana’s nursing home population has remained steady at about 39,000 people over the past five years, Medicaid spending for the homes has increased by $900 million, in large part because of the extra federal dollars, according to state data. Total spending on Indiana nursing homes was $2.2 billion in 2016.

The funding enhancements were pioneered in Indiana, but hospitals in several other states, including Pennsylvania and Michigan, have also used the process. Advocates say it has been a key factor in helping to keep Indiana’s city and county hospitals economically vital at a time when many rural hospitals nationwide are facing serious financial difficulties.

Westminster Village North, a nursing home and retirement community in Indianapolis, recently redesigned patient rooms in the nursing home to ease wheelchair use. (Courtesy of Westminster Village North)

But critics argue that the money flow has not significantly improved nursing home quality and has slowed adoption of community and home health services.

More than two-thirds of Indiana’s Medicaid long-term-care dollars go to nursing homes, compared with the U.S. average of 47 percent.

Joe Moser, who until May was Indiana’s Medicaid director, said while in office that the hospital-nursing home marriages were partly responsible for keeping more people in nursing homes. “It is a factor that has contributed to our imbalance,” he said.

Daniel Hatcher, a law professor at the University of Baltimore and author of last year’s “The Poverty Industry,” said this funding arrangement is a bad deal for the poor and undercuts the purpose of the Medicaid program. “The state is using an illusory practice and taking away money from low-income elderly individuals who are living in poor performing nursing homes,” he said. He noted Indiana is ranked near the bottom of states for nursing home quality by several government and private reports.

But proponents of the practice say that even when hospitals get most of the money, it is well spent.

Marion County Hospital and Health Corp., the large safety-net hospital system in Indianapolis, owns or leases 78 nursing homes across the state, more than any other county hospital.

Sheila Guenin, vice president of long-term care there, said the hospital keeps 75 percent of the additional Medicaid dollars and the nursing homes get the rest. Still, the additional money has improved care. The transfer of the license to the hospital has kept several nursing homes from closing and increased staffing rates at many others, she said.

A couple reads the paper in one of the common rooms at the Westminster Village North nursing home. (Courtesy of Westminster Village North)

About 40 percent of the county hospital’s nursing homes have five-star ratings from the federal government, up substantially from 10 years ago, she said. Among the improvements at the nursing homes were the addition of electronic health records as well as high-capacity emergency generators to provide power in case of a natural disaster.

Still, some patient advocates said the extra funding is flowing to hospitals and nursing homes with little public accounting. Ron Flickinger, a regional long-term-care ombudsman in Indiana, said, “A lot of extra money is being spent here, but I’m not sure patients have seen it benefit them.”

Practice Dates To 2003

Medicaid, which typically covers about two-thirds of nursing home residents, is jointly financed by the federal and state governments. States pay no more than half of the costs, although the federal match varies based on a state’s wealth. In Indiana the federal government covers about two-thirds of Medicaid costs.

The enhanced nursing home payments began in 2003 when a financially strapped Indianapolis hospital owned by the county took advantage of the Medicaid funding provision to bolster its bottom line. In this case, the hospital purchased a nursing home, then provided the money for the state to increase what it spent on the home to the federally allowed maximum.

That increase, in turn, drew down more federal matching funds. Since the federal remittance is larger than the hospital contribution, the hospital got back its initial investment and divided the extra money with the nursing home.

Other county-owned hospitals in Indiana slowly followed suit.

Hatcher said Indiana government leaders embraced the funding arrangement because it let them avoid the politically difficult step of raising taxes to increase state funding to improve care at nursing homes. “It’s a revenue generator for the state and counties,” he said.

All the Medicaid funding for nursing homes should be going to those homes to care for the poor, not shared with hospitals to use as they choose, he added.

The strategy, promoted by consultants advising hospitals and nursing homes in Indiana, is used heavily there because of the plethora of county-owned hospitals. But the federal government is tightening the rules about such payments.

Texas has secured Medicaid approval for a similar strategy starting this month, but federal officials have made the extra funding dependent on nursing homes meeting quality measures, such as reducing falls. Oklahoma is seeking to get federal approval as well.

And in a rule released last year, the federal Centers for Medicare & Medicaid Services announced that it would gradually force states to shift to payment systems that tie such reimbursements to quality of care. Michael Grubbs, an Indiana health consultant, said that rule does not stop the Indiana hospital funding program, but it’s unclear that it will last.

