Tiny — and very blue — Vermont could be at the leading edge of the health reforms envisioned by the Trump administration and a Republican Congress.
The Green Mountain State, population around 626,000, got a broad waiver last October from the federal government to redesign how its health care is delivered and paid for. The statewide experiment aims to test new payment systems, prevent unnecessary treatments, constrain overall growth in the cost of services and drugs, and address public health problems such as opioid abuse.
The six-year initiative — an outgrowth of a failed attempt by Vermont a few years ago to adopt a single-payer plan for all residents — could eventually encompass almost all of its 16 hospitals, 1,933 doctors and 70 percent of its population, including workers insured through their jobs and people covered under Medicare and Medicaid.
The Obama administration approved the experiment, but it fits the Republican mold for one way the Affordable Care Act could be replaced or significantly modified. The Trump administration and lawmakers in Congress have signaled that they want to allow states more flexibility to test ways to do what Vermont is doing — possibly even in the short-term before Republicans come to an agreement about the future of the ACA.
Two Republican senators, Bill Cassidy of Louisiana and Susan Collins of Maine, introduced legislation in January that would permit individual states to design their own health reforms and keep provisions of the health law intact.
Coincidentally, the ACA contains a provision that allows states to launch such experiments starting this year, as long as they meet the ACA's overall goals for coverage expansions and consumer protections. One possible scenario, then, is that the Trump administration and Congress would agree to retain a version of that provision — modified to make it easier for states to experiment, experts say.
"It's a very reasonable approach, especially if it looks as if Congress can't agree on an immediate replacement plan," said Stuart Butler, a senior fellow in economics and health policy at the Brookings Institution in Washington, D.C. "States have long been the laboratories for social change and policy reform, and I think many governors, Republican and Democrat, would welcome this opportunity."
Chris Jennings, a longtime health policy adviser to Bill and Hillary Clinton and Barack Obama, said Democratic states also may be amenable. "There's a long way to go on this and there are downsides — for example, what would state legislatures actually do — but it looks like it will be a meaningful debate."
'We Want To Simplify How Things Work'
Al Gobeille, Vermont's secretary of Human Services and a Republican serving under newly elected Republican Gov. Phil Scott, said the hope is that the Trump administration will preserve the state's initiative.
"We are doing what [the Republicans] seem to be talking about," said Gobeille, who owns a restaurant company in the state. "We want to simplify how things work, with both coverage and access to care. We want to enhance competition and we want to lower cost growth even as we improve quality."
Scott and Gobeille this month announced the formal launch of the program's pilot phase. In 2017, 30,000 of the state's roughly 190,000 Medicaid patients will get care, under a set budget, through an organization called OneCare Vermont. OneCare's network of hospitals and doctors already provide care to about 100,000 Vermonters.
The state will give OneCare $93 million, in monthly payments, for the care of the 30,000 Medicaid patients — $3,100 per person. If OneCare spends more than $93 million, the company will absorb the loss. If OneCare spends less than that amount, the company and the state share the savings.
"This tests the concept of a global budget and streamlined payment which incentivizes better care," says Todd Moore, OneCare's CEO. "We may be a small state but we are trying a big thing. If it works, many states are likely to stand up and take notice."
Moore added that patients will be informed they are part of the program and can seek redress with the state's Department of Human Services if they feel their care is stinted in any way.
About 30,000 of the state's roughly 190,000 Medicaid patients will get care through an organization called OneCare Vermont. (Screenshot)
In announcing the pilot program, Scott said that if it's successful the experiment will be expanded in 2018 and beyond to encompass the rest of the Medicaid population, Medicare beneficiaries and people who have insurance through private employers and on their own, including through Vermont Health Connect, the state's Obamacare insurance exchange. Additional hospitals, doctors and other providers would become involved, likely under the umbrella of OneCare Vermont.
Medicaid covers almost 30 percent of Vermont residents, Medicare covers 21 percent, and the rest have either private insurance, coverage through the VA or Tricare (military) or are uninsured. About 4 percent of Vermonters were uninsured in 2015, one of the lowest rates in the nation.
Under the terms of Vermont's contract with the Obama administration, the target for the state's maximum overall cost increase in health spending would be 3.5 percent per year from 2018 to 2022 — that's two percentage points lower than the annual 5.6 percent average increase in health care spending nationally the federal government projects between this year and 2025.
Success or failure will also be assessed based on population health and quality of care measures. For example, the plan calls for a reduction of substance abuse deaths by at least 10 percent by 2022. Likewise, the plan sets a target for not more than a 1 percent rise statewide in the number of people with chronic diseases such as diabetes, high blood pressure and COPD (chronic obstructive pulmonary disease). The allowance for the slight increase takes account of the state's aging population.
The number of people with ready access to a primary care physician will also be evaluated, with a target of 90 percent of residents by 2022.
A Shift From 'Fee For Service'
To make all this work, almost every doctor and hospital would have to join OneCare Vermont or create their own accountable care organizations, or ACOs. In these organizations, providers agree to work together to improve and coordinate care and reduce spending under a set budget.
ACOs are also set up to allow payers to gradually shift to global per-patient payment, or other simplified forms of payment, and abandon traditional "fee-for-service" payment. Fee-for-service payment in medicine is widely viewed as providing incentives for excessive and wasteful care, as well as fraudulent billing. Both the Affordable Care Act and a 2015 law setting up an incentive-payment system in Medicare for doctors take major steps to test whether ACOs and alternative payment systems improve the efficiency and quality of care.
Vermont's initiative builds on those efforts.
Some in Vermont are skeptical the experiment will work well, however. Paul Reiss is a family doctor in Williston and chief medical officer for HealthFirst, Vermont's largest independent practice association. HealthFirst represents (but does not own or operate) 66 doctor groups with 250 doctors, physician assistants and nurses. Reiss said the state's largest hospital system — the University of Vermont Medical Center — dominates health care in parts of state.
"We are fearful that much of a restricted pot of money will still go mostly to that company, baking in the inefficiencies of a bloated hospital budget, and not be deployed equitably to the front lines of patient care across the state," Reiss said.
