DNA Links Deadly Germs, Tainted Heart Surgery Devices To German Factory

KFF Health News, July 13, 2017

The analysis provides a critical piece of the puzzle behind more than 100 sometimes fatal infections in cardiac surgery patients since 2013, researchers said. At least five other manufacturers also sell heater-coolers in the U.S. and they all share a design that could pose a risk for infections, experts say.

This article first appeared July 12, 2017 on Kaiser Health News.

By JoNel Aleccia

Contamination at a German factory that makes crucial machines used during open-heart surgery is the likely source of a global outbreak of deadly infections tied to the devices, the largest analysis to date shows.

Scientists using whole-genome sequencing matched the DNA fingerprints of samples taken from infected heart-surgery patients from several countries, including the U.S., to samples from the devices, called heater-cooler units, in multiple hospitals — and at the production site.

The study, published Wednesday in The Lancet Infectious Diseases journal, concludes that heater-cooler devices made at the LivaNova PLC plant in Munich, Germany, were contaminated during production.

The analysis provides a critical piece of the puzzle behind more than 100 severe — and sometimes fatal — infections in cardiac surgery patients worldwide since 2013, researchers said.

“Our study closes the missing gap,” said Stefan Niemann, a professor with the German Center for Infection Research and one of the study’s co-authors.

However, officials with LivaNova said that the study was too limited to draw conclusions.

“LivaNova is concerned that the article expresses a level of certainty about a point source tie to the manufacturing process that is not warranted by the data,” spokeswoman Deanna Wilke wrote in an email.

Scientists from Germany, the Netherlands and Switzerland analyzed 250 DNA samples of Mycobacterium chimaera, an organism typically found in soil and tap water.

The review included samples from 21 infected patients in Switzerland, Germany, the Netherlands and the United Kingdom, and data from another 12 in the U.S. and Australia. The analysis included samples from heater-cooler devices by LivaNova and a second German brand, Maquet, plus hospital water sources and environmental sources.

Scientists found a high degree of similarity in samples from the patients and from the LivaNova heater-cooler units and the LivaNova factory.

The authors noted that they were not able to link individual patients to particular heater-cooler units because they lacked enough water and air samples to document transmission. Infections have been linked to contaminated water in the devices that is then misted into the air.

They also warned against ending investigations into the problem too soon. Researchers found that some hospital water systems and Maquet heater-coolers were contaminated, raising concerns about local contamination.

Vincent Karst, 55, of York, Pa., was among those infected with Mycobacterium chimaera. Known as Vinnie, the father of five and grandfather to 15 appeared to do well after open-heart surgery in March 2015. But, according to a lawsuit, he fell mysteriously ill and had to be re-hospitalized with what doctors later said was an infection tied to the heater-cooler unit used during his operation.

Karst died in May from complications of the infection, his lawyer said.

Patients in several other states have filed lawsuits claiming they were infected, too.

Karst’s surgery used a Sorin 3T heater-cooler, a device that circulates water to warm or cool patients’ blood during bypass operations. More than 250,000 operations using the devices are performed each year in the U.S., and about 60 percent are done with the Sorin 3T models approved for sale in 2006. After a 2015 merger, Sorin became LivaNova.

At least five other manufacturers also sell heater-coolers in the U.S. — and they all share a design that could pose a risk for infections, experts say.

The heater-cooler devices use fans to regulate airflow. If the water in the system is contaminated with bacteria, the machines can send the germs into the air, where they can settle in open surgical sites or on cardiac implants before insertion. One complicating factor is that it can take months or even years to detect the slow-growing infections.

Early reports of infections tied to heater-cooler units date to 2002, and Food and Drug Administration officials have said they were aware of the problem by 2014. At least 15 people in the U.S. have died, according to reports submitted to the agency.

But the FDA waited more than a year to warn the public about the risk — and even longer to provide recommendations for action to hospitals and patients. Critics contend that if the agency had intervened earlier, more patients would have avoided infections, even death.

The agency now warns that for 3T devices manufactured before September 2014, there is strong evidence of common contamination at the manufacturing site in Germany. But spokeswoman Stephanie Caccomo said local contamination can also occur and hospitals should “perform appropriate follow-up measures.”

Lawrence Muscarella, a Pennsylvania patient-safety consultant, said he’s concerned that a focus on contamination at the factory might lead hospitals to relax their vigilance about what are often called Nontuberculous mycobacteria, or NTM, infections.

“[They] might incorrectly conclude that what’s to blame for these infections is contamination at a company’s manufacturing plant, something the hospital can do nothing about, rather than understanding that hospitals can reduce the risk of NTM infections in open-chest patients,” he said.

At the University of Iowa Hospitals and Clinics, where six patients developed infections tied to heater-cooler units, experts solved the problem by putting the devices in a room connected to — but separate from — the operating room, said Dr. Michael Edmond.

“I don’t think we can safely say the machines can be decontaminated,” said Edmond, a clinical professor of infectious diseases. “The only safe mitigation strategy is you have to separate the air that comes out of that machine from the air in the operating room.”

Since the hospital took that action in January 2016, no new infections have been detected.

“It works beautifully,” Edmond said.