Nursing home operators in Indiana say the financing arrangement has helped them keep up with rising costs and improve care for residents.

Zach Cattell, president of the Indiana Health Care Association, a nursing home trade group, noted the number of nursing homes in the state earning Medicare’s top, five-star rating has increased 9 percentage points since 2011. He said the percentage of high-risk residents with pressure ulcers and those physically restrained also dropped significantly.

An Opportunity Or A Loophole?

In Indiana, the small, county-run rural hospitals generally are not facing the financial threat that has become common elsewhere, in part because of the extra Medicaid funding gained from buying nursing homes, hospital officials say.

“The money has meant a great deal to us,” said Gregg Malot, director of business development at Pulaski Memorial Hospital in northern Indiana. “I don’t see this as a loophole but see it as an opportunity for small rural community hospitals to improve our quality and access to care.”

His hospital is the only one in Pulaski County. The extra Medicaid revenue from acquiring 10 nursing homes statewide — about $2 million a year — has helped finance the hospital’s obstetrics care and the purchase of the hospital’s first MRI, so doctors don’t have to rely on a mobile unit that used to come twice a week, he said. The hospital also spent some of the funding to add a centralized telemetry unit to monitor patients.

Steve Long, CEO of Hancock Regional Hospital in Greenfield, Ind., said his hospital recently built two fitness centers in the county with help from its extra Medicaid dollars. “This would not be possible without the additional funding.”

He rejects the notion that additional Medicaid money reduces the hospital’s incentive to add home- and community-based care in the community. He said new Medicare financing arrangements, such as accountable care organizations, give the hospital motivation to find the most efficient ways to care for patients after they leave the hospital.

But he acknowledged the hospital benefits from seeing more patients go to nursing homes licensed under its name.

“Welcome to health care — it’s a complex and confusing environment where we have all different competing incentives,” Long said.

2 Senators Reach Deal On A Health Law Fix, But Bringing Congress Along Is Tricky

KFF Health News, October 18, 2017

The agreement would guarantee payment of subsidies that help some low-income policyholders, for two years. It would also restore $110 million in 'outreach' funding cut by the Trump administration.

Sen. Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.) talk during a Senate Health, Education, Labor and Pensions Committee hearing on Oct. 17. (Tom Williams/CQ Roll Call)

This article first appeared October 17, 2017 on Kaiser Health News.

By Julie Rovner

After nearly two months of negotiations, key senators said Tuesday they have reached a bipartisan deal on a proposal intended to stabilize the Affordable Care Act’s insurance market, which has been rocked by recent actions by President Donald Trump.

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), respectively the chairman and the top Democrat of the Senate Health, Education, Labor and Pensions Committee, negotiated the emerging deal. The milestone agreement, they said, would guarantee payment of “cost-sharing reduction” subsidies that help some policyholders with low incomes afford their deductibles and other out-of-pocket costs for two years, 2018 and 2019.

Trump announced last week that he would stop funding the subsidies, which have been the subject of a long-running lawsuit. These subsidies are separate from the tax credit subsidies that help eligible consumers pay for their premiums. Those premium subsidies are not affected by Trump’s action.

Even if it fails to become law, the deal marks a singular achievement that has been almost completely missing in Congress for the past eight years — a bipartisan compromise on how to make the nation’s health insurance system work.

“This is an agreement I am proud to support,” said Murray on the Senate floor, “because of the message it sends about how to get things done.

The proposal — which will require 60 votes to pass the Senate and agreement from a still-dubious House of Representatives — would also restore $110 million in “outreach” funding cut by the Trump administration. That funding would help guide eligible individuals to sign up for coverage on the health insurance exchanges during the open enrollment period that runs from Nov. 1 to Dec. 15.

In exchange for those provisions, urged by Democrats and state officials, Republicans will win some changes to make it easier for states to apply for “waivers” that would let them experiment with alternative ways to provide and subsidize health insurance. The deal would also allow the sale of less comprehensive “catastrophic” plans in the health exchanges. Such plans currently can be sold only to those under age 30.

On the Senate floor Tuesday afternoon, Alexander said, “This agreement avoids chaos. I don’t know a Democrat or a Republican who benefits from chaos.”

Senate Majority Leader Mitch McConnell (R-Ky.) reserved judgment about the deal.

