Hospices Grapple With Stolen Meds

KFF Health News, August 23, 2017

Several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.

This article first appeared August 22, 2017 on Kaiser Health News.

By Melissa Bailey

Nothing seemed to help the patient — and hospice staff didn’t know why.

They sent home more painkillers for weeks. But the elderly woman, who had severe dementia and incurable breast cancer, kept calling out in pain.

The answer came when the woman’s daughter, who was taking care of her at home, showed up in the emergency room with a life-threatening overdose of morphine and oxycodone. It turned out she was high on her mother’s medications, stolen from the hospice-issued stash.

Dr. Leslie Blackhall handled that case and two others at the University of Virginia’s palliative care clinic, and uncovered a wider problem: As more people die at home on hospice, some of the powerful, addictive drugs they are prescribed are ending up in the wrong hands.

Hospices have largely been exempt from the national crackdown on opioid prescriptions because dying people may need high doses of opioids. But as the nation’s opioid epidemic continues, some experts say hospices aren’t doing enough to identify families and staff who might be stealing pills. And now, amid urgent cries for action over rising overdose deaths, several states have passed laws giving hospice staff the power to destroy leftover pills after patients die.

Blackhall first sounded the alarm about drug diversion in 2013, when she found that most Virginia hospices she surveyed didn’t have mandatory training and policies on the misuse and theft of drugs. Her study spurred the Virginia Association for Hospices and Palliative Care to create new guidelines, and prompted national discussion.

Most hospice patients receive care in the place they call home. These settings can be hard to monitor, but a Kaiser Health News review of government inspection records sheds light on what can go wrong. According to these reports:

  • In Mobile, Ala., a hospice nurse found a man at home in tears, holding his abdomen, complaining of pain at the top of a 10-point scale. The patient was dying of cancer, and his neighbors were stealing his opioid painkillers, day after day.

  • In Monroe, Mich., parents kept “losing” medications for a child dying at home of brain cancer, including a bottle of the painkiller methadone.

  • In Clinton, Mo., a woman at home on hospice began vomiting from anxiety from a tense family conflict: Her son had to physically fight off her daughter, who was stealing her medications. Her son implored the hospice to move his mom to a nursing home to escape the situation.

In other cases, paid caregivers or hospice workers, who work largely unsupervised in the home, steal patients’ pills. In June, a former hospice nurse in Albuquerque, N.M., pleaded guilty to diverting oxycodone pills first by recommending prescriptions for hospice patients who didn’t need them and then intercepting the packages with the intention of selling the drugs herself.

Hospice, available to patients who are expected to die within six months, is seeing a dramatic rise in enrollment as more patients choose to focus on comfort, instead of a cure, at the end of life.

The fast-growing industry serves more than 1.6 million people a year. Most of hospice care is covered by Medicare, which pays for hospices to send nurses, aides, social workers and chaplains, as well as hospital beds, oxygen machines and medications to the home.

There’s no national data on how frequently these medications go missing. But “problems related to abuse of, diversion of or addiction to prescription medications are very common in the hospice population, as they are in other populations,” said Dr. Joe Rotella, chief medical officer of the American Academy of Hospice and Palliative Medicine, a professional association for hospice workers.

“It’s an everyday problem that hospice teams address,” Rotella said. In many cases, opioid painkillers or other controlled substances are the best treatment for these patients, he said. Hospice patients, about half of whom sign up within two weeks of death, often face significant pain, shortness of breath, broken bones, or aching joints from lying in bed, he said. “These are the sickest of the sick.”

Earlier this year in Missouri, government investigators installed a hidden camera in a 95-year-old hospice patient’s kitchen to investigate suspected theft. A personal care aide was charged with stealing the patient’s hydrocodone pills, opiate painkillers, and replacing them with acetaminophen, the active ingredient in Tylenol. Hospice nurses in Louisiana and Massachusetts also have been charged in recent years with stealing medication from patients’ homes.

But many suspected thefts don’t get caught on hidden cameras, or even reported.

In Oxnard, Calif., in 2015, a person claiming to be a hospice employee entered the homes of five patients and tried to steal their morphine, succeeding twice. The state cited the hospice for failing to report the incidents.

In Norwich, Vt., in 2013, a family looked for morphine to ease a dying patient’s shortness of breath. But the bottle was missing from the hospice-issued comfort care kit. The family suspected that an aide, who no longer worked in the home, had stolen the drug, but they had no proof. State inspectors cited the hospice, Bayada Home Health Care, for failing to investigate.

David Totaro, spokesman for Bayada Home Health Care, told KHN that situations like that are “very rare” at the hospice, which takes precautions, such as limiting medication supply, to prevent misuse.

There is no publicly available national data on the volume of opioids hospices prescribe. But OnePoint Patient Care, a national hospice-focused pharmacy, estimates that 25 to 30 percent of the medications it delivers to hospice patients are controlled substances, according to Erik Jung, a vice president of pharmacy operations.

Jung said company drivers deliver medications in unmarked cars to prevent attempted robberies, which have happened on occasion.

Two recent studies suggest hospice doctors and social workers across the country are not prepared to screen patients and families for drug misuse, nor to address the theft of pain medication.

For family members struggling with addiction, bottles of pills lying around the house can be hard to resist. Sarah B., a 43-year-old construction worker in Vancouver, Wash., said when her father entered hospice care at his home in Oregon, she was addicted to opioids, stemming from a hydrocodone prescription for sciatica.

After he died, hundreds of pills were left on his bedside table. She took them all, enough Norco, oxycodone and morphine to last a month.

“I have some shame about it,” said Sarah, who declined to give her full last name because of the nature of her actions.

Sarah, who was one of her father’s primary caretakers, said the hospice “didn’t talk about addiction or ask if any one of us were addicts or any of that.”

“No one gave us instructions on how to dispose of all the medications that were left,” she added.

Medicare requires hospices to establish a safe way to administer drugs to each patient — by identifying a reliable caregiver, staff member or volunteer to manage the drugs or, if need be, relocating the patient. And it requires hospices to set policies, and talk to families, about how to safely manage and dispose of medications.

But there’s little oversight: Unlike nursing homes, hospices may go years without inspection, and even when they are cited for noncompliance, they rarely face any consequence except coming up with a plan to improve.

And in most states, hospices have little control over the pills after a patient dies. The U.S. Drug Enforcement Administration encourages hospice staff to help families destroy leftover medications, but forbids staff from destroying the meds themselves unless allowed by state law. Leftover pills belong to the family, which has no legal obligation to destroy them or give them up.

However, some states are taking action. In the past three years, Ohio, Delaware, New Jersey and South Carolina have passed laws giving hospice staff authority to destroy unused drugs after patients die. Similar bills moved forward in Illinois, Wisconsin and Georgia this year.

In Massachusetts, one of the states hit hardest by drug overdose deaths, VNA Care Hospice and Palliative Care advises families to empty leftover pills into kitty litter or coffee grounds before disposal — a common practice to prevent reuse, since flushing them down the toilet is now considered environmentally hazardous.