Crippling Medicaid Cuts Could Upend Rural Health Services

KFF Health News, July 12, 2017

Patient advocates predict that would lead to fewer enrollees, more shutdowns of rural facilities, reduced payments to doctors and fewer programs for people with health needs or disabilities.

This article first appeared July 11, 2017 on Kaiser Health News.

By Virginia Anderson

ATLANTA - Each day as Ginger Peebles watches daughter Brenlee grow, she sees the importance of having a hospital close by that delivers babies.

Brenlee’s birth was touch-and-go after Peebles realized something was wrong. “I couldn’t feel the baby move, and my blood pressure was sky-high,” said Peebles, a nurse.

Dr. Roslyn Banks-Jackson, then an OB-GYN specialist at Emanuel Medical Center in Swainsboro, Ga., diagnosed preeclampsia, a potentially lethal complication of pregnancy, and induced labor to save Peebles and the baby. Brenlee was born on Oct. 28, 2014, completely healthy.

Had Peebles given birth the following year, she might not have been so fortunate, she said. Emanuel shuttered its labor-and-delivery unit the next spring, becoming one of a handful of such units in the state to close from 2010 to 2015, most because of budget problems. Another is expected to close this month, said Daniel Thompson, executive director of the Georgia OBGyn Society.

Republican bills to replace the federal health law would worsen rural areas’ financial straits through reductions in Medicaid funding. Patient advocates predict that would lead to fewer enrollees, more shutdowns of rural facilities, reduced payments to doctors and fewer programs for people with health needs or disabilities. In the aggregate, such changes threaten the health of thousands of state residents, especially those in rural areas.

“I’ve seen changes, and I’ve seen cuts, but I’ve never seen changes like what’s being proposed in this bill,” said Eric Jacobson, executive director of the Georgia Council on Developmental Disabilities. “This is the first time it’s been this scary.”

Possible Strains On A Lean Budget

One of the key aims of the House and Senate bills is reversing the Affordable Care Act’s expansion of Medicaid. But the legislation also would institute changes to the federal-state health program for low-income residents that could devastate states such as Georgia that didn’t expand Medicaid. Georgia already ranks 45th in the nation in per capita Medicaid spending, according to the Georgia Budget and Policy Institute.

The bills would switch Medicaid from an entitlement — in which the federal government agrees to pay its share of costs for anyone who qualifies for the program — to a system in which the federal government by 2020 would limit its payments and reimburse states based on a per capita formula.

The nonpartisan Congressional Budget Office concluded in a report released June 29 that the Senate plan would slash 35 percent of expected federal Medicaid funding by 2036.

“Cuts now would cripple rural Georgia,” said Dr. Ben Spitalnick, president of the Georgia chapter of the American Academy of Pediatrics.

He said that is because most primary care visits, which include OB-GYN, pediatric and adult care, in the state’s sparsely populated areas rely heavily on Medicaid reimbursements.

The federal cutbacks would have to be offset by the state. But that means taking money from other programs or raising taxes. As a result, state officials facing those shortfalls would likely scale back an already lean Medicaid coverage.

“If you cut back, [people] still go to the hospital, they’ll still need care. No matter what you do, the buck stops somewhere,” said Renee Unterman, a Republican state senator who chairs the health and human services committee. In the end, she added, the cost for that uncompensated care gets passed to taxpayers and consumers through higher health costs and insurance premiums.

Georgia’s rural hospitals have proved vulnerable. Five closed in the past five years and another two merged. Plus, several have closed their emergency rooms.

That translates to a loss of doctors in affected counties. Of Georgia’s 159 counties, 79 do not have an OB-GYN specialist, and 65 do not have a pediatrician, according to 2015 figures from the Georgia AAP and the Georgia OBGyn Society.

Close to 1.7 million Georgians, or nearly 1 in 5 state residents, live in these areas, according to figures from the Rural Health Information Hub.

Improving Pay For Doctors

For 15 years, Georgia Medicaid reimbursed primary care doctors at only 60 percent of the amount that the federal Medicare program reimbursed similar services, said Ward.

But in 2015, the Legislature implemented three rounds of pay increases to primary care doctors, including pediatricians and OB-GYNs, to bring them in line with the Medicare reimbursement.

Many of these doctors are now concerned those rates would be the first to be lowered. “That’s our big fear,” said Rick Ward, executive director of the Georgia chapter of the AAP. “We just clawed our way back and to deal with it again would just be unbelievable.”

Key among those concerns are prenatal care in rural areas. With a maternal mortality rate that is among the worst in the country, OB-GYNs are worried that the cuts would eliminate fragile solutions to doctor shortages that the state has implemented.

For example, pregnant, low-income women in 17 counties around Augusta can arrange for a ride in a van, paid for by Medicaid, for their prenatal visits at the medical school at Augusta University. The service has been vital in keeping these women healthy and insuring successful births. Advocates fear it is the type of program that could face problems if Medicaid funding becomes tight.

People With Disabilities Fearful

Advocates for residents with disabilities worry that home health care would be likely to suffer from the cuts.

That’s because while states are required under Medicaid to pay for nursing home stays, care for people living at home has been optional.