Both parties still have some major disagreements when it comes to health care, Senate Minority Leader Chuck Schumer (D-N.Y.) told reporters Tuesday afternoon, but “I think there’s a growing consensus that in the short term we need stability in the markets. So we’ve achieved stability if this agreement becomes law.”

More than 60 senators have already participated in the meetings that led to the deal, Alexander said on the Senate floor. But the path to passage in the House is uncertain — with many conservatives vehemently opposed to anything that could be construed as helping the law they call “Obamacare” succeed.

Tweeted Rep. Mark Walker (R-N.C.), chairman of the conservative Republican Study Committee, Tuesday: “The GOP should focus on repealing & replacing Obamacare, not trying to save it. This bailout is unacceptable.”

Both Murray and Alexander said Tuesday they were still struggling over language to make sure that if the cost-sharing payments are resumed, insurers would not receive a windfall by keeping both those payments and the higher premiums that many states are allowing in anticipation of the payments being ended.

“We want to make sure that the cost-sharing payments go to the benefit of consumers, not the insurance companies,” Alexander said.

Trump, who as recently as Monday called the cost-sharing subsidies “a payoff” to insurance companies, took credit for the negotiations. “If I didn’t cut the CSR’s, they wouldn’t be meeting,” he said. That was not, in fact, the case. The negotiations had picked up some weeks ago after being called off earlier in September while the Senate tried for one last-ditch repeal vote.

On Friday, White House Budget Director Mick Mulvaney told Politico that the president would not allow a short-term fix, calling a restoration of the cost-sharing reduction funds “corporate welfare and bailouts for the insurance companies.”

But on Tuesday the president hailed the deal. “We think it’s going to not only save money, but give people much better health care with a very, very much smaller premium spike,” he told reporters.

The Storm Has Passed, But Puerto Rico's Health Faces Prolonged Recovery

KFF Health News, October 17, 2017

The situation in Puerto Rico’s health system is far more vulnerable than those in Texas or Florida, which also weathered hurricanes this fall.

Dr. Sandra Alvarez gives Mercedes Perez a health care checkup in her apartment at the Pedro America Pagan de Colon assisted living facility in San Juan in the aftermath of Hurricane Maria. Members of the First Medical Relief team visited the complex and said the residents need water, and many are hungry and need their medication, which is difficult to get. (Joe Raedle/Getty Images)

This article first appeared October 16, 2017 on Kaiser Health News.

By Carmen Heredia Rodriguez and Rachel Bluth

As President Donald Trump signals impatience to wind down emergency aid to Puerto Rico, the challenges wrought by Hurricane Maria to the health of Puerto Ricans and the island’s fragile health system are in many ways just beginning.

Three weeks after that direct hit, nearly four dozen deaths are associated with the storm. But the true toll on Puerto Rico’s 3.4 million residents is likely to involve sickness and loss of life that will only become apparent in the coming months and in indirect ways.

As victims continue to be found and stranded people reached, it will take time to assess the consequences of their missed care or undertreatment.

The situation in Puerto Rico’s health system is far more vulnerable than those in Texas or Florida, which also weathered hurricanes this fall — medically, economically and politically. A month after Hurricane Katrina in 2005, only about half of the final official fatalities had been tallied.

Puerto Rico has a higher rate of diabetes than any state, according to 2015 data from the U.S. Centers for Disease Control and Prevention. About half of the island’s population depends on Medicaid. And, unlike in the States, Puerto Rico’s Medicaid system receives a fixed amount to meet residents’ needs, a pot of money that could run dry next month, said Jenniffer González-Colón, Puerto Rico’s delegate to Congress.

“We’ve had a fiscal crisis, a Medicaid funding cliff, Hurricane Irma and Hurricane Maria —we are being hit from every angle,” she said.

Orlando Gutiérrez, an associate professor of nephrology at the University of Alabama-Birmingham and a board member of the American Kidney Fund, said Puerto Rico is the “perfect storm” for a disaster.

The Federal Emergency Management Agency has distributed food and water to help stave off disease or dehydration, relief workers have prioritized efforts to get hospitals and other health facilities operating again, and the Navy dispatched the hospital ship USNS Comfort, which has 250 beds.