But families “don’t have to comply,” said VNA Care medical director Dr. Joel Bauman. “Our experience is maybe only half do. We don’t know what happens to these medications. And we have no right, really, to further inquire.”

Hospices across the country told KHN they take precautions, including counting pills when nurses visit the homes, limiting the volume of each drug delivery, giving families locked boxes for medication and giving patients random urine tests. They also said they prescribe medications that are harder to misuse, such as methadone.

Some, like VNA Care, have also started screening families of patients for history of drug addiction, and writing up agreements with families outlining the consequences if drugs go missing.

But “there’s so much moral distress” about punishing dying patients for family members’ actions, said Bauman. He said he tries to avoid doing that: “Why should we fire a patient for having inappropriate pill counts, when it may not be their fault in the first place?”

Though Blackhall helped spark a national discussion about hospice drug diversion, she said she’s also worried about restricting access to painkillers. Hospices must strike a balance, she said.

“It’s important to treat the horrible suffering that people have from cancer,” said Blackhall. But substance abuse is another form of suffering which is “horrible for anyone in the family or community that might end up getting those medications.”

Often Missing In The Health Care Debate: Women’s Voices

KFF Health News, August 21, 2017

In recent months, as leaders in Washington discussed the future of American healthcare, women were not always allowed in the room.

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

By Anna Gorman and Jenny Gold

Women, in particular, have a lot at stake in the fight over the future of health care.

Not only do many depend on insurance coverage for maternity care and contraception, they are struck more often by such diseases as autoimmune conditions, osteoporosis, breast cancer and depression. They are more likely to be poor and depend on Medicaid — and to live longer and depend on Medicare. And it commonly falls to them to plan health care and coverage for the whole family.

Yet in recent months, as leaders in Washington discussed the future of American health care, women were not always allowed in the room. To hammer out (behind closed doors) the Senate’s initial version of a bill to replace Obamacare, Majority Leader Mitch McConnell appointed 12 colleagues, all male. Some Congress members made clear they don’t see issues like childbirth as a male concern. Why, two GOP representatives wondered aloud during the House debate this spring, should men pay for maternity or prenatal coverage?

It is telling, perhaps, that two of the three GOP senators to kill the Republican’s repeal bill were women. Though Arizona Sen. John McCain’s vote was most heralded by the bill’s opponents, Sens. Lisa Murkowski of Alaska and Susan Collins of Maine voiced objections all along, including to plans to suspend Planned Parenthood funding. And for their opposition they were pilloried — even threatened — by members of their own party.

Republican repeal efforts are stalled, for now, but the fate of America’s health care system remains highly uncertain.

Many of the programs women depend on are still targets, most especially Medicaid, which pays for about half of U.S. births. Some programs are already shrinking under the Republican-controlled government — federal funding for teen pregnancy prevention and research, for example. In addition, states have been empowered to cut Title X family planning programs.

Discussion over health reform shows some signs of becoming more open and bipartisan, perhaps bringing more women’s perspectives to the debate.

But women are hardly speaking in unison when it comes to overhauling health care. “Women’s health” means very different things to different people, based on their backgrounds and ages. A 20-year-old may care more about how to get free contraception, while a 30-year-old may be more concerned about maternity coverage. Women in their 50s might be worried about access to mammograms, and those in their 60s may fear not being able to afford insurance before Medicare kicks in at 65.

Many older women vividly recall when abortion in the U.S. was performed dangerously and illicitly; some fought hard for the right to choose termination that was affirmed in the 1973 Roe v. Wade Supreme Court decision. Still, nearly 45 years later, the nation remains at war over abortion, and women are on both sides of that battle. More than a third say it should be illegal in most or all cases.

To get a richer sense of women’s viewpoints on health care as the national debate continues, we asked several around the country and across generations to share their thoughts and personal experiences.

Patricia Loftman, 68

New York City

Loftman spent 30 years as a certified nurse-midwife at Harlem Hospital Center and remembers treating women coming in after having botched abortions.

Some didn’t survive.

“It was a really bad time,” Loftman said. “Women should not have to die just because they don’t want to have a child.”

Now retired, Patricia Loftman, 68, is a board member for the American College of Nurse-Midwives and advocates for better care for minority women. (Courtesy of Patricia Loftman)

When the Supreme Court ruled that women had a constitutional right to an abortion, Loftman remembers feeling relieved. Now she’s angry and scared about the prospect of stricter controls. “Those of us who lived through it just cannot imagine going back,” she said.

A mother and grandmother, Loftman also recalls clearly when the birth control pill became legal in the 1960s. She was in nursing school in upstate New York and glad to have another, more convenient option for contraception. Already, women were gaining more independence, and the Pill “just added to that sense of increased freedom and choice.”

To her, conservatives’ attack on Planned Parenthood, which already has closed many clinics in several states, is frustrating because the organization also provides primary and reproductive health care to many poor women who wouldn’t be able to get it otherwise.

Now retired, Loftman sits on the board of the American College of Nurse-Midwives and advocates for better care for minority women. “There continues to be a dramatic racial and ethnic disparity in the outcome of pregnancy and health for African-American women and women of color,” she said.

Terrisa Bukovinac, 36

San Francisco

Bukovinac calls herself a passionate pro-lifer. As president of Pro-Life Future of San Francisco, she participates in marches and protests to demonstrate her opposition to abortion.

“Our preliminary goal is defunding Planned Parenthood,” she said. “That is crucial to our mission.”

Terrisa Bukovinac, 36, serves as president of Pro-Life Future of San Francisco and participates in anti-abortion demonstrations. (Courtesy of Terrisa Bukovinac)

As much as the organization touts itself as being a place where people get primary care and contraception, “abortion is their primary business model,” Bukovinac said.

She said the vast majority of abortions are not justifiable and that she supports a woman’s right to an abortion only in cases that threaten the patient’s life. “We are opposed to what we consider elective abortions,” she said.

Bukovinac said she also tries to help women in crisis get financial assistance so they don’t end their pregnancies just because they can’t afford to have a baby. “We have to help women obtain the resources necessary to sustain their pre-born children’s lives,” she said.

She supports women’s access to health insurance and health care, both of which are costly for many. “Certainly the more people who are covered, the better it is” for both the mother and baby.

Bukovinac, however, is uninsured because she said the premiums cost more than she would typically pay for care. Self-employed in e-commerce, Bukovinac has a disorder that causes vertigo and ringing in the ear and spends about $300 per month on medication for that and for anxiety.

She doesn’t know if the Affordable Care Act is to blame, but she said that before the law “I was able to afford health insurance and now I’m not.”

Irma Castaneda, 49

Huntington Beach, Calif.

Castaneda is a breast cancer survivor. She’s been in remission for several years but still sees her oncologist annually and undergoes mammograms, ultrasounds and blood tests.

Irma Castaneda, 49, says the bright side of becoming eligible for Medicaid was her family now faces fewer out-of-pocket expenses for health care. (Courtesy of Irma Castaneda)

The married mom of three, a teacher’s aide to special-education students, is worried that Republicans may make insurance more expensive for people like her, with preexisting conditions. “They could make our premiums go sky-high,” she said. “I didn’t ask to get cancer.”