About 38,000 people in the state get the services, also called community-based benefits. Qualifying takes years, and benefits are not guaranteed, even for people who are eligible. Almost 10,000 Georgians are on the waiting list, according to Jacobson, because there is not enough money in the Medicaid budget to cover everyone.

One of those who is getting coverage is Joshua Williams, 22, who has severe cerebral palsy and needs constant care at home and school.

“I’m terrified” that funding cuts could end the program, said his mother, Mitzi Proffitt, 53. “I’d have to quit my job” to take care of him. Williams’ stepfather, Jack Proffitt, 65, has advanced cancer and cannot provide much assistance.

Joshua Williams, who receives home health care services through Medicaid, is worried about funding changes being considered by Congress. But he is counting on President Donald Trump to keep disability benefits in place because "he said he has heart." (Photo by Virginia Anderson/KHN)

Nursing home or institutional care for a year, on average, is $172,280, said Jacobson, while the average home health care is $28,901.

Williams, who is on the dean’s list at East Georgia State College in Swainsboro and loves NASCAR, also admits to being “very scared.” He said if his coverage is discontinued, he would have to drop out of college, ruining his hopes of becoming a sports broadcaster. He is eager to get a part-time job until he graduates.

“I want to work. I don’t want handouts,” he said.

A supporter of President Donald Trump’s, Williams said he is counting on the president to keep disability benefits in place and to ensure that health care is affordable for all.

“He thinks that if Trump knew his story, he’d get on this and fix things,” said Mitzi Proffitt.

“I like him because he’s a businessman, but he said he has heart,” Williams added.

Double Booking Surgeries

Double-Booked: When Surgeons Operate On Two Patients At Once

KFF Health News, July 12, 2017

Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists.

This article first appeared July 12, 2017 on Kaiser Health News.

By Sandra G. Boodman

The controversial practice has been standard in many teaching hospitals for decades, its safety and ethics largely unquestioned and its existence unknown to those most affected: people undergoing surgery.

But over the past two years, the issue of overlapping surgery — in which a doctor operates on two patients in different rooms during the same time period — has ignited an impassioned debate in the medical community, attracted scrutiny by the powerful Senate Finance Committee that oversees Medicare and Medicaid, and prompted some hospitals, including the University of Virginia’s, to circumscribe the practice.

Related: Concurrent Surgery Gets the Spotlight Treatment

Known as “running two rooms” — or double-booked, simultaneous or concurrent surgery — the practice occurs in teaching hospitals where senior attending surgeons delegate trainees — usually residents or fellows — to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR and are seeing patients elsewhere.

Hospitals decide whether to allow the practice and are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation — and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.

The issue was catapulted into public consciousness in October 2015 by an exhaustive investigation of concurrent surgery at Harvard’s famed Massachusetts General Hospital by The Boston Globe. The validity of the story has been vehemently disputed by hospital officials who defend their care as safe and appropriate.

The article detailed concerns by some doctors and other hospital staff about complications — including one patient who was paralyzed and two who died — possibly linked to double-booking over a 10-year period. It described patients waiting under anesthesia for prolonged periods and surgeons who could not be located, leaving residents or fellows to perform surgeries without supervision.

Patients who signed standard consent forms said they were not told their surgeries were double-booked; some said they would never have agreed had they known.

The practice has also figured prominently in cases in South Florida, Nashville and, most recently, Seattle.

Related: 'Alarmed' Senate Committee Wants Action on Concurrent Surgeries

Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists. Surgery, they say, is not piecework and cannot be scheduled like trains: Unexpected complications are not uncommon.

All patients “deserve the sole and undivided attention of the surgeon, and that trumps all other considerations,” said Michael Mulholland, chair of surgery at the University of Michigan Health System, which halted ­double-booking a decade ago. Surgeons might leave the room when a patient’s incision is being closed, Mulholland said. A computerized system records the doctor’s entry and exit.

“It doesn’t do any good to check out your surgeon if they’re not even going to be in the room,” said Lisa McGiffert, director of Consumers Union’s Safe Patient Project. “We all know about the dangers of multitasking. This adds a layer of danger if you have the most expert person coming in and out.”

Indiana orthopedic surgeon James Rickert regards double-booking as a form of bait-and-switch. “The only reason it has continued is that patients are asleep,” said Rickert, president of the Society for Patient-Centered Orthopedics, a doctor group.

“Having a fellow so you can run two rooms helps augment your income,” he added. “You can bill for six procedures: You do three and the fellow does three.” The critical portion of the operation required by Medicare and designated by the surgeon can mean “running in and checking two screws for 10 seconds.”

Defenders of the practice, which has been the subject of a handful of studies with mixed results, say it can be done safely and allows more patients to receive care.

“It’s extremely important for us to make sure [all surgeries are] done with the highest quality,” said Peter Dunn, Mass General’s executive medical director of perioperative administration. Officials at his hospital, Dunn said in a recent interview, have “never traced back a quality issue” to concurrent surgery, which involves a minority of procedures.

Mass General complies with all applicable guidelines and regulations, Dunn said. The hospital now explicitly requires doctors to inform patients if an operation will overlap as part of the consent process, which may occur just before the start of surgery.