The University of Vermont Medical Center vigorously denied that its budget was bloated. Moore, who is affiliated with the hospital as well as being OneCare Vermont's CEO, said: "Statewide data do not confirm those assertions. The medical center is, in fact, a strong leader in ushering in a value-based system for Vermont."
Scott, in announcing the launch of the pilot phase this month, said if it does not work this year, the state would consider terminating the experiment early.
The ACA was a game changer for these clinics — it has enabled them to get reimbursement for much more of the care they provided. With repeal of the ACA looming, clinic directors said they stay up at night wondering what's next.
Treating people for free or for very little money has been the role of community health centers across the U.S. for decades. In 2015, 1 in 12 Americans sought care at one of these clinics; nearly 6 in 10 were women, and hundreds of thousands were veterans.
The community clinics — now roughly 1,300-strong — have also expanded in recent years to serve people who gained insurance under the Affordable Care Act. In 2015, community health centers served 24.3 million people — up from 19.5 million in 2010. Most of the centers are nonprofits with deep roots in their communities and they meet the criteria to be a federally qualified health center. That means they can qualify for federal grants and a higher payment rate from Medicaid and Medicare.
The ACA was a game changer for these clinics — it has enabled them to get reimbursement for much more of the care they provided, because more of their patients now had private insurance or were on Medicaid. Revenue at many clinics went up overall, and many of the health centers used federal funding available under the law to expand their physical facilities and add more services, such as dentistry, urgent care or mental health care.
With repeal of the ACA looming, clinic directors said they stay up at night wondering what's next. We spoke with four, who all say their clinics are in a holding pattern as Congress debates the health law's future.
Saban Community Clinic, Los Angeles
Julie Hudman, the CEO of Saban Community Clinic in Los Angeles, Calif., said there's a lot at stake for her patients.
"A lot of the folks that we see are single adults," she explained. "They're maybe more transitional. They're homeless patients. They have behavioral health challenges. They're really, to be honest, some of the most vulnerable and poorest patients of all."
Before the ACA went into effect, eligibility for Medi-Cal, as Medicaid is known in California, depended on a variety of factors, including income, household size, family status, disability and others. Under Obamacare, according to the California Department of Health Care Services, people can now qualify for Medi-Cal on the basis of income alone if their household makes less than 138 percent of the federal poverty level — that's $16,395 for an individual and $33,534 for a family of four.
Prior to the ACA, about half of the Saban clinic's 18,000 patients were uninsured, Hudman said. They paid little for treatment — maybe a copay of $5 or $10. Almost all of those patients qualified for Medi-Cal after the health law expanded eligibility, she said, and that's made a big difference for the clinic's bottom line: Medi-Cal pays the clinic around $200 per patient visit.
These days, more than half of Saban's revenue comes from health insurance. The possibility of losing some of that money, Hudman said, is forcing some hard decisions. She had been looking to lease or buy a fourth facility, she said, but now that plan is on hold; as are her hopes of expanding free help for the homeless.
"I'm not willing to move forward and take some of those risks," she said. "I need to make sure that we're able to pay our bills and pay our staff."
Before the last election, Hudman said, "we had a lot of momentum moving forward. And now we've just sort of stalled." — Rebecca Plevin, KPCC, Los Angeles
Jordan Health, Rochester, N.Y.
In the last few years, funding has been on the rise at Jordan Health, in Rochester, N.Y., and so has the extent of the clinic's services.
The boost in funding has partly come from higher reimbursement rates the ACA authorizes, and from the increased number of patients at the clinic who have insurance. But Jordan Health, which has 10 locations in the area, has also benefited from the federal government's pumping of more money into what are known as section 330 grants that enable expansion of services and facilities.
The 330 grant money gives qualified clinics the option of offering services that aren't billable to insurance plans. At Jordan Health, the funds enabled the hiring of some different types of health practitioners who were not previously part of the team — dietitians, behavioral health specialists and care coordinators. And that, in turn, said Janice Harbin, president and CEO of Jordan Health, means patients can increasingly get the different kinds of care they need in one place.
Almost 90 percent of Jordan's patients are considered a racial or ethnic minority, and over 97 percent live at or below 200 percent of the federal poverty line, according to data gathered by the federal Health Resources & Services Administration.
"When you're dealing with a situation of concentrated poverty," Harbin said, "your patient needs more than just 'OK, let me give you a checkup, and pat you on the back and say now go out and do all these things I told you to do.'"
Jordan Health received an increase of about $1 million since 2013, according to its grant coordinator, Deborah Tschappat.
Tschappat said she expects Jordan will get about the same annual award in 2017, assuming federal funding for the 330 program stays about the same. If federal funding is cut significantly, they would potentially lose some services.
For now, Jordan Health plans to "expand services judiciously, while increasing efficiency and productivity," Tschappat said.
In the coming months Harbin and her colleagues will be lobbying lawmakers in Albany and Washington, D.C., to renew Jordan's funding — including the 330 grant, which is set to end in September.
"We're used to doing a lot with a little, but we increasingly know that we do need to have financial support," Harban said. "And that's keeping us up at night." — Karen Shakerdge, WXXI, Rochester
Adelante Healthcare, Phoenix
Adelante Healthcare has been part of the health safety net in Phoenix for nearly four decades — when its doctors began helping farm workers in the city's surrounding fields. But the Affordable Care Act enabled Adelante to expand like a brand new business.
"Adelante has grown by 35 percent in the last 12 months," said Dr. Robert Babyar, Adelante's assistant chief medical officer. "We've increased our provider staffing — almost doubled our providers. And the number of services we provide has doubled."
Adelante operates nine clinics throughout the Phoenix metro area. The one where Babyar met with me includes play areas for children and a dental office.
Most of their 70,000 patients are low-income and about half are covered by either Medicaid or KidsCare — Arizona's version of the Children Health Insurance Program. In 2014, Arizona became one of the Republican-led states that expanded Medicaid under the ACA. That brought more than 400,000 people onto the state's Medicaid rolls and created big demand for Adelante. Low-income patients who did not have insurance before the expansion had relied on Adelante's sliding fee schedule. Much of that population now has health coverage, either through the ACA marketplace or the state.