Her family previously purchased a plan on Covered California, the state’s Obamacare exchange. But Castaneda said the plan had a high deductible, so she had to come up with a lot out-of-pocket before insurance kicked in. “I was paying medical bills up the yin-yang,” she said. “I felt like I was paying so much for this crappy plan.”

Then, about a year ago, Castaneda’s husband got injured at work and the family’s income dropped in half. Now they are relying on Medicaid, the government program for low-income people, until he starts working again. Becoming eligible for Medicaid was a “blessing in disguise,” she said, because it meant fewer out-of-pocket expenses for health care.

Whatever the coverage, Castaneda said, she needs high-quality health care. “God forbid I get sick again,” she said. It’s essential for her teenage daughter, too, she said. Her daughter is transgender and receives specialized physical and mental health care.

“Right now she is pretty lucky because there is coverage for her,” Castaneda said. “With the Trump stuff, what’s going to happen then?”

Celene Wong, 39

Boston

The choice was agonizing for Wong. A few months into her pregnancy, she and her husband learned that her fetus had chromosomal abnormalities. The baby would have had severe special needs, she said.

“We always said we couldn’t handle that,” Wong said. “We had to make a tough decision, and it is not a decision that most people ever have to face.”

The couple terminated the pregnancy in January 2016, when she was about 18 weeks pregnant. “At the end of the day, everybody is going to go away except for your husband and you and this little baby,” she said. “We did our research. We knew what we would’ve been getting into.”

Wong, who works to improve the experience for patients at a local hospital, said she is fortunate to have been able to make the choice that was right for her family. “If the [abortion] law changes, what is going to happen with that next generation?” she said.

Most of Wong’s care was covered by insurance from her job but she worries about those who rely on Planned Parenthood for reproductive health care. She said the organization should change its name to “Women’s Health.”

“If you are saying you want to end funding for women’s health, people are going to be more up in arms about it,” she said.

Lorin Ditzler, 33

Des Moines, Iowa

Ditzler is frustrated that her insurance coverage may be a deciding factor in her family planning. She quit her job last year to take care of her 2-year-old son and was able to get on her husband’s plan, which doesn’t cover maternity care.

If she gets pregnant accidentally, she says, they would be in a real bind. “To me it seems very obvious that our system isn’t set up in a way to support giving birth and raising very small children.”

While maternity benefits are required under the Affordable Care Act, her husband’s plan is grandfathered under the old rules, not uncommon among employers that offer coverage. Skirting maternity coverage might become more common if Republicans in Congress succeed in passing a replacement proposal that allows states to no longer consider maternity coverage an “essential benefit.”

Lorin Ditzler, 33, says concerns about insurance coverage could play a role as she and her husband decide whether to have a second child. (Courtesy of Lorin Ditzler)

Ditzler looked into switching to an Obamacare plan that they could buy through the exchange, but the rates were much higher, and she has only a short window to sign up each year on the exchange.

“It’s already this big decision where we don’t know if we’re going to have another kid or when,” says Ditzler. “When Jan. 1 came around, we had to decide if we were going to try to get pregnant this year. And if we changed our mind, well too bad.”

If she went back to work, she could get on a better insurance plan that covers maternity care. But that makes little sense to her. “I would go back to a full-time job so I could have a second child, but if I do that, it will be less appealing and less feasible to have a second child because I’d be working full time.”

Ashley Bennett, 34

Spartanburg, S.C.

Bennett, who is devoutly Christian, is grateful that she was able to plan her family the way she wanted, with the help of birth control. She had her daughter at 22 and her son two years later.

“I felt free to make that choice, which I think is an awesome thing,” she said. She’s advised her 12-year-old daughter to wait for sex until marriage but has also been open with her about birth control within the context of marriage.

But she draws the line at abortion. “I just feel like we’re playing God. If that conception happens, then I feel like it was meant to be.”

Ashley Bennet, 34, says she voted for Trump in the 2016 election because he was the anti-abortion candidate. (Courtesy of Ashley Bennett)

Bennett had apprehensions about Trump but voted for him because he was the anti-abortion candidate. “That was the deciding factor for me, [more than] him yelling about how he’s going to build a wall.”

She added that opposition to abortion must be coupled with support for babies once they are born — something she says not all Christians emphasize enough. She supports adoption and is planning to become a foster parent.

She also is concerned about the mental and physical well-being of young women. Bennett teaches seventh-grade math and coaches the school’s cheerleading and dance teams.

She watches the girls take dozens of photos of themselves to get the perfect shot, then add filters to add makeup or slim them down.

“There’s going to be an aftermath that we haven’t even thought about,” she said. “I worry we’re going to have more and more kids suffering from depression, eating disorders and even suicide because of the effects of the social media.”

Maya Guillén, 24

El Paso, Texas

When Guillén was growing up, her family spent years without health insurance. They crossed the border into Juárez, Mexico, for dental care, doctor appointments and optometry visits. “I remember feeling safe, because it was so cheap.”

Guillén is now on her parents’ insurance plan, under a provision of the Affordable Care Act that allows children to stay on until they turn 26. She’s been disheartened by Republicans’ proposed changes to contraception and abortion coverage, she said.

In high school, Guillén received abstinence-only sex education. She watched her friends get pregnant before they had graduated.

Maya Guillén says she worries Republicans efforts to defund Planned Parenthood could prevent young girls, especially those in predominantly Hispanic communities like hers, from getting access to contraceptives. (Courtesy of Maya Guillén)

When it came time to consider sex, she thought she’d be able to count on Planned Parenthood, but the clinic in El Paso has closed, as have 20 other women’s health clinics in Texas. She worries that if Republicans defund Planned Parenthood, more young girls, especially those in predominantly Hispanic communities like hers, will not get access to, or education about, contraceptives.

Guillén is also dismayed by the way Trump talks about women, particularly in the “Access Hollywood” tapes that emerged in October.

“I feel like men could now do anything to me and dispose of my body because the president had made those comments, because he condones it.”

“I feel like a lot of young people try to voice their opinions, but we’re not being taken into consideration. We’re so much more open-minded, but our president and all the people in power are trying to send us back.”

Jaimie Kelton, 39

New York City

When Kelton’s wife gave birth to their baby 3½ years ago, she thought the country was finally becoming more open-minded toward gays and lesbians.

Kelton said she was lucky to live in New York City, where she said it doesn’t matter that her children have two moms. She thought that was how the majority of the country felt, especially after the Supreme Court legalized gay marriage in 2015.

Jaimie Kelton (left), 39, poses with her daughter and wife. (Courtesy of Suzanne Fiore Photography)

“Now I am coming to realize that we are the bubble and they are the majority and that’s really scary,” said Kelton, now pregnant with her second child.

Kelton said it seems as though Republicans have launched a war against women in general, with reproductive rights and maternity care at risk.

“It is crazy to think that most of the people making these laws are men,” she said. “Why do they feel the need to take away health care rights from women?”