In January, a Boston jury found that a Mass General spine surgeon who failed to inform a 45-year-old financial analyst that he was running two rooms was not responsible for the patient’s subsequent quadriplegia.

Divided Attention

No one knows how many of the nation’s 4,900 hospitals that receive Medicare payments — about 1,000 of which are teaching hospitals — allow the practice, the Senate Finance Committee noted in a recent report. The committee called on hospitals to adopt stronger policies and consent forms that go beyond opaque boilerplate statements that grant broad permission without specifying who is doing what. And the report noted that concurrent surgery may also occur in outpatient surgery centers and non-teaching hospitals and that it can involve patients who are not covered by Medicare.

The practice surprised some primary care doctors and a veteran medical ethicist.

“I certainly knew that for many procedures, residents might be involved,” said Arthur Caplan, a professor of bioethics at NYU School of Medicine. (NYU Langone Medical Center does not permit concurrent surgery.) “But I was a little taken aback that the attending surgeon was not in the room.”

Proponents say that overlapping operations can improve efficiency and better utilize a surgeon’s valuable time.

“Much of surgery is team-based,” said David Hoyt, executive director of the American College of Surgeons (ACS), which last year issued guidelines governing concurrent surgery. Largely similar to Medicare rules, the guidelines state that surgeons should inform patients of overlapping operations.

Robert Cima, a colorectal surgeon and medical director of surgical outcomes research at the Mayo Clinic, agrees. Overlapping surgery has been used safely since Mayo’s inception more than 100 years ago, he said. A recent study he co-authored found that 11,000 overlapping operations at Mayo did not have a higher death rate than non-overlapping surgeries.

Allowing qualified junior doctors to perform parts of an operation, Cima said, is vital in “training the next generation of surgeons.” Determining what portion of an operation is critical should be left to the individual surgeon, he said, not defined by Medicare or insurers, because it can vary from patient to patient.

But L.D. Britt, a past president of the ACS and chairman of surgery at Eastern Virginia Medical School in Norfolk, says that efficiency has little to do with concurrency. “Unless you’re closing, that surgeon should be there,” he said. “Most [surgeons] are doing it for lifestyle.”

Indiana’s Rickert and Britt say they are troubled by what they regard as a double standard: Very few surgeons would consent to the practice for themselves or a relative. “This happens to the Medicaid patient,” Rickert said, “not the partner’s wife.”

He advocates that Medicare and insurers define the critical portion requiring the presence of an attending surgeon as being everything between the making of an incision and the start of its closure, a task frequently performed by residents. “The critical components should not depend on whether the surgeon has opera tickets that night.”

Ghost Surgery?

Some surgeons say they are troubled by the resemblance of double-booking to a practice known as “ghost surgery,” in which patients learn, usually after something goes wrong, that someone other than the surgeon they hired performed their operation.

In April, a Seattle jury awarded an anesthesiologist and her husband $8.5 million for botched abdominal surgery that disfigured his penis. After his operation, the couple discovered that a crucial part of the procedure was performed by a fellow, not the senior surgeon to whom he had explicitly granted consent.

“I always prided myself in telling patients I would be there from the moment they went to sleep to the moment they woke up,” said Stanley Shapshay, a head and neck surgeon in Albany, N.Y., who co-authored a 2016 editorial opposing simultaneous surgery.

Many things can go wrong during “noncritical” portions of an operation, particularly if a resident or fellow is unsupervised, said Shapshay, a professor of otolaryngology at Albany Medical College. A major artery or nerve can be cut accidentally, he said. “By the time the surgeon [arrives, the damage] has already been done.”

Trainees, Shapshay observed, vary. “Some are very good, some are OK and some need more experience.”

His view was reinforced by his experience at a hospital in the Southeast several years ago. A senior surgeon he was visiting left in the middle of an operation, after telling a family that surgery had gone well. While he and Shapshay were having coffee, the surgeon received an urgent page and had to rush back to the OR to deal with a serious breathing problem. The family was later told only that an unexpected event had occurred, not that the attending had been out of the room.

“That illustrated to me very clearly that you don’t leave the OR until the patient has left the OR,” Shapshay said.

Adequate informed consent is essential, said Robin Diamond, senior vice president for patient safety and risk management at the Doctors Company, a California-based malpractice insurer that has begun tracking malpractice claims related to overlapping surgery. She expects such lawsuits will increase.

“I think it can be done safely and has been safe in many cases,” said Diamond, who has degrees in nursing and law. But surgeons who plan to run two rooms should obtain explicit consent from patients at least a week ahead of surgery, she said, not the day before or the day of, as is common, to allow time to reconsider.

“It’s a basic patient right to know” who is doing their operation, Diamond said.

Patients don’t seem enamored of overlapping surgery. A recent study based on an online survey by Harvard researchers found that fewer than 4 percent of 1,454 people had heard of concurrent surgery and that only 31 percent supported the practice; 95 percent said it should be disclosed in advance.

A Surprising Result

After the fallout at Mass General, officials at U.Va. decided it was time to largely eliminate concurrent surgery in all specialties; the practice had been most common in orthopedics.