"That opened up more options for our patients, more specialists they could see, procedures they could have done," Babyar said.
As Congress moves to repeal and replace the health care law, Adelante is in a holding pattern. It has delayed the groundbreaking of a new site until later this year because of the uncertainty. A full repeal of the ACA — without a replacement that keeps its patients covered — would limit any future growth, and strain the new staff and resources it has added. It wouldn't be the first time Adelante had to scale back its services because of changes to Medicaid. In 2010 and 2011, Arizona lawmakers froze enrollment for its CHIP program and for childless adults in Medicaid. Then, in 2012, Adelante lost more than a million dollars.
Babyar said it has taken several years to get their new patients into the system and working with doctors consistently to manage their conditions.
"All the progress we made with those patients to stay and be healthy — that can fall apart really quick," said Babyar. — Will Stone, KJZZ, Phoenix
"Definitely this clinic has benefited from Obamacare," said Dr. Michael Russum, who practices family medicine for Denver Health and helps lead the clinic. "And this population has benefited from Obamacare by the expansion of Medicaid."
That's what helped make the economics work as Denver Health put a new $26 million clinic in a high poverty neighborhood in 2016, said Dr. Simon Hambidge, Denver Health's CEO of Community Health Services. With the ACA in place, he said, the health system was able to count on the new clinic having a population of paying patients with insurance that could help support it.
Hambidge predicted the hospital will weather the storm if Obamacare is repealed and there are serious cuts to safety-net programs, like Medicaid and Medicare, as some Republicans have suggested. But it will probably be harder to open new clinics in other high-need neighborhoods, he conceded.
"We'll survive," Hambidge said. "We may not be able to be as expansive, because we would be back to less secure times." — John Daley, Colorado Public Radio
The bill says that it is the "intent of the Legislature" to enact a law that would establish a single-payer health care program for the benefit of everyone in the state. It does not offer specifics of what the plan would look like, nor does it mention a timetable.
This article first appeared February 22, 2017 on the Kaiser Health News website
Legislation introduced in the California Senate last week would set the state on a path toward the possible creation of a single-payer health care system―a proposal that has failed to gain traction here in the past.
The bill, which is a preliminary step, says that it is the "intent of the Legislature" to enact a law that would establish a comprehensive, single-payer health care program for the benefit of everyone in the state. The legislation, introduced by state Sen. Ricardo Lara (D-Bell Gardens), does not offer specifics of what the plan would look like, nor does it mention a timetable.
A single-payer system would replace private insurance with a government plan that pays for coverage for everyone. Proponents argue that single-payer systems make health care more affordable and efficient, but opponents say they raise taxpayer costs and give government too much power.
Medicare, the federally funded health coverage for the elderly, is often held up as a model of what a single-payer system might look like.
Lara said in an interview late last week that the state needs to be prepared in case the Affordable Care Act is repealed, as President Donald Trump and Congressional Republicans have promised.
"The health of Californians is really at stake here and is at risk with what is being threatened in Congress," Lara said, as the debate continued in Washington about the future of President Barack Obama's signature health law. "We don't have the luxury to wait and see what they are going to do and what the plan is."
Lara noted that while the Affordable Care Act expanded health coverage for many Californians, it left others uninsured or underinsured. He said the single-payer bill builds upon his "health for all kids" legislation, which resulted in coverage beginning last May for 170,000 immigrant children here illegally.
"I've met many children who have asked me point blank, 'What about my mom? What about my dad?' " Lara said.
He recently withdrew a requestto the federal government, based on a bill he had introduced, that would have allowed adult immigrants here illegally to purchase unsubsidized health plans through Covered California, the state's insurance exchange.
According to the text of the Lara's bill, a single-payer system would help address rising out-of-pocket costs and shrinking networks of doctors.
No state has a single-payer health system. Perhaps the best-known effort to create one was in Vermont, but it failed in 2014 after the state couldn't figure out how to finance it. Last year, Colorado residents rejected a ballot measure that would have used payroll taxes to fund a near universal coverage system.
In California, voters rejected a ballot initiative in 1994 that would have established a government-run universal health program. Gov. Arnold Schwarzenegger later vetoed two bills that would have accomplished the same goal.
It's difficult to create consensus on single-payer plans because they dramatically shift how health care is delivered and paid for, said Larry Levitt, a senior vice president at the Kaiser Family Foundation (California Healthline is produced by Kaiser Health News, an editorially-independent program of the foundation.)
"Single-payer plans have lots of appeal in their simplicity and ability to control costs," Levitt said. "But what I think has always held back a move to single-payer is the disruption they create in financing and delivery of care."
The problem, Levitt said, is that even if they end up costing less overall, single-payer plans look to the public like a "very big tax increase."
The California Nurses Association, the primary sponsor of the new bill, is planning a rally in Sacramento this week in support of a single-payer system. Bonnie Castillo, the group's associate executive director, said the goal is to create a system that doesn't exclude anyone and helps relieve patients' financial burdens.
"Patients and their families are suffering as a result of having very high co-pay and premium costs," she said. "They are having to make gut-wrenching decisions whether they go to the doctor or they stick it out and see if they get better on their own."
Castillo said that with so much uncertainty at the national level, California has the ability to create a better system. "We think we can get this right," she said.
Charles Bacchi, president and CEO of the California Association of Health Plans, said he hadn't yet seen the bill, but the trade group has opposed single-payer proposals in the past.
"It's hard to tell until you know the details," Bacchi said. "But past studies have shown [single-payer systems] are incredibly expensive and would be disruptive."
He said health plans, doctors, hospitals and others are "laser-focused on protecting and enhancing the gains we have made in coverage" under the Affordable Care Act and ensuring that California continues to receive critical funding. "We think that's where the focus should be," he said.
One possible concept of a single-payer system in California would be to bring together funding from several sources under one state umbrella: Medi-Cal, which covers the poor; Medicare, the federal program that covers older adults, and private insurance.
Lara said he has not yet figured out the financing, saying that it is still early in the legislative process. But he said that even as California continues to defend the Affordable Care Act, it is time to put forward an alternative.
"I think we've reached a tipping point now that we haven't had before," he said.