Phyllis Sandel, 89

Bothell, Wash.

Sandel, who lives in a retirement community outside Seattle, meets regularly with other residents to talk about current events, including the push to repeal Obamacare. She’s concerned about the Republican proposals and their potential effects on women. “I think it’s going to be devastating,” she said.

Former health care administrator and nursing home consultant Phyllis Sandel, 89, has been advocating for women’s rights for decades and volunteered for Planned Parenthood in the 1960s. (Courtesy of Phyllis Sandel)

Sandel has been advocating for women’s rights for decades, since she volunteered for Planned Parenthood in Denver in the 1960s. She signed up for phone banks in the ’70s, and walked door-to-door and got signatures for petitions — all in support of the women’s movement and the Equal Rights Amendment. “I was one of a few people in my coffee klatch group who became active,” she said.

A former health care administrator and nursing home consultant, Sandel said legislators are in the “wrong territory” in their push to defund Planned Parenthood and restrict access to abortion.

“Because we have such conservative control in our legislature, this is going to be a hard fight. But we have to stand up for it,” she said.

She attended a caucus for Hillary Clinton during the election and said she was among a few “grayhairs” in the room.

“I am encouraged by the number of young women who are active and participating in affecting change,” she said. “That wasn’t true when I was growing up.”

Few Patients Shop Around for Healthcare

KFF Health News, August 21, 2017

Three-quarters of study participants said they did not know of any resource that would allow them to compare costs. 

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

By Michelle Andrews

Despite having more financial “skin in the game” than ever, many consumers don’t make any attempt to compare prices for health care services, a newly released study found.

In a survey of nearly 3,000 adults younger than 65, about half of the roughly 1,900 who said they spent money on medical care in the previous year reported that they knew in advance what their costs would be. Of those who didn’t anticipate how much they would owe before receiving care, only 13 percent said they tried to predict their out-of-pocket expenses. An even smaller proportion, 3 percent, compared prices from multiple providers ahead of time.

It wasn’t that survey respondents were ignorant of price differences or didn’t care about them. More than 90 percent said they believed that prices vary greatly among providers, and 71 percent said that the amount they spent out-of-pocket was important or very important when choosing a doctor. Yet most respondents said they didn’t comparison shop or even ask how much they would owe in copayments or other cost-sharing expenses before they turned up for an appointment.

Researchers conducted the online survey in February and March of 2015, dividing respondents into three groups: uninsured, insured in a plan with an annual deductible higher than $1,250 for single coverage or $2,500 for family coverage, or insured in a plan with a lower deductible or no deductible. The results were published in the August issue of Health Affairs.

Three-quarters of the study participants said they did not know of any resource that would allow them to compare costs, while half said that if a website showing such information were available, they would use it.

“If price shopping is an important policy goal, it will be necessary to increase the availability of information on price and decrease the complexity of accessing the information,” the researchers wrote. They noted that patients trying to figure out pricing information and their share of the cost must often know specific procedures’ billing codes, the difference between professional fees and facility fees, and the details of how their insurance plan is structured.

“Our results emphasize that simply passing price transparency laws or regulations (as over half of states have done) appears insufficient to facilitate price shopping,” they added.

Most respondents said they did not think there was a relationship between lower cost and lower quality.

One reason for the lack of shopping activity may be that consumers value the ongoing relationship they have with an existing doctor and don’t want to disrupt that, said Neeraj Sood, professor of public policy at the University of Southern California in Los Angeles and one of the study’s authors.

Another possible explanation is that despite efforts by states, employers and insurers to make price information readily available, shopping for health care services is nowhere near as user-friendly and intuitive as buying something on Amazon or Expedia.

“Maybe right now these tools are so primitive that even though there is a financial incentive to shop, people aren’t doing it,” Sood said.

People surveyed were most likely to search out prices before going to a retail or urgent care clinic compared with other care facilities. Consumers who received physical therapy or lab and imaging services were more likely than others to comparison shop for providers, the survey found.

Medicare Unveils ‘Skeletal’ Site For Hospice Comparison Shopping

KFF Health News, August 18, 2017

The Centers for Medicare & Medicaid Services this week released Hospice Compare. the measurements of quality, which are self-reported by hospices, have limited utility, some experts say.

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

By Melissa Bailey<

Medicare launched a website aimed at helping families choose a hospice — but experts say it doesn’t help very much.

The Centers for Medicare & Medicaid Services this week released Hospice Compare, a consumer-focused website that lets families compare up to three hospice agencies at a time, among 3,876 nationwide. Following similar websites for hospitals and nursing homes, the site aims to improve transparency and empower families to “take ownership of their health,” according to a press release.

Through the website, families can see how hospices performed in seven categories, including how many patients were screened for pain and breathing difficulties, and how many patients on opioids were offered treatment for constipation.

But the measurements of quality, which are self-reported by hospices, have limited utility, some experts say. Over three-quarters of hospices scored at least 91 percent out of 100 on six of the seven categories, a recent paper in Health Affairs found. Because so many hospices reported high marks, there is “little room” for using these metrics to measure hospice quality, argued the authors, led by Dr. Joan Teno at the University of Washington.

The Hospice Compare grades are based on hospices reporting whether they followed a specific process, such as screening for pain when the patient arrives. This type of metric may lead staff to just check a box to indicate they completed the desired process, resulting in high grades for everyone, which is not helpful for consumers or for quality improvement, the authors wrote.

Meanwhile, Teno’s other research has found troubling variation in hospice quality, measured by how often hospice staff visit a patient when death is imminent.

“It’s nice that they’re at least beginning to be concerned about hospice quality,” said Dr. Joanne Lynn of the Altarum Institute, a longtime hospice physician and researcher, of CMS’ new website. But “at the present time, it’s of pretty limited value.”

Lynn said people trying to choose a hospice would be better helped by other kinds of information, such as the average caseload for hospice staff; what percentage of patients are discharged alive; and whether the hospice predominantly serves nursing home patients or devotes significant resources to at-home care.

The Hospice Compare website also doesn’t say how often hospices run awry of federal regulations: Inspection reports, which contain verified consumer complaints as well as problems uncovered during routine inspections, are not part of the website, as they are for nursing homes.

Recent hospice inspection reports may be hard to find. Until a recent federal rule change, hospices could go as long as six years without being inspected. By 2018, CMS requires states to increase the frequency to once every three years.

Common quality measures for hospitals and nursing homes, such as mortality rates, don’t translate well to the hospice setting, where people are expected to die, Lynn noted.

Although Hospice Compare is “skeletal” at the moment, Lynn said, it does enable families to search which hospices are near them, and find the hospice’s phone number to start asking questions.

“I’m hoping that it continues to improve over time,” as CMS’ other consumer-focused websites have, she said.

Next year, CMS plans to add family ratings of hospices, including how timely hospice staff were when a patient needed help. CMS is also collecting data on the number of staff visits a patient received in the final week before death. That information should be made public in late 2018, a CMS spokesman said Wednesday.