In return for an end to simultaneous surgeries, hospital executives agreed that orthopedic surgeons would not be “disadvantaged,” said Richard Shannon, executive vice president for health affairs at U.Va. Part of the process involved overhauling the way surgeries were scheduled.

“It was an important wake-up call,” Shannon said of the controversy. “We wanted to redesign our system to eliminate the risk” as part of a larger patient-safety push.

Eliminating most concurrent procedures, Shannon said, actually resulted in an increase of 560 surgeries in 2016 over 2015, using the same number of operating rooms. “Concurrency was masking an efficiency problem,” said Shannon, who plans to publish the results of U.Va.’s efforts. “There was a lot of waste.”

“This debunks the urban legend” that overlapping surgery is more efficient, he said. “Like many things in health care, if you apply a rigorous disciplined approach, you may get an answer you didn’t expect.”

Rickert and others advise patients who want to avoid overlap to ask detailed questions well in advance and to put their request in writing and on the consent form.

“If you say, ‘I want only you to do the surgery,’ doctors will typically do it,’” Rickert said. “They want the business.”

He also recommends asking, “Are you going to be in the room the entire time during my surgery?” and then repeating that statement in front of the OR nurses the day of surgery. “If the doctor’s not willing to say yes, vote with your feet.”

If a surgeon says he or she will be “present” or “immediately available,” a patient should ask what that means. It may mean that the surgeon is somewhere on a sprawling hospital campus but not in — or even near — your operating room.

The Union That Roars: Nurses Aren’t Giving Up On California’s Single-Payer Push

KFF Health News, July 11, 2017

Dramatic and, to some, offensive, tactics are nothing new for this California union of about 100,000 registered nurses, which has made a name for itself in the state and nationally as a progressive and aggressive political powerhouse.

This article first appeared July 11, 2017 on Kaiser Health News.

By Pauline Bartolone

To some, the California Nurses Association’s political tactics in pushing for a single-payer health system seemed a bit, well, extreme.

Never mind the raucous demonstrations it brought to the state Capitol in recent weeks, the “shame on you” chants in the hallways, the repeated unfurling of banners in the rotunda despite admonitions from law enforcement.

To further the nurses’ cause, the union’s executive director, RoseAnn DeMoro, tweeted out a picture of the iconic California grizzly bear being stabbed in the back with a knife emblazoned with the name of a powerful state lawmaker who stalled the single-payer bill sponsored by the union.

Before and after that tweet, the legislator — a Democrat — said he was besieged by death threats.

Meanwhile, the union’s public relations guy blasted a blogger for Mother Jones magazine — named after the famous union firebrand — for being insufficiently liberal in his single-payer coverage. “Maybe you can recommend the name of your magazine be changed … to Milton Friedman, which would better reflect your class sympathies,” communications director Chuck Idelson wrote acidly.

Dramatic and, to some, offensive, tactics are nothing new for this California union of about 100,000 registered nurses, which has made a name for itself in the state and nationally as a progressive and aggressive political powerhouse. Its reach has only broadened with the advent of social media. Leader DeMoro counts more than 29,000 Twitter followers, and CNA’s operation has a knack for mobilizing protesters and drawing crowds.

“The politicians are afraid of these angry intense grass-roots activists” mobilized by the union, said Mike Madrid, a Republican and principal at the public affairs firm Grassroots Lab, who believes the tactics could backfire. “Using fear and intimidation as a tactic in the legislature usually doesn’t get you too far.”

Others are impressed with the union’s drive and creativity, recalling how in 2005 CNA members taunted California’s then-governor, Arnold Schwarzenegger, trailing him wherever he went to protest his attempts to roll back hard-won nurse-to-patient requirements in hospitals. Activists dressed up as the Republican leader and staged theatrical protests at baseball games, rock concerts and even the San Francisco Ritz-Carlton.

In the single-payer fight, the union has shown it will go just as fervently after Democratic leaders in a heavily Democratic legislature. While the union isn’t responsible for everything freelance activists do in a campaign, the Assembly Democratic caucus has condemned the “bullying tactics” and violent rhetoric in the CNA-led effort.

Though not always admired for its approach, the CNA often gets results — or works up a sweat trying. It counts among its legislative successes the 1999 passage of the strict nurse-to-patient ratios, the nation’s first such mandate to bolster staffing in hospitals. It has fended off attempts to overturn that law, worked to protect employee pensions and pushed for campaign financing reform. And it lent its considerable political muscle to Bernie Sanders’ presidential campaign.

Historically, the nurses have had the upper hand in labor negotiations, says Joanne Spetz, director of the Health Workforce Research Center at UC-San Francisco. That’s partly because in some areas of California it represents most or all of the registered nurses, including many thousands who work for the managed-care giant Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Members of the California Nurses Association Board of Directors, Martha Kuhl (left) and Nancy Casazza, show their support for a 1994 state proposition to implement single-payer health care in California. (Courtesy of the California Nurses Association)

The union, founded in 1903, has always “punched above its weight,” said Thad Kousser, chair of the political science department at University of California-San Diego.

Sherry Bebitch Jeffe, a professor of public policy communication at the University of Southern California, agreed.

“I’m not sure we would be discussing single-payer if not by the push of the nurses’ association,” Jeffe said.