Aetna will stop requiring doctors seek approval before prescribing particular medications―such as Suboxone―that are used to mitigate withdrawal symptoms.
Aetna, one of the nation's largest insurance companies, will remove a key barrier for patients seeking medication to treat opioid addiction. The change will take effect in March and apply to commercial plans, a company spokeswoman confirmed, and will make it the third major insurer to make the switch.
Specifically, Aetna will stop requiring doctors seek approval before prescribing particular medications ― such as Suboxone ― that are used to mitigate withdrawal symptoms, and typically given along with steady counseling. The insurance practice, called "prior authorization," can result in delays of hours to days in getting a prescription filled.
The change comes as addiction to opioids, which include heavy-duty painkillers and heroin, still sweeps the country. More than 33,000 people died from overdosing on these drugs in 2015, the most recent year for which statistics are available. And it puts Aetna in the company of Anthem and Cigna, which both recently dropped the prior authorization requirement for privately insured patients across the country. Anthem made the switch in January and Cigna this past fall.
Both companies took the step after facing investigation with New York's attorney general, whose office was probing whether their coverage practices unfairly barred patients from needed treatment. They made this adjustment as part of larger settlements.
It sounds like just a technicality ― a brief delay before treatment. But addiction specialists say this red tape puts people's ability to get well at risk. It gives them a window of time to change their minds or go into withdrawal symptoms, causing them to relapse.
"If someone shows up in your office and says, 'I'm ready,' and you can make it happen right then and there ― that's great. If you say, 'Come back tomorrow, or Thursday, or next week,' there's a good chance they're not coming back," said Josiah Rich, a professor of medicine and epidemiology at Brown University and doctor at Providence-based Miriam Hospital, who frequently treats patients with opioid addictions. "Those windows of opportunity present themselves. But they open and close."
As these major carriers drop the requirement, treatment specialists hope a trend could be emerging in which these addiction meds become more easily available. In New York, for instance, the attorney general's office will be following up with other carriers who still have prior authorization requirements, an office spokesperson said. The office would not specify which carriers it will next examine.
Meanwhile, though little research pinpoints precisely how widespread this coverage practice is for drugs that treat opioid addiction, experts say it's a fairly common practice.
"Just think of any big health insurance company that hasn't recently announced they're doing away with this, and it's a pretty safe bet they've got prior authorization in place," said Andrew Kolodny, a Brandeis University senior scientist and the executive director of Physicians for Responsible Opioid Prescribing, an advocacy group.
How does the problem manifest? Take Boston Medical Center, located in a region that's been particularly hard hit by opioid addiction. Doctors there wanted to launch an urgent care center focused on this patient population. Less than a year old, the program's treated thousands of people.
But prior authorization requirements have been intense, said Traci Green, an associate professor at Boston University's School of Medicine and deputy director of the hospital's injury prevention center. To help people get needed care ― before it was too late ― the center hired a staffer devoted specifically to filling out all the related insurance paperwork.
"It was like, 'This is insanity,'" Green said, adding that "navigating the insurance was a huge problem" for almost every patient.
But defenders of the requirement maintain that such controls have value. Insurance plans using prior authorization may view it as a safeguard when prescribing a potentially dangerous drug. "[It's] not a tool to limit access. It's a tool to ensure patients get the right care," said Susan Cantrell, CEO of the Academy of Managed Care Pharmacy, a trade group.
Other large insurance carriers ― such as United Healthcare and Humana ― list on their drug formularies a prior authorization requirement for at least some if not all versions of anti-addiction medication. A spokesperson from Humana said the practice is used "to ensure appropriate use."
Also, though, it is generally agreed that the practice is used to control the prescribing of expensive medications. Per dose, the cost of these drugs varies based on brand and precise formulation, but it can go as high as almost $500 for a 60-pack dose, which can last a month.
Regardless of intent, critics say, those extra forms and hoops do make it more difficult for patients in need to get these medications ― ultimately, they say, doing more harm than good.
"If you would like a physician to not do a particular treatment, put a prior authorization in front of it," Rich said. "That's what they're used for."
Meanwhile, addiction treatment advocates and health professionals are hoping to build on what they see as new momentum.
Earlier this month, the American Medical Association sent a letter to the National Association of Attorneys General, calling for increased attention to insurance plans that require prior authorization for Suboxone or other similar drugs.
Minnesota's attorney general has written to health plans in the state, asking they end prior authorization for addiction treatment. New York has also heard from other states interested in tackling the issue, the attorney general spokesperson said. And another project, called Parity Track, is soliciting complaints from consumers.
They're arguing based on a requirement that insurance plans, thanks to so-called "parity laws," must cover addiction treatment, and cover it at the same level as they do other kinds of health care.
The prior authorization requirement "doesn't meet the sniff test for parity," said Corey Waller, an emergency physician who chairs the American Society of Addiction Medicine's legislative advocacy committee. "It's a first-line, Food and Drug Administration-approved therapy for a disease with a known mortality. Every other disease with a known mortality ― the first-line drugs are available right away."
But the justification for legal cases like New York's could get weaker. The 2010 health law, which lawmakers are working to repeal, included requirements that mental health and addiction treatment be considered an "essential health benefit." If that disappears, robust coverage for addiction could be less widely available, several noted.
Meanwhile, the stakes are substantial, Rich said. He recalled a patient who was taking a version of buprenorphine ― the active ingredient in Suboxone ― who had a brief relapse with heroin. That led to complications in the paperwork for renewing his prescription for treatment.
"Now he's out of the office, in the street, using more," Rich said of that case. "Incumbent upon [effective treatment] is the ability to get people started right away. If there's prior authorization? It's infuriating."
The number of California seniors who land in emergency rooms after falling has risen sharply in recent years, as their population grows and they live longer with more chronic illnesses often requiring an array of medications.
The number of visits to California emergency rooms by people over 65 who fell surged 38 percent from 167,785 in 2010 to 232,146 in 2015, according to data from the state's Office of Statewide Health Planning and Development.
Some of the rise appears to be explained by the estimated 21 percent growth in the state's senior population, from about 4.28 million in 2010 to 5.19 million in 2015, according to the California Department of Finance.