CBO: Killing Cost-Sharing Subsidies Would Hike Silver Plan Premiums And Deficit

KFF Health News, August 16, 2017

Most states would let insurers compensate for the termination of payments by raising premiums substantially for silver plans offered through the marketplaces, the Congressional Budget Office said.

This article first appeared August 15, 2017 on Kaiser Health News.

By Phil Galewitz

If President Donald Trump were to follow through on his threats to cut federal cost-sharing subsidies, health insurance premiums for silver plans would soar by an average of 20 percent next year and the federal deficit would rise by $194 billion over the next decade, the nonpartisan Congressional Budget Office said Tuesday.

The change would not be expected to have much long-term effect on the number of uninsured people, according to the analysis. But it could cause a shift in which plans are popular with marketplace customers as insurers realign some of their prices to defray the loss of the federal payments, the CBO said. Surprisingly, some customers might find better deals by looking at higher-end products.

The cost-sharing subsidies are paid directly to insurers to help cover out-of-pocket costs, such as deductibles and copayments, for people who earn between 100 and 250 percent of the federal poverty level and who choose a marketplace silver plan. About 7 million consumers receive the benefit.

These payments are separate from the subsidies offered as tax credits to help consumers pay their marketplace plan premiums, which are available to people earning up to 400 percent of the poverty level.

The CBO estimated that the federal government would spend $8 billion on the cost-sharing subsidies in 2018, if they are continued.

The loss of the payments would be expected to have minimal effect on the number of uninsured people over the next decade, CBO said. That is because the CBO predicts that insurers would raise their premiums on silver plans to make up for the loss of the federal payments, which insurers would still need to give to those customers. That price increase would spur a rise in the premium tax credits, too. The higher tax credits would, in turn, make the marketplace plans more attractive for some lower-income Americans who have not been customers.

Most states would let insurers compensate for the termination of payments by raising premiums substantially for silver plans offered through the marketplaces, the CBO said.

CBO officials based their estimates on a model in which the administration continues the payments through this year but tells insurers by the end of this month that the subsidies would be discontinued in 2018. Different timing would produce different outcomes, but CBO staff said the results would be less destabilizing for the marketplaces if a decision is announced before insurers set their rates by Sept. 5.

The CBO estimate of the effect of ending the cost-sharing payments on premium hikes nearly matches what independent nonpartisan experts previously predicted. The Kaiser Family Foundation earlier this year predicted that premiums would rise an average of 19 percent. (Kaiser Health News is an editorial independent program of the foundation.)

The payments have faced a legal challenge from House Republicans for several years, and Trump has threatened to drop the funding as part of his effort to let the “health care law implode.”

But the administration has continued paying the subsidies month to month as it waited for Congress to overhaul the Affordable Care Act. The Senate failed to pass a bill in July, and it’s unclear if congressional Republicans will renew that effort this fall.

“If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!” Trump tweeted at end of July.

“The CBO’s report once again exposes the vast cynicism of President Trump’s threats to purposefully raise Americans’ health costs by cutting off cost sharing reduction payments,” House Minority Leader Nancy Pelosi said in a statement. She called on Republicans to drop the threats to the cost-sharing subsidies to “stabilize the markets, and lower costs for all Americans.”

Cost-sharing payments were included in the health law as a way to make insurance more affordable.

Amid all the uncertainty about these payments and the administration’s efforts on marketplace enrollment, insurers are running out of time to plan for next year. Some have dropped out of the market, citing financial losses as claims for medical care exceeded their expectations.

The increase in the federal deficit cited by the CBO would be a result of the expected higher premiums. For people getting subsidized coverage, that added expense would be borne by the federal government and their costs would be little changed, the CBO said.

“When the premiums for the benchmark plan go up, the amount of the tax credits goes up, and the amount of the premiums paid by an enrollee who is eligible for the credits is generally unchanged,” the CBO pointed out in its report.

Gross premiums for marketplace silver plans, which cover 70 percent of the value of the insurance, would be 20 percent higher in 2018 and 25 percent higher by 2020 — boosting the amount of premium tax credits, according to the statutory formula.

But the CBO predicted that insurers would not raise the premiums for their bronze plans or gold plans. Therefore, some customers getting the higher tax credits could find a better deal with higher-value gold plans, which cover 80 percent of the value, according to the analysis.

For example, according to the CBO estimates, the premium for a silver plan for a 40-year-old earning $34,100 (225 percent of the poverty level) in 2026 would run from $6,500 to $8,200 because of the loss of cost-sharing subsidies. Her premium tax credit would also increase from $3,450 to $4,850, so her net premium cost would go up from $3,050 to $3,350. But a gold plan would cost $7,900, so after she applied her tax credit to that, she would be able to buy the gold plan for $3,050, or $300 cheaper than the silver plan.

“Gross premiums for gold plans would eventually be lower than those for silver plans,” CBO said.

The CBO analysis was requested by House Democratic leaders.

Doctors Warm To Single-Payer Health Care

KFF Health News, August 16, 2017

Physicians believe the simplicity of single-payer would create fewer distractions and enable them to focus on taking care of patients rather than reimbursement.

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

By Rachel Bluth

Single-payer health care is still a controversial idea in the U.S., but a majority of physicians are moving to support it, a new survey finds.

Fifty-six percent of doctors registered either strong support or were somewhat supportive of a single-payer health system, according to the survey by Merritt Hawkins, a physician recruitment firm. In its 2008 survey, opinions ran the opposite way — 58 percent opposed single-payer. What’s changed?

Red tape, doctors tell Merritt Hawkins. Phillip Miller, the firm’s vice president of communications, said that in the thousands of conversations its employees have with doctors each year, physicians often say they are tired of dealing with billing and paperwork, which takes time away from patients.

“Physicians long for the relative clarity and simplicity of single-payer. In their minds, it would create less distractions, taking care of patients — not reimbursement,” Miller said.

In a single-payer system, a public entity, such as the government, would pay all the medical bills for a certain population, rather than insurance companies doing that work.

A long-term trend away from physicians owning their practices may be another reason that single-payer is winning some over. Last year was the first in which fewer than half of practicing physicians owned their practice — 47.1 percent — according to the American Medical Association’s surveys in 2012, 2014 and 2016. Many doctors are today employed by hospitals or health care institutions, rather than working for themselves in traditional solo or small-group private practices. Those doctors might be less invested in who pays the invoices, Miller said.

There’s also a growing sense of inevitability, Miller said, as more doctors assume single-payer is on the horizon.

“I would say there is a sense of frustration, a sense of maybe resignation that we’re moving in that direction, let’s go there and get it over with,” he said.

Merritt Hawkins emailed its survey Aug. 3 and received responses from 1,003 doctors. The margin of sampling error is plus or minus 3.1 percentage points.

The Affordable Care Act established the principle that everyone deserves health coverage, said Shawn Martin, senior vice president for advocacy at the American Academy of Family Physicians. Inside the medical profession, the conversation has changed to how best to provide universal coverage, he said.

“That’s the debate we’re moving into, that’s why you’re seeing a renewed interest in single-payer,” Martin said.