The union, which is affiliated with National Nurses United, makes no apologies for its approach, saying it is determined to hold lawmakers accountable. And it has no intention of backing off its campaign for a single-payer system in the state, an effort that would put the California government in charge of funding health care.

“We’re going to demand that the legislature legislate and move this bill,” said Michael Lighty, director of public policy at California Nurses Association/National Nurses United. The group planned to stage a “people’s assembly health committee” mock hearing Tuesday in Sacramento.

Lighty said that the rallies reflect Californians’ desperation and fear about losing health coverage under Republican proposals to repeal Obamacare more than anything else.

Although Lighty said the union’s elected nurse leaders collectively decide on its actions, supporters and critics alike see DeMoro as setting the tone and agenda.

People focus on DeMoro because she “pushes the parameters of the politically possible” and that rubs “defenders of the status quo” the wrong way, Lighty said. DeMoro, on vacation, was unavailable for comment.

Former state senator Sheila Kuehl, who attempted several times to pass a single-payer bill, said the California Nurses Association has always been “very aggressive for the things they believed in.”

Former state senator Sheila Kuehl, who authored single-payer legislation in the 2000s, participates in a 2008 rally in San Francisco. (Courtesy of the California Nurses Association)

A smaller health consumer advocacy group persuaded Kuehl to carry the bill for the first time in 2003-04, Kuehl recalled, but the California Nurses Association brought more visibility and credibility when they joined her effort. Eventually, it became a co-sponsor.

“CNA, as fierce and progressive as they are, gave the idea a real boost,” said Kuehl, now a Los Angeles County supervisor.

Two of her bills passed through the legislature, but both were vetoed by Schwarzenegger.

Kuehl doesn’t buy the argument that the union’s in-your-face strategies may hurt their chances of passing single-payer later. Union members made nasty comments about Schwarzenegger at their rallies and that didn’t hurt the CNA’s reputation, she said.

Madrid, the Republican political consultant in Sacramento, says the CNA’s aggressive advocacy for a single-payer health system reflects the intense political polarization seen around the country right now — as well as conflicts among members of left-leaning causes.

More mainstream Democrats, including Assembly Speaker Anthony Rendon — the recipient of online death threats — say the legislature’s priority is to defend California against a GOP-proposed repeal of the Affordable Care Act and massive cuts to Medicaid, the state and federal health plan for the poor.

Rendon also said the single-payer bill, though approved by the state Senate, was “woefully incomplete” and needed to be recast. Among other problems, it carried a $400 billion annual price tag, according to an analysis by the state Senate Appropriations Committee.

But the CNA sees an opportunity for broader change and believes single-payer can move forward even as the state fights the Republican proposals in Washington.

If the single-payer bill stays idle in the legislature this year, the group vows to try again next year, making it a campaign issue in the 2018 elections.

“The best way to fight the GOP is to have an alternative,” Lighty said.

California Healthline correspondent Ana B. Ibarra contributed to this report.

Senate GOP Bill Aims To Add Psych Beds; Squeeze On Medicaid Signals Their Undoing

KFF Health News, July 10, 2017

The Senate bill would allow states to receive federal matching Medicaid funds for up to 30 consecutive days of inpatient psychiatric hospital care, or 90 days in a year.

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

By Liz Szabo

A little-discussed provision in the Senate health care bill is designed to boost the number of hospital beds for psychiatric care, providing a long-sought victory for mental health advocates.

The provision would amend an obscure Medicaid funding rule that has sharply limited the number of beds for those with schizophrenia, bipolar disorder or other mental illnesses.

Yet leading mental health groups say they see no reason to celebrate.

That’s because the Senate bill would also wring out $772 billion from Medicaid — the joint state-federal insurance program that is the single-largest provider of care for people with serious mental illness. The nonpartisan Congressional Budget Office has said that the Senate bill, drafted by Republicans as a replacement for the Affordable Care Act, would reduce overall Medicaid spending by 26 percent by 2026 and by 35 percent the following decade.

The loss of those funds would devastate health care services for people with mental illness, who are some of the most vulnerable and disadvantaged people in the country, said Bethany Lilly, deputy director of policy and legal advocacy at the Bazelon Center for Mental Health Law, an advocacy group.

“Medicaid is the safety net for people with serious mental illness,” said Ronald Honberg, senior policy adviser at the National Alliance on Mental Illness.

Without decent mental health care and support services, people with psychotic disorders can quickly deteriorate, ending up in overcrowded emergency rooms, jail and prison cells or dangerous city streets, Honberg said. “This bill is a prescription for making all these problems worse.”

Republicans who crafted the Senate draft bill have noted that Medicaid spending will still increase under their plan but at a rate lower than currently projected. The Senate bill would make Medicaid spending more sustainable, said Julia Lawless, a spokeswoman for the Senate Finance Committee, one of the Senate committees that oversees health legislation.

“Even before Obamacare’s unprecedented Medicaid expansion, the program was plagued by quality issues, states were barred from using innovative solutions to improve patient care, and both federal and state Medicaid spending was growing at unprecedented, unsustainable levels,” Lawless said. “The Senate bill will reverse this course and slow the growth of Medicaid without cutting actual benefits.”