The ranks of people 85 and older, who account for one-third of all fall-related ER visits, are also swelling: That population grew by 19 percent in the same five-year period, according to the department's data.
In addition to their growing numbers, older adults nationwide have multiple chronic diseases and are taking numerous medications, both of which can contribute to falling, according to the CDC. And elderly adults may have cognitive decline, poor balance, physical weakness, and deteriorated vision.
"These kinds of things really affect the oldest of the old," said Jon Pynoos, professor of gerontology, policy and planning at the USC Leonard Davis School of Gerontology. "They are more prone to have complicated medical conditions."
Nationwide, about 2.8 million older adults are treated in emergency departments each year for injuries caused by falling, and more than 800,000 are hospitalized because of them, according to the U.S. Centers for Disease Control and Prevention.
Medical costs associated with falls are more than $31 billion each year, with hospital care accounting for about two-thirds of those expenses, according to the CDC. About one-fifth of falls cause serious injuries.
Fall-related injuries are particularly worrisome because they can lead to other problems, including immobility and even premature death, said Ted Chan, chairman of the Department of Emergency Medicine at UC San Diego and a professor at the medical school there. Hip fractures, in particular, can lead to severe health problems, including blood clots in the legs and lungs, pneumonia and loss of muscle mass, which can increase the risk of falling again.
"It is often when the real decline really starts to happen," Chan said. "They may never quite fully recover."
He said elderly patients who have serious falls need to be seen in the emergency room because they may have significant injuries requiring immediate medical attention. Doctors also need to determine why they fell.
"It may not be that they just tripped over something," Chan said. "It could be related to their heart or blood pressure."
Certain groups are more likely to end up in the emergency room after a fall, including homeless people, nursing home residents, people who live alone, and those of very advanced age, said Pynoos, the USC gerontology professor.
Joanne Lynch, 86, fell about two years ago while she was outside at night watering the garden at her Sacramento home. She was living alone at the time.
"I went face first into the flower bed," said Lynch, a retired hospital clerk.
A neighbor heard her yell and called 911. At the emergency room, doctors told her she had broken her wrist. Going to the emergency room assured her she didn't have an even more serious injury, she said.
"You can have a lot of things wrong with you internally that you don't even know," she said. "Peace of mind to an older person is worth more than anything else."
Some counties saw sharper increases than others in the number of fall-related emergency room visits by seniors. From 2010 to 2015, the number rose 54 percent in San Bernardino County, 47 percent in San Diego County and 31 percent in Los Angeles County.
The problem could worsen, as 10,000 baby boomers turn 65 every day in the United States.
The CDC urges older adults to talk to their doctors about whether their medications could make them dizzy or sleepy. The agency also recommends seniors build up their strength through exercise or physical therapy, get their eyes checked regularly and ensure their homes are free of hazards that could trip them. The agency also encourages medical providers to screen patients for the risk of falling.
There are several programs that have been proven to reduce fall rates or the fear of falling, according to the National Falls Prevention Resource Center, part of the National Council on Aging. Among them are Stepping On, which helps build seniors' self-confidence by teaching them about such topics as medication and home safety, and the Otago Exercise Program, in which physical therapists work on strength and balance with frail older adults over several months.
"The one good thing is there is more awareness," Pynoos said. "But people have to practice what they learn."
Low-wage workers were less likely to get preventive care even though many of those services are available without cost-sharing under the 2010 health law.
Low-wage workers with job-based health insurance were significantly more likely than their higher-income colleagues to wind up in the emergency department or be admitted to the hospital, in particular for conditions that with good primary care shouldn't result in hospitalization, a new study found.
At the same time, low-wage workers were much less likely to get preventive care such as mammograms and colonoscopies, even though many of those services are available without cost-sharing under the 2010 health law.
There's no single reason for the differences in health care use by workers at different wage levels, said Dr. Bruce Sherman, an assistant clinical professor at Case Western Reserve University in Cleveland and the study's lead author, which was published in the February issue of Health Affairs.
Finances often play a role. Half of workers with employer-sponsored insurance are enrolled in plans with a deductible of at least $1,000 for single coverage. As deductibles and other out-of-pocket costs continue to rise, low-wage workers may opt to pay the rent and put food on the table rather than keep up-to-date with regular doctor visits and lab work to manage their diabetes, for example.
Likewise, convenient access to care can be problematic for workers at the lower end of the pay scale.
"Individuals are penalized if they leave work to seek care," Sherman said. "So they go after hours and their access to care is limited to urgent care centers or emergency departments."
The study examined the 2014 health care claims, wage and other data of nearly 43,000 workers at four self-funded companies that offered coverage through a private health insurance exchange. Workers were stratified into four categories based on annual maximum wages of $30,000, $44,000, $70,000 and more than $70,000.
Workers in the lowest wage category were three times more likely to visit the emergency department than top earners, and more than four times more likely to have avoidable hospital admissions for conditions such as bacterial pneumonia or urinary tract infections. But they used preventive services only half as often, the study found.
There are no easy solutions. Varying premiums or deductibles based on workers' wages could take some of the bite out of low-wage workers' out-of-pocket costs, but very few employers have adopted that strategy, Sherman said. Offering plans that pay for certain services, such as care related to chronic conditions, before the deductible is met could boost the use of care. But preventive services are available without cost-sharing in most plans and many low-wage workers aren't getting recommended services.
"Health literacy concerns are important," said Sherman, but it may not be the only barrier. "Some focus groups I've participated in, employees have said, 'I understand the services are free, but if an abnormality is found that requires further services, I'll have to [pay for it]. So because I feel fine, I'm not going to go.'"
The Trump administration's new regulation makes it harder for patients to sign up outside of annual open enrollment periods and would allow insurers to collect past-due premiums before starting coverage for a new year.
While Congress continues to struggle with how to "repeal and replace" the Affordable Care Act, the Trump administration today unveiled its first regulation aimed at keeping insurers participating in the individual market in 2018.
"These are initial steps in advance of a broader effort to reverse the harmful effects of Obamacare, promote positive solutions to improve access to quality, affordable care and ensure we have a health system that best serves the needs of all Americans," Tom Price, secretary of the Department of Health and Human Services said in a Twitter message.