Dr. Steven Schroeder, who chaired a national commission in 2013 that studied how physicians are paid, said the attitude of medical students is also shifting.

Schroeder has taught medicine at the University of California-San Francisco Medical Center since 1971 and has noticed students’ increasing support for a single-payer system, an attitude they likely carry into their professional careers.

“Most of the medical students here don’t understand why the rest of the country doesn’t support it,” said Schroeder.

The Merritt Hawkins’ findings follow two similar surveys this year.

In February, a LinkedIn survey of 500 doctors found that 48 percent supported a “Medicare for all” type of system, and 32 percent opposed the idea.

The second, released by the Chicago Medical Society in June, reported that 56 percent of doctors in that area picked single-payer as the “best care to the greatest number of people.” More than 1,000 doctors were surveyed.

Since June 2016, more than 2,500 doctors have endorsed a proposal published in the American Journal of Public Health calling for a single-payer to replace the Affordable Care Act. The plan was drafted by the Physicians for a National Health Program (PNHP), which says it represents 21,600 doctors, medical students and health professionals who support single-payer.

Clare Fauke, a communications specialist for the organization, said the group added 1,065 members in the past year and membership is now the highest since PNHP began in 1987.

End-Of-Life Advice: More Than 500,000 Chat On Medicare’s Dime

KFF Health News, August 14, 2017

Nearly 23,000 providers submitted about $93 million in charges in 2016. Use was much higher than expected.

This article first appeared August 14, 2017 on Kaiser Health News.

By JoNel Aleccia

The 90-year-old woman in the San Diego-area nursing home was quite clear, said Dr. Karl Steinberg. She didn’t want aggressive measures to prolong her life. If her heart stopped, she didn’t want CPR.

But when Steinberg, a palliative care physician, relayed those wishes to the woman’s daughter, the younger woman would have none of it.

“She said, ‘I don’t agree with that. My mom is confused,’” Steinberg recalled. “I said, ‘Let’s talk about it.’”

Instead of arguing, Steinberg used an increasingly popular tool to resolve the impasse last month. He brought mother and daughter together for an advance-care planning session, an end-of-life consultation that’s now being paid for by Medicare.

In 2016, the first year health care providers were allowed to bill for the service, nearly 575,000 Medicare beneficiaries took part in the conversations, new federal data obtained by Kaiser Health News show.

Nearly 23,000 providers submitted about $93 million in charges, including more than $43 million covered by the federal program for seniors and the disabled.

Use was much higher than expected, nearly double the 300,000 people the American Medical Association projected would receive the service in the first year.

That’s good news to proponents of the sessions, which focus on understanding and documenting treatment preferences for people nearing the end of their lives. Patients and, often, their families discuss with a doctor or other provider what kind of care they want if they’re unable to make decisions themselves.

“I think it’s great that half a million people talked with their doctors last year. That’s a good thing,” said Paul Malley, president of Aging with Dignity, a Florida nonprofit that promotes end-of-life discussions. “Physician practices are learning. My guess is that it will increase each year.”

Still, only a fraction of eligible Medicare providers — and patients — have used the benefit, which pays about $86 for the first 30-minute office visit and about $75 for additional sessions.

Nationwide, slightly more than 1 percent of the more than 56 million Medicare beneficiaries enrolled at the end of 2016 received advance-care planning talks, according to calculations by health policy analysts at Duke University. But use varied widely among states, from 0.2 percent of Alaska Medicare recipients to 2.49 percent of those enrolled in the program in Hawaii.

“There’s tremendous variation by state. That’s the first thing that jumps out,” said Donald Taylor Jr., a Duke professor of public policy.

In part, that’s because many providers, especially primary care doctors, aren’t aware that the Medicare reimbursement agreement, approved in 2015, has taken effect.

“Some physicians don’t know that this is a service,” said Barbie Hays, a Medicare coding and compliance strategist for the American Academy of Family Physicians. “They don’t know how to get paid for it. One of the struggles here is we’re trying to get this message out to our members.”

There also may be lingering controversy over the sessions, which were famously decried as “death panels” during the 2009 debate about the Affordable Care Act. Earlier this year, the issue resurfaced in Congress, where Rep. Steve King (R-Iowa) introduced the Protecting Life Until Natural Death Act, which would halt Medicare reimbursement for advance-care planning appointments.

King said the move was financially motivated and not in the interest of Americans “who were promised life-sustaining care in their older years.”

Proponents like Steinberg, however, contend that informed decisions, not cost savings, are the point of the new policy.

“It’s really important to say the reason for this isn’t to save money, although that may be a side benefit, but it’s really about person-centered care,” he said. “It’s about taking the time when people are ill or even when they’re not ill to talk about what their values are. To talk about what constitutes an acceptable versus an unacceptable quality of life.”

That’s just the discussion that the San Diego nursing home resident was able to have with her daughter, Steinberg said. The 90-year-old was able to say why she didn’t want CPR or to be intubated if she became seriously ill.

“I believe it brought the two of them closer,” Steinberg said. Even though the daughter didn’t necessarily hear what she wanted to hear. It was like, ‘You may not agree with your mom, but she’s your mom, and if she doesn’t want somebody beating her chest or ramming a tube down her throat, that’s her decision.”

Climbing Cost Of Decades-Old Drugs Threatens To Break Medicaid Bank

KFF Health News, August 14, 2017

Rising costs for 313 brand-name drugs lifted Medicaid’s spending by as much as $3.2 billion in one year, analysis shows.

This article first appeared August 14, 2017 on Kaiser Health News.

By Sydney Lupkin

Skyrocketing price tags for new drugs to treat rare diseases have stoked outrage nationwide. But hundreds of old, commonly used drugs cost the Medicaid program billions of extra dollars in 2016 vs. 2015, a Kaiser Health News data analysis shows. Eighty of the drugs — some generic and some still carrying brand names — proved more than two decades old.

Rising costs for 313 brand-name drugs lifted Medicaid’s spending by as much as $3.2 billion in 2016, the analysis shows. Nine of these brand-name drugs have been on the market since before 1970. In addition, the data reveal that Medicaid outlays for 67 generics and other non-branded drugs cost taxpayers an extra $258 million last year.

Even after a medicine has gone generic, the branded version often remains on the market. Medicaid recipients might choose to purchase it because they’re brand loyalists or because state laws prevent pharmacists from automatically substituting generics. Drugs driving Medicaid spending increases ranged from common asthma medicines like Ventolin to over-the-counter painkillers like the generic form of Aleve to generic antidepressants and heartburn medicines.

Among the stark examples:

  • Ventolin, originally approved in 1981, treats and prevents spasms that constrict patients’ airways and make it difficult to breathe. When a gram of it went from $2.58 to $2.90 on average, Medicaid paid out an extra $54.5 million for the drug.
  • Naproxen sodium, a painkiller originally approved in 1994 as brand-name Aleve, went from costing Medicaid an average of $0.72 to $1.70 a pill, an increase of 136 percent. Overall, the change cost the program an extra $10 million in 2016.
  • Generic metformin hydrochloride, an oral Type 2 diabetes drug that’s been around since the 1990s, went from an average 10 cents to 13 cents a pill from 2015 to 2016. Those extra three pennies per pill cost Medicaid a combined $8.3 million in 2016. And cost increases for the extended-release, authorized generic version cost the program another $6.5 million.