The Medicaid program has traditionally refused to pay for inpatient stays in large freestanding psychiatric hospitals, making exceptions for patients under age 21 and facilities with 16 beds or fewer. The rule, which has changed little since Medicaid was created five decades ago, was aimed to prevent the federal government from paying for long-term care in psychiatric institutions.

But the Medicaid rule also has contributed to a severe shortage of psychiatric beds for people in crisis, said John Snook, executive director of the Treatment Advocacy Center, a nonprofit that focuses on people with serious mental illness.

Last year, the Centers for Medicare & Medicaid Services eased the policy, paying for up to 15 days of inpatient hospital care for patients in Medicaid managed-care plans. But in a letter to the Medicaid program last year, the National Association of Medicaid Directors noted that some patients with mental illness or substance abuse disorders might need closer to a month of inpatient care.

The Senate bill, dubbed the Better Care Reconciliation Act, would allow states to receive federal matching Medicaid funds for up to 30 consecutive days of inpatient psychiatric hospital care, or 90 days in a year.

The Medicaid change was included in the Republican bill because several senators were concerned that patients didn’t have enough access to hospital care for mental illness and addiction, according to a GOP Senate aide who was authorized to speak only on condition of anonymity. The senators involved included Orrin Hatch (R-Utah) and Rob Portman (R-Ohio).

While Honberg welcomes that change, he said that reducing overall Medicaid spending could devastate rural hospitals and ones that serve as “safety nets” — providing free care to people who are uninsured or poor — and force closures.

If these hospitals go out of business, the total number of hospital beds available to people with mental illness could shrink, not expand, Honberg said.

Medicaid pays for a wide variety of supportive services for people with schizophrenia and other serious mental illnesses, beyond doctor’s visits and medications, Honberg said. States can use Medicaid funds to pay for case managers; transportation to and from doctor’s appointments; supportive housing, which helps people with serious mental illness live independently; supported employment, which provides job training and other services; and teams of professionals who assist people who need intensive, comprehensive help navigating the health system and social services.

Half The Time, Nursing Homes Scrutinized On Safety By Medicare Are Still Treacherous

KFF Health News, July 7, 2017

While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to a Kaiser Health News analysis of federal health inspection data.

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

By Jordan Rau

Cheryl Powers fixes the hair of her mother, Elaine Fisher, at the Rehabilitation Center of Bakersfield in Bakersfield, Calif., where Fisher moved after problems at a previous home. She fractured a hip after slipping from a wheelchair. (Jenna Schoenefeld for The New York Times)

In 2012, Parkview Healthcare Center’s history of safety violations led California regulators to issue an ultimatum reserved for the most dangerous nursing homes.

The state’s public health department designated Parkview, a Bakersfield, Calif., nursing home, a “special focus facility,” requiring it to either fix lapses in care while under increased inspections or be stripped of federal funding by Medicare and Medicaid — a financial deprivation few homes can survive. After 15 months of scrutiny, the regulators deemed Parkview improved and released it from extra oversight.

But a few months later, Elaine Fisher, a 74-year-old who had lost the use of her legs after a stroke, slid out of her wheelchair at Parkview. Afterward, the nursing home promised to place a nonskid pad on her chair but did not, inspectors later found. Twice more, Fisher slipped from her wheelchair, fracturing her hip the final time.

The violation drew a $10,000 penalty for Parkview, one of 10 fines totaling $126,300 incurred by the nursing home since the special focus status was lifted in 2014.

While special focus status is one of the federal government’s strictest forms of oversight, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to a Kaiser Health News analysis of federal health inspection data. Of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.

These nursing homes are in 46 states. Some gave patients the wrong medications, failed to protect them from violent or bullying residents and staff members, or neglected to tell families or physicians about injuries, inspection records show. Years after regulators conferred clean bills of health, levels of registered nurses tend to remain lower than at other facilities.

Yet, despite recurrences of patient harm, nursing homes are rarely denied Medicare and Medicaid reimbursement. Consequences can be dire for patients like Fisher.

The Parkview Healthcare Center in Bakersfield, Calif., has a history of safety violations, including one involving Fisher. (Brian P. Hall for The New York Times)

“She used to go to bingo every day and she was very involved in the nursing home,” said her son-in-law, Eric Powers. He said that although Fisher moved to a different nursing home for better care, “after this whole thing, she has to be on painkillers. She’s mainly in her room all the time. It’s the saddest thing in the world.”

Parkview’s owner at the time of the violations, LifeHouse Health Services, did not respond to requests for comment. Dr. David Silver, who purchased Parkview last fall, said he had replaced top management and staff members who resisted a new approach.

“We were not happy with the level of patient care,” he said.

Regulators rarely return homes to the watch list, instead issuing fines for subsequent lapses. Some homes continue operating despite multiple penalties.

“When you’re looking at these large corporations, that’s just the cost of doing business,” said Neil Gehlawat, who is representing Fisher in her pending lawsuit against Parkview. “It doesn’t have the effect of changing behavior.”