But the new rule, which had been widely expected, was actually begun by the outgoing Obama administration. In part, it is an effort to address complaints by insurers that consumers were "gaming" the system to purchase coverage only when they were sick and then dropping it when they were healthy.
To combat that, the regulation makes it harder for patients to sign up outside of annual open enrollment periods and would allow insurers to collect past-due premiums before starting coverage for a new year. It would also shorten the annual enrollment period by half, from three months to 45 days, ending right between Thanksgiving and Christmas. And it would give insurers more flexibility in the types of plans they offer and return regulation of the size and adequacy of health care provider networks to the states.
But it remains unclear whether the action will be too little, too late to ensure insurance is available next year. That would be necessary to keep congressional Republicans' promises that people "do not get the rug pulled out from under them" during the transition to a new program, as House Speaker Paul Ryan (R-Wis.) says frequently.
On Tuesday, Humana announced it would stop selling policies in the health exchanges at the end of this year, and on Wednesday Mark Bertolini, the CEO of Aetna, suggested his firm might follow suit, repeating GOP charges that the individual market exchanges are in a "death spiral" where only sick people buy coverage.
While Humana was not a major player in the state exchange market—it only sold policies in 11 states for 2017—its exit could leave at least 16 counties in Tennessee, including Knoxville, with no insurance company offering policies on the health exchange, according to data from the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
That alarmed Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, who has been one of the leading voices in Congress advocating a slower repeal and replace strategy.
"Yesterday's news from Humana should light a fire under every member of Congress to work together to rescue Americans trapped in the failing Obamacare exchanges before they have no insurance options next year," Alexander said in a statement.
Last year Aetna's Bertolini also cited losses in the market as the reason for the company's scaling back participation in the exchanges, although in an unrelated case, a judge's ruling later said the decision had at least as much to do with pushing federal officials to allow Aetna to merge with Humana. On Monday that merger was officially called off after being blocked by a judge.
The new rules were greeted with cautious optimism by insurance industry trade groups.
"While we are reviewing the details, we support solutions that address key challenges in the individual market, promote affordability for consumers, and give states and the private sector additional flexibility to meet the needs of consumers," Marilyn Tavenner, president and CEO of America's Health Insurance Plans, said in a statement.
The Alliance of Community Health Plans, which represents nonprofit insurers, called the regulation "a promising first step." But in a statement, president and CEO Ceci Connolly warned that the rule "does not resolve all of the uncertainty for plans and patients alike. Without adequate funding it will be extremely difficult to provide high-quality, affordable coverage and care to millions of Americans."
Ron Pollack, executive director of the consumer group Families USA, said the new administration "is deliberately trying to sabotage the Affordable Care Act, especially by making it much more difficult for people to enroll in coverage."
Sick people are likely to jump through any hoops required to get coverage, but healthy people are less inclined to sign up when it is more difficult. So by making it harder for healthy people to enroll, said Pollack, "they are creating their own death spiral that would deter young adults from gaining coverage, thereby driving up costs for everyone."
And the American Cancer Society said that the new rules could hurt cancer patients in particular—for example, when they need to purchase new coverage after becoming too sick to work or moving to be closer to health providers. The proposed changes "would require documentation that is often challenging to quickly obtain," and could "delay a patient's treatment and jeopardize a person's chance of survival," said a statement from Chris Hansen, president of the society's Cancer Action Network.
Meanwhile, the Republican-led Congress remains in a deadlock between conservatives in the House, who want to repeal the health law as soon as possible, and moderates in the Senate like Alexander, who want to wait until there is agreement on what will replace it.
"We should just do what we said we would do," Rep. Raul Labrador (R-Idaho) told reporters on Tuesday.
Conservatives say, at a minimum, Congress should pass the partial repeal bill it passed in 2015 that President Barack Obama vetoed. That measure would eliminate the expansion of the Medicaid program, financial help for people to purchase insurance, the penalties for not having coverage, and all the taxes that pay for the program, among other things.
"Why would it be difficult to get [the Senate] to vote for something they already voted for?" asked Rep. Mark Meadows (R-N.C.).
But congressional budget scorekeepers in January said that bill, which has no replacement provisions, could result in a doubling of premiums and 32 million more people without insurance.
And Republicans in the Senate, as well as President Donald Trump, continue to say that repeal and replace should take place simultaneously.
"I thought we were embarked on an effort to replace it," said Sen. John McCain (R-Ariz.).
Nearly 14,000 providers billed almost $35 million—including nearly $16 million paid by Medicare—for advance care planning conversations from January through June.
End-of-life counseling sessions, once decried by some conservative Republicans as "death panels," gained steam among Medicare patients in 2016, the first year doctors could charge the federal program for the service.
Nearly 14,000 providers billed almost $35 million — including nearly $16 million paid by Medicare — for advance care planning conversations for about 223,000 patients from January through June, according to data released this week by the Centers for Medicare & Medicaid Services. Full year figures won't be available until July, but use appears to be higher than anticipated.
Controversy is threatening to reemerge in Congress over the funding, which pays doctors to counsel some 57 million Medicare patients on end-of-life treatment preferences. Rep. Steve King, R-Iowa, introduced a bill last month, the Protecting Life Until Natural Death Act, which would revoke Medicare reimbursement for the sessions, which he called a "yet another life-devaluing policy."
"Allowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years," King said on Jan. 11.
While the fate of King's bill is highly uncertain — the recently proposed measure hasn't seen congressional action — it underscores deep feelings among conservatives who have long opposed such counseling and may seek to remove it from Medicare should Republicans attempt to make other changes to the entitlement program.
Proponents of advance care planning, however, cheered evidence of program's early use as a sign of growing interest in late stage life planning.
"It's great to hear that almost a quarter million people had an advance care planning conversation in the first six months of 2016," said Paul Malley, president of Aging with Dignity, a Florida nonprofit. "I do think the billing makes a difference. I think it puts it on the radar of more physicians."
Use of the counseling sessions is on track to outpace an estimate by the American Medical Association, which projected that about 300,000 patients would receive the service in the first year, according to the group, which backed the rule.