“People always thought, ‘They’re generics. They’re cheap,’” said Matt Salo, who runs the National Association of Medicaid Directors. But with drug prices going up “across the board,” generics are far from immune.

Historically, generics tend to drive costs lower over time, and Medicaid’s overall spending on generics dropped $1.6 billion last year because many generics did get cheaper. But the per-unit cost of dozens of generics doubled or even tripled from 2015 to 2016. Manufacturers of branded drugs tend to lower prices once several comparable generics enter a market.

Medicaid tracks drug sales by “units” and a unit can be a milliliter or a gram, or refer to a tablet, vial or kit.

Old drugs that became far more expensive included those used to treat ear infections, psychosis, cancer and other ailments:

  • Fluphenazine hydrochloride, an antipsychotic drug approved in 1988 to treat schizophrenia, cost Medicaid an extra $8.5 million in 2016. Medicaid spent an average $1.39 per unit in 2016, an increase of 347 percent vs. the year before.
  • Depo-Provera was first approved in 1960 as a cancer drug and is often used now as birth control. It cost Medicaid an extra $4.5 million after its cost more than doubled to $37 per unit in 2016.
  • Potassium phosphates — on the market since the 1980s and used for renal failure patients, preemies and patients undergoing chemotherapy — cost Medicaid an extra $1.8 million in 2016. Its average cost to Medicaid jumped 290 percent, to $6.70 per unit.

A shortage of potassium phosphates began in 2015 after manufacturer American Regent closed its facility to address quality concerns, according to Erin Fox, who directs the Drug Information Center at the University of Utah and tracks shortages for the American Society of Health-System Pharmacists.

When generics enter a market, competition can drive prices lower initially. But when prices sink, some companies inevitably stop making their drugs.

“One manufacturer is left standing … [so] guess who now has a monopoly?” Salo said. “Guess who can bring prices as far up as they want?”

According to a Food and Drug Administration analysis, drug prices decline to about half of their original price with two generic competitors on the market and to about a third of the original price with five generics available. But if there’s only one generic, a drug’s price drops just 6 percentage points.

The increases paid by Medicaid ultimately fall on taxpayers, who pay for the drugs taken by its 68.9 million beneficiaries. And those costs eat “into states’ ability to pay for other stuff that matters to [every] resident,” said economist Rena Conti, a professor at the University of Chicago who co-authored a National Bureau of Economics paper about generic price hikes in July. The manufacturers’ list prices for the drugs named here also rose in 2016, according to Truven Health Analytics, which means customers outside Medicaid also paid more.

Conti said that about 30 percent of generic drugs had price increases of 100 percent or more the past five years.

Medicaid spending per unit doesn’t include rebates, which drug manufacturers return to states after they pay for the drugs upfront. Such rebates are extremely complicated, but generally start at the federally required 23.1 percent for brand-name drugs, plus supplemental rebates that vary by state, Salo said. Final rebate amounts are considered proprietary, he noted. “All rebates are completely opaque … [it’s] “black-box stuff.”

Fox said drug prices could also jump when a pharmaceutical product changes ownership, gets new packaging or just hasn’t had a price increase in a long time.

Recently named FDA Commissioner Scott Gottlieb has made increasing generic competition a core mission. Plans include publishing lists of off-patent drugs made by one manufacturer and preventing brand-name drugmakers from using anti-competitive tactics to stave off competition.

Doctors, pharmacists and patients don’t always receive warning when a price hike is about to occur, Fox said.

“Sometimes, we will get notices. Other times, it’s like a bad surprise,” she said, adding that the amount of wiggle room for alternatives depends on the drug and the patient.

Following some price hikes, doctors can use fewer units of a drug or switch it out entirely, she said.

Ofloxacin otic, long used to treat swimmer’s ear, became so expensive when generic manufacturers exited the market that doctors started using eye drops in patients’ ears, Fox said.

When old drugs get more expensive, hospitals try to eliminate waste by making smaller infusion bags and keeping really expensive drugs in the pharmacy instead of stocked in readily available shelves and drawers. But that’s not always possible.

“These drugs do have a place in daily therapy. Sometimes they’re life-sustaining and sometimes they’re lifesaving,” said Michael O’Neal, a pharmacist at Vanderbilt University Medical Center. “In this case, you just need to take it on the chin, and you hope one day for competition.”

Big Employers Vow To Continue Offering Health Insurance

KFF Health News, August 9, 2017

Two surveys of large employers show companies continue to try to control costs while backing away from shrinking or dropping health benefits.

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

By Jay Hancock

The shrinking unemployment rate has been a healthy turn for people with job-based benefits.

Eager to attract help in a tight labor market and unsure of Obamacare’s future, large employers are newly committed to maintaining coverage for workers and often their families, according to new research and interviews with analysts.

Two surveys of large employers — one released Aug. 2 by consultancy Willis Towers Watson and the other out Tuesday from the National Business Group on Health, show companies continue to try to control costs while backing away from shrinking or dropping health benefits. NBGH is a coalition of large employers.

“The extent of uncertainty in Washington has made people reluctant to make changes to their benefit programs without knowing what’s happening,” said Julie Stone, a senior benefits consultant with Willis Towers Watson. “They’re taking a wait-and-see attitude.”

That’s a marked change from three years ago, when many big employers — those with 1,000 employees or more — contemplated ending medical benefits and shifting workers to the Affordable Care Act’s marketplaces.

In 2014, only 25 percent of big companies were “very confident” they would have a job-based health plan for employees in 10 years, according to the Willis Towers Watson survey.

This year, 65 percent expected to offer health benefits in a decade. And 92 percent said they were very confident a company-based health plan would exist in five years.

Many managers once eyed Obamacare marketplaces as workable coverage alternatives despite the law’s requirement that employers offer health insurance, analysts said.

But problems with marketplace plans, including fewer offerings, rising premiums and shrinking medical networks, have made employers think twice, they said.

Another big reason to maintain rich coverage is “the strength of the economy,” said Paul Fronstin, director of health research at the Employee Benefit Research Institute, an industry group. “Employers are doing what they have to do to get the right workers.”

Unemployment has fallen from 9.9 percent when Obamacare became law in 2010 to 4.3 percent last month, which equaled a 16-year low reached in May.

With such a steep decline, he added, “employers are thinking, ‘We need to offer this benefit for recruitment and retention.’”

Second Thoughts On High-Deductible Plans

Companies are even rethinking the long-standing expedient of shifting a portion of rising medical costs to employees through high-deductible plans and a greater share of the premium bill, other research shows.

“Employers are beginning to recognize that cost sharing has its limits,” said a June report from PwC, a multinational professional services network. Low unemployment and competition for workers mean “employers have less appetite for scaling back benefits and continuing with a plan design that has proven largely unpopular.”