Coordinated efforts to deliver fuel, water and medications to health facilities have allowed some to reopen. As of Oct. 12, federal emergency officials said nearly all Puerto Rican hospitals were open, although some are still dependent on generators. The Puerto Rican government said electricity has been restored to more than half of the hospitals. Nearly all of the dialysis centers are operating now, though many patients have missed treatments.

But Katia León, deputy director of primary care for the Association of Primary Care in Puerto Rico, said she believes the population’s health has worsened since the storm hit. Cases of diarrhea, pink eye and skin rashes are appearing in larger numbers, she said, and health officials are concerned about infections from contaminated water.

The potential for outbreaks means it is now more important than ever to keep clinics open, León said, even though the operating costs are likely to be high.

“We are talking about a situation that is going to continue in the long term … because this is a crisis without precedent,” she said.

Many residents are still unable to get to clinics or health centers for their chronic health conditions, such as diabetes or heart disease. Diabetes test strips and dialysis equipment have been in short supply since the storm. Patients went days or weeks without medication and treatment. Nutritious food and working refrigerators to store it in are scarce.

Some medicines are in tight supply or require arduous travel to secure.

Slow gains to provide electricity threaten patients on dialysis, who rely on power to filter their blood and survive. And mental trauma caused by the storm will linger long after buildings are reconstructed.

In addition, Puerto Rico was already facing a significant “brain drain,” as many young professionals, including doctors, moved to the U.S. mainland, said Andrew Schroeder, who works for DirectRelief, a private charity that has been coordinating shipments of medical supplies to the island. It will be an uphill battle to persuade these doctors and other health specialists to stay on the island now.

Hospitals and health clinics are working hard to get back to speed. Eddie Perez-Caban, the executive director of the Camuy Health Services clinic on the western side of Puerto Rico, said he was astonished after making the 25-minute commute through downed wires and fallen electric poles the day after Maria hit. He found a damaged roof, a broken air conditioning system and no electricity or running water — and about 75 of his employees ready to work. Five days later, the clinic opened with running water and AC and light powered by a generator.

“For so many people to show up — truthfully, it filled me with a lot of satisfaction to work with a group of people that have that commitment to the community and the patients we serve,” he said.

Republican leaders in the House of Representatives have proposed allotting an additional $1 billion for Puerto Rico’s Medicaid program to resupply its coffers as part of a bill that would extend the Children’s Health Insurance Program. But the legislation has been stalled in committee.

Puerto Rico’s program is different than those in the States. While states receive open-ended federal funding, Puerto Rico’s annual funding amount is capped — typically at more than $300 million. Nearly half of the island’s residents rely on the program for coverage. If the money runs out, as many as 900,000 beneficiaries could lose their health coverage, according to estimates from the Department of Health and Human Services under the Obama administration.

Another bill under consideration in Congress could offer Puerto Rico millions of dollars in disaster relief, an effort that has broad support. More than 6 in 10 Americans said Puerto Rico isn’t getting all the help it needs yet, and more than half said the emergency response has been too slow, with the federal government not doing enough to restore electricity and access to food and water, according to a poll released Thursday by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

In Puerto Rico, most of the roughly four dozen dialysis centers are now seeing patients, though that service is dependent on getting shipments of fuel to power generators and water and dialysis solution for the treatments. Some clinics are shortening their hours and the time of treatment. Instead of four-hour treatments, patients are receiving only three hours of dialysis, which saves on staffing time, supplies and use of generators.

Mike Spigler, an official with the American Kidney Fund, who is handling some of the emergency response for kidney patients on the island, describes the situation as “tenuous.”

In the short term, patients can function without dialysis, or with limited treatments. But as time goes on, the risk of heart failure and stroke begins to climb.

Schroeder also said he is worried about mental health services, which often get lower priority than food and shelter after a storm. He said people are traumatized and, without counseling, anxiety and depression could become major public problems. Multiple news outlets report that two of the island’s 34 total deaths attributed to the hurricane were suicides.

Older residents of the island are particularly vulnerable to mental trauma in the aftermath of the storm, said José Acarón, the director of the Puerto Rican branch of AARP. Approximately 1.2 million people in Puerto Rico are 50 or older, Acarón said. Many of them live outside of traditional nursing homes or independent living facilities, making them harder to reach.

“We still have a lot of challenges to overcome before things can go back to normal,” said Acarón. “But a return to normal is not going back to where we were before the hurricane. It’s a new normal.”

Staff writer Phil Galewitz contributed to this article.

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