Providers in California, New York and Florida led use of the policy that pays about $86 a session for the first 30-minute office-based visit and about $75 per visit for any additional sessions.
The rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions.
The new reimbursement led Dr. Peter Sutherland, a family medicine physician in Morristown, Tenn., to schedule more end-of-life conversations with patients last year.
"They were very few and far between before," he said. "They were usually hospice-specific."
Now, he said, he has time to have thorough discussions with patients, including a 60-year-old woman whose recent complaints of back and shoulder pain turned out to be cancer that had metastasized to her lungs. In early January, he talked with an 84-year-old woman with Stage IV breast cancer.
"She didn't understand what a living will was," Sutherland said. "We went through all that. I had her daughter with her and we went through it all."
The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians' assistants may also seek payment for end-of-life talks.
The idea of letting Medicare reimburse such conversations was first introduced in 2009 during debate on the Affordable Care Act. The issue quickly fueled allegations by some conservative politicians, such as former Republican vice presidential candidate Sarah Palin and presidential candidate John McCain, that they would lead to "death panels" that could disrupt care for elderly and disabled patients.
The idea was dropped "as a direct result of public outcry," King said in a statement.
"The worldview behind the policy has not changed since then and government control over this intimate choice is still intolerable to those who respect the dignity of human life," he said.
But in 2015, CMS officials quietly issued the new rule allowing Medicare reimbursement as a way to improve patients' ability to make decisions about their care.
End-of-life conversations have occurred in the past, but not as often as they should, Malley said. Many doctors aren't trained to have such discussions and find them difficult to initiate.
"For a lot of health providers, we hear the concern that this is not why patients come to us," Malley said. "They come to us looking to be cured, for hope. And it's sensitive to talk about what happens if we can't cure you."
A 2014 report by the Institute of Medicine, a panel of medical experts, concluded that Americans need more help navigating end-of-life decisions. A 2015 Kaiser Family Foundation poll found that 89 percent of people surveyed said health care providers should discuss such issues with patients, but only 17 percent had had those talks themselves. (KHN is an editorially independent program of the foundation.)
Use of the new rule was limited in the first six months of 2016. In California, which recorded the highest Medicare payments, about 1,300 providers provided nearly 29,000 services to about 24,000 patients at an overall cost of about $4.4 million — including about $1.9 million paid by Medicare.
The data likely reflect early adopters who were already having the talks and quickly integrated the new billing codes into their practices, said Dr. Ravi Parikh, an internal medicine resident at Brigham and Women's Hospital in Boston, who has written about advance care planning. Many others still aren't aware, he said.
Data from Athenahealth, a medical billing management service, found that only about 17 percent of 34,000 primary care providers at 2,000 practices billed for advance care planning in all of 2016.
The numbers will likely grow, said Malley, who noted that requests from doctors for advance care planning information tripled during the past year.
To counter objections, providers need to ensure that informed choice is at the heart of the newly reimbursed discussions.
"If advance care planning is only about saying no to care, then it should be revoked," Malley said. "If it truly is about finding out patient preferences on their own turf, it's a good thing."
The confirmation of Tom Price, the orthopedic surgeon-turned-Georgia congressman, as secretary of Health and Human Services represents the latest victory in the ascendancy of a little-known but powerful group of conservative physicians in Congress he belongs to — the GOP Doctors Caucus.
During the Obama administration, the caucus regularly sought to overturn the Affordable Care Act, and it's now expected to play a major role determining the Trump administration's plans for replacement.
Robert Doherty, a lobbyist for the American College of Physicians, said the GOP Doctors Caucus has gained importance with Republicans' rise to power. "As political circumstances have changed, they have grown more essential," he said.
"They will have considerable influence over the considerable discussion on repeal and replace legislation," Doherty said.
Price's supporters have touted his medical degree as an important credential for his new position, but Price and the caucus members are hardly representative of America's physician in 2017. The "trust us, we're doctors" refrain of the caucus obscures its heavily conservative agenda, critics say.
"Their views are driven more by political affiliation," said Mona Mangat, an allergist-immunologist and chair of Doctors for America, a 16,000-member organization that favors the current health law. "It doesn't make me feel great. Doctors outside of Congress do not support their views."
For example, while the American College of Obstetrics and Gynecology has worked to increase access to abortion, the three obstetrician-gynecologists in the 16-member House caucus are anti-abortion and oppose the ACA provision that provides free prescription contraception.
While a third of the U.S. medical profession is now female, 15 of the 16 members of the GOP caucus are male, and only eight of them are doctors. The other eight members are from other health professions, including a registered nurse, a pharmacist and a dentist. The nurse, Diane Black of Tennessee, is the only woman.
On the Senate side, there are three physicians; all of them Republican.
While 52 percent of American physicians today identify as Democrats, just two out of the 14 doctors in Congress are Democrats.
About 55 percent of physicians say they voted for Hillary Clinton and only 26 percent voted for Donald Trump, according to a survey by Medscape in December.
Meanwhile, national surveys show doctors are almost evenly split on support for the health law, mirroring the general public. And a survey published in the New England Journal of Medicine in January found almost half of primary care doctors liked the law, while only 15 percent wanted it repealed.
Rep. Michael Burgess, R-Texas, a caucus member first elected in 2003, is one of the longest serving doctors in Congress. He said the anti-Obamacare Republican physicians do represent the views of the profession.
"Doctors tend to be fairly conservative and are fairly tight with their dollars, and that the vast proportion of doctors in Congress [are] Republican is not an accident," Burgess said.
Price's ascendancy is in some ways also a triumph for the American Medical Association, which has long sought to beef up its influence over national health policy. Less than 25 percent of AMA members are practicing physicians, down from 75 percent in the 1950s.
Price is an alumnus of a boot camp the AMA runs in Washington each winter for physicians contemplating a run for office. Price is one of four members of the caucus who went through the candidate school. In December, the AMA immediately endorsed the Price nomination, a move that led thousands of doctors who feared Price would overturn the health law to sign protest petitions.
Even without Price, Congress will have several GOP physicians in leadership spots in both the House and Senate.