At Fidelity Investments, a Boston-based financial firm with more than 45,000 employees, worker contributions have grown to about 30 percent of total health costs.

Jennifer Hanson, the company’s benefits chief who sits on NBGH’s board, doesn’t see that continuing.

As costs grow, “if you continue to shift more of a bigger number to employees, health care becomes unaffordable,” she said in an interview. “As employers, we really do need to pay attention less to who’s paying for what and more to how much everything costs.”

More than half of Americans with job-based insurance face deductibles — out-of-pocket costs for most care before insurance kicks in — of more than $1,000 for single-person coverage. Family deductibles can be much higher.

High On The To-Do List: Controlling Drug Costs

Big employers’ planned changes for next year focus on controlling drug costs and improving health results through telemedicine and steering patients to efficient, high-quality hospitals, noted the Willis Towers Watson report and the NBGH survey.

Employer health costs continue to rise, but not at the double-digit clip seen for many plans sold to individuals and families through the ACA marketplaces.

Employers expect health costs to increase 5.5 percent next year, up from 4.6 percent in 2017, according to the Willis Towers Watson report.

Companies in the NBGH survey predicted health costs will rise 5 percent next year, up from an average 4.1 percent increase for 2016.

That’s still far faster than inflation, which is less than 3 percent, and overall wage growth.

By many accounts, soaring costs for specialty pharmaceuticals used to treat cancer, rheumatoid arthritis, hemophilia and other complex conditions are the biggest factor.

“These are very expensive drugs,” said Brian Marcotte, NBGH’s CEO. “They cost thousands or tens of thousands per treatment.”

Often these drugs require infusion into the blood in a clinical setting, which can drive up their price tag.

For instance, hospital-based infusions have been found to cost as much as seven times more than those performed in, say, a doctor’s office.

Employers are working hard to steer patients to the least expensive, appropriate site, Marcotte said.

Big employers are also offering more on-site nurses and doctors; setting up accountable care organizations with incentives for doctors and hospitals to control costs; and striking deals with particular hospitals for high-cost operations such as transplants and joint replacements, the NBGH survey found.

Job-based insurance covers some 160 million people younger than 65, according to Census and Labor Department data, far more than the 10 million or so insured by plans sold through Obamacare marketplaces.

Government employers and companies with at least 500 workers, which historically have been more likely to offer health benefits than smaller employers, cover more than 90 million employees and dependents.

Willis Towers surveyed 555 large employers with about 12 million workers and dependents. NBGH surveyed 148 large companies with more than 15 million employees and dependents.

Health Gap Widens Between Appalachia and Rest of the U.S.

KFF Health News, August 8, 2017

A Health Affairs study finds disparities driven by higher rates of infant mortality, smoking, obesity and early deaths from motor vehicle accidents and drug overdoses.

This article first appeared August 07, 2017 on Kaiser Health News.

By Vickie Connor

Brian and Sandy Willhite (Courtesy of the Willhite family)

Sandy Willhite doesn’t mind driving 45 minutes to the nearest shopping center. But living in Hillsboro, W.Va., became problematic when she had to travel nearly six hours for proper foot treatment.

“There just aren’t any quality surgeons or specialists in our area,” Willhite said, when explaining why she went to a doctor in Laurel, Md.

Getting health care is a common problem for the residents of Hillsboro, a tiny hamlet in the middle of Appalachia with a population of just under 250 residents.

And the Appalachian region is in dire need of health care. This section of the U.S., long acknowledged to be among the most economically disadvantaged in the country, is showing a growing gap in health outcomes with the rest of the United States.

A study released Monday in the journal Health Affairs found disparities widening sharply between Appalachia and the rest of the country, driven by higher rates of infant mortality, smoking, obesity and early deaths from motor vehicle accidents and drug overdoses.

“Although life expectancy increased everywhere in the United States between 1990 and 2013, less rapid declines in mortality and slower gains in life expectancy among people in Appalachia have led to a widening health gap,” the study said.

The study focused on the 428 counties within the 13 states that constitute Appalachia. Gopal Singh, an author of the study and a senior health equity adviser at the Health Resources and Services Administration, found that counties with high rates of poverty have the highest infant mortality rate and lowest life expectancy. These areas are seen mostly in central and southern Appalachia.

Courtesy of Health Affairs

The researchers found Appalachia lagged behind the rest of the country on health measures in the early 1990s — but only slightly. Infant mortality rates were not statistically different. And life expectancy was about 75 years — just 0.6 years shorter than that outside of the region.

But when the researchers analyzed data from 2009 to 2013, they found the infant mortality rate for Appalachia to be 16 percent higher than the rest of the country and the difference in life expectancy was 2.4 years.

When researchers examined specific demographic groups, some of the disparities were much greater. For instance, they noted a 13-year gap in life expectancy between black men in high-poverty areas of Appalachia (age 70.4) and white women in low-poverty areas elsewhere in the country (83).

According to the study, the association between poverty and life expectancy was stronger in Appalachia than the rest of the country.

“You do see a more rapid improvement in the rest of the country compared to Appalachia, but there are specific reasons why Appalachia I guess continues to fall behind,” said Singh, the lead author.

The study points to specific health problems, including lack of access to doctors and other providers, high rates of preterm births and low-weight births, and high rates of smoking-related diseases, such as lung cancer, chronic obstructive pulmonary disease and heart disease.

“Smoking-related diseases accounted for more than half of the life-expectancy gap between Appalachia and the rest of the country,” the study said.

Dr. Joanna Bailey treats some of Appalachia’s patients every day as a family medicine physician in Wyoming County, W.Va. She grew up there and said the lifestyle plays a large role in health outcomes. “I treat a lot of diabetes; I see a lot of high blood pressure; I see a lot of heart disease. I see a lot of obesity, because it is a place where it has been normalized quite a bit.”

“I think that the culture is such that getting those conditions under control is difficult for many reasons,” Bailey said.

The economic issues compound the situation, she said.

“There’s the problem of poverty,” she added. “A lot of people are on disability and they rely on food stamps to get their food for the month.” Many of Bailey’s patients pay someone to drive them to the grocery store. She said it’s difficult to coach them to buy healthful groceries when the food is good only for a few days.

“By the end of the month, they are back to eating cereal and Hamburger Helper,” Bailey said.

She thinks the widening health gap in recent years has accelerated with an increasing number of young people leaving the area for job opportunities.

“We’re left with an older, sicker population who can’t work or don’t work, and those people are notoriously sicker,” Bailey said.

Both Bailey and Singh agree that addressing the health gap requires socioeconomic change. The communities need better higher-education opportunities and infrastructure improvements, such as improved roadways so patients can more easily get to larger towns and cities to access health care.

Until then, Willhite and her family will continue to drive hours for care, such as the foot doctor in Laurel, whom she had consulted when she lived in Maryland.

“There are just absolutely so many (health) issues here in this region, you can’t begin to put your finger on one,” Willhite said. “It’s like a big vicious circle.”

Pages