‘Worst Of The Worst’

The Centers for Medicare & Medicaid Services, or CMS, sets the federal standards for nursing homes and determines whether they are in compliance, based on inspections performed primarily by state health departments. States license facilities and have the authority to revoke the licenses.

Special focus facility status is reserved for the poorest-performing facilities out of more than 15,000 skilled nursing homes. The federal government assigns each state a set number of slots, roughly based on the number of nursing homes. Then state health regulators pick which nursing homes to include.

More than 900 facilities have been placed on the watch list since 2005. But the number of nursing homes under special focus at any given time has dropped by nearly half since 2012, because of federal budget cuts negotiated by President Barack Obama and Congress. This year, the $2.6 million budget allows only 88 nursing homes to receive the designation, though regulators identified 435 as warranting scrutiny. California and Texas each has six slots, the most of any state. Twenty-nine states have just one.

Especially troubling is that more than a third of operating nursing facilities that graduated from the watch list before 2014 still hold the lowest possible Medicare rating for health and safety: one star of five, KHN’s analysis found.

“You have this recidivism of nursing homes that are special focus facilities,” said Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group in Manhattan. “These are the worst of the worst and they’re back?”

CMS defended the program, saying that nursing homes on the watch list showed more improvement than did comparably struggling facilities not selected for enhanced supervision. “CMS continues to work to improve oversight to prevent any facility from regressing in performance,” the statement said.

Andrew Edwards is among the patients who were harmed by nursing homes that had earlier been given a clean bill of health by Medicare and health regulators. (Doug Kapustin for KHN)

Short-Term Oversight

Special scrutiny was lifted for about one-fourth of the nursing homes in less than a year. Facilities need to pass only two consecutive inspections without major violations or substantiated complaints.

“The period of time is just not long enough for them to show that they can sustain improvement,” said Robyn Grant, director for public policy at the National Consumer Voice for Quality Long-Term Care in Washington. “There needs to be some significant changes in the program.”

In 2010, NMS Healthcare of Hagerstown, Md., left the watch list after 10 months.

Last year, Maryland’s attorney general sued the facility and its owner, Neiswanger Management Services, alleging that they evicted frail, infirm and mentally disabled residents “with brutal indifference” when their health coverage ran out or the facility had the opportunity to get someone with better insurance.

Among those was Andrew Edwards, who was told by NMS that he was being discharged to an assisted-living center, according to the lawsuit. Instead, in January 2016, the staff sent him to a crowded, unlicensed Baltimore City row house where the owner confiscated his bank card and withdrew $966 over his objections, the lawsuit said. Although NMS said it had arranged for his outpatient kidney dialysis, “that was false,” Edwards said in an interview. He ended up in an emergency room after he missed his treatment.

NMS maintains it stopped referring patients to that owner when told of the conditions. This month, CMS expelled the Hagerstown nursing home from Medicare and Medicaid after citing it for more violations. The company is closing the facility. NMS, which still runs other homes in Maryland, has sued state regulators, claiming they are vindictively trying to drive the chain out of business.

Few Terminations

Some nursing homes on the watch list do maintain improvements. After Evergreen Nursing Home in southern Alabama was designated a special focus facility in 2005, the owners brought in new managers and added nursing supervisors, said Kimberly Bush, the facility’s administrator.

Medicare now rates Evergreen a five-star facility. “I’d like to say there’s some kind of magic recipe to this, but it’s just doing the job and holding people accountable,” Bush said.

But even prolonged supervision does not guarantee progress. Poplar Point Health and Rehabilitation in Memphis stayed on the watch list for 2½ years until 2009. A federal lawsuit brought last year claims that Poplar and its owner, Vanguard Healthcare, regularly provided “nonexistent, grossly substandard, worthless care” as far back as 2010. Vanguard, now in bankruptcy court, declined to comment.

The ultimate enforcement threats are termination from Medicare and Medicaid or closure by state or federal authorities. But only 17 percent of former special focus facilities are no longer operating, and that can include ones that went out of business for unrelated reasons, KHN found.

State regulators are reluctant to close nursing homes because of the upheaval it causes patients and families. In some areas, there are no alternative facilities nearby, making termination even less appealing.

“At the end of the day, there are those centers that cannot be corrected, can’t fix themselves, and the best thing for the patients and the residents might be for them to move to another location,” said Lyn Bentley, an executive at the American Health Care Association, a nursing facility trade group. But, she said, “it’s always difficult to close someone’s home.”

Lack Of Nurses

Too few nurses, particularly registered nurses, provide care at some of the most troubled homes, KHN’s analysis shows. Registered nurse staffing was still 12 percent lower than at other facilities, even three years after the homes were released from the watch list.

In 2009, Pennsylvania health regulators released Golden LivingCenter-West Shore in Camp Hill after 17 months of supervision. The company said in a recent statement that when a home was put on that list, “we mobilize the resources necessary to help get that LivingCenter back into compliance.”

But data from Medicare’s Nursing Home Compare website show the facility has among the worst nurse-to-patient staffing ratios in the nation, with registered nurses devoting an average of 12 minutes for each patient daily. The state average is 58 minutes daily per patient.

Golden LivingCenter-West Shore was fined $59,150 in 2015 after being cited for, among other violations, allowing a