Those include Rep. Phil Roe of Tennessee, the caucus co-chair, who also chairs the House Veterans Affairs Committee, and Burgess, who chairs the House Energy and Commerce subcommittee on health. Sen. Bill Cassidy of Louisiana sits on both the Finance and the Health, Education, Labor and Pension Committees. Sen. John Barrasso of Wyoming chairs the Senate Republican Policy Committee.
Roe acknowledges that his caucus will have newfound influence. Among his goals in molding an ACA replacement are to kill the requirement that most people buy health insurance (known as the individual mandate) as well as to end the obligation that 10 essential benefits, such as maternity and mental health care, must be in each health plan.
He said the caucus will probably not introduce its own bill, but rather evaluate and support other bills. The caucus could be a kingmaker in that role. "If we came out publicly and said we cannot support this bill, it fails," Roe said.
The GOP Doctors Caucus has played a prominent role in health matters before Congress. For example, in 2015, when former House Speaker John Boehner needed help to permanently repeal a Medicare payment formula that threatened physicians with double-digit annual fee cuts, he turned to the GOP Doctors Caucus. It got behind a system to pay doctors based on performance — the so-called doc fix.
"When the speaker had a unified doctors' agreement in his coat pocket, he could go to Minority Leader Nancy Pelosi and show that, and that had a lot to do with how we got this passed," Roe said.
But not all doctors are unified behind the caucus. Rep. Raul Ruiz, one of the two physicians in the House who are Democrats, said he worries because few doctors in Congress are minorities or primary care doctors.
Ruiz, an emergency room physician from California who was elected in 2012, said he is wary about Price leading HHS because he is concerned Price's policies would increase the number of Americans without insurance.
Indeed, many doctors feel the caucus' proposals will not reflect their views — or medical wisdom. "My general feeling whenever I see any of their names, is that of contempt," said Don McCanne of California, a senior fellow and past president of the Physicians for a National Health Program. "The fact that they all signed on to repeal of ACA while supporting policies that would leave so many worse off demonstrated to me that they did not represent the traditional Hippocratic traditions which place the patient first."
Robert Califf, MD, who stepped down last month, shared his thoughts about keeping Americans safe — and making sure drugs actually work — after about a year overseeing the federal agency.
The just-departed commissioner of the Food and Drug Administration has concerns about plans to speed up drug approvals and dramatically reduce regulations at the agency, as advocated recently by President Donald Trump.
Dr. Robert Califf, who stepped down last month, shared his thoughts about keeping Americans safe — and making sure drugs actually work — after about a year overseeing the federal agency. His takeaways:
1. Faster drug approvals, being advocated by Trump and others, don't necessarily mean less expensive drugs.
"What I'm concerned about is that when people hear 'faster approval,' you get an image of the FDA sitting on this application and, you know, twiddling thumbs," Califf said. "That's not what happens."
Califf explained that the slow part of getting a drug into patients' hands happens well before the drugmaker submits an application to the FDA. It can take decades to discover, tweak and test a new drug molecule, and that development process is what needs a boost.
"The real action [happens] before the application gets submitted and that can be a time frame from years to decades as people try to figure out what will work and what will not," Califf said.
Although faster drug development could bring development costs down, Califf said, "There's not a direct relationship between the cost of development and the price of drugs or devices."
2. A law passed in December should streamline drug approvals — in a positive way.
The 21st Century Cures Act, a bipartisan bill signed by President Barack Obama late last year, is a "very well-rounded piece of legislation that will speed up product development."
To begin with, it encourages the FDA to consider pieces of information in its approval process in addition to traditional clinical trials, including "real world evidence" and biomarkers. Biomarkers are used in studies in place of outcomes that are more difficult to measure. For example, tumor shrinkage is sometimes a biomarker for surviving cancer.
"Using real world evidence in clinical trials is one that I'm particularly excited about as a way to get better answers at a lower cost and faster at the same time," Califf said.
3. But Califf has concerns about maintaining drug safety standards and ensuring thorough clinical trials.
"The concept of safety is much more complex than most people think about until they look into it deeply," Califf said. "All drugs have risk. None of them are absolutely safe. And the actual safety risks are only revealed through clinical trials with the same quality and number of patients involved as it takes to look at efficacy."
About 92 percent of drugs that get into human clinical trials don't make it to market because they fail to show any benefit or, worse, they have unexpected toxicity, he said.
"Declaring a drug is safe after very little information is treacherous," Califf said.
Califf recently wrote for JAMAon the FDA's balancing act of protecting the public and encouraging innovation. And the FDA released a paper last month documenting examples of a promising drug, vaccine or device that each did well in a Phase 2 clinical trial but "bombed out" in Phase 3, Califf said. Drugs typically go through three "phases" of studies called clinical trials before gaining FDA approval. With each new phase, researchers test drugs or other products on more people and on more measures of safety and effectiveness.
"It's 22 examples of why it's a big mistake to think that you can judge the balance of risk and benefit from a small amount of data," Califf said.
4. Faster, better drugs can't be approved if the FDA is understaffed, he argued.
Califf called a potential FDA hiring freeze "unfortunate" and said new staff is needed to meet the faster approval timelines and to give advice to those developing drugs so "bad mistakes" aren't made.
The FDA has been steadily hiring staff to keep up with the growing industry it oversees. But hundreds of openings are still left to be filled.
Califf said the drug industry's most valued interaction with the FDA is "during the process of [drug] development," which begins before a drug application is submitted for approval. FDA staff can provide timely feedback and advice that can help a company choose the right studies needed for approval and, effectively, speed up drug development.
"A hiring freeze at this time when we are just revving up with 21st Century Cures is unfortunate. I hope that the dust will settle soon and the FDA can get back to its hiring," Califf said.
5. The FDA is using big data to track the safety of drugs already on the market — and it plans to do that a lot more.
The FDA has an established adverse event database but after pain reliever Vioxx was pulled from the market in 2004, the agency began working on a system called Sentinel.
The initiative uses claims data to look at drug safety. It has 180 million individual electronic records and tracks every dispensed prescription, hospitalization as well as serious outcomes, Califf said. In addition, Sentinel is now being opened up to industry and academia.
"It's used every day by the FDA," Califf said, adding that the system is "getting better and better."
KHN's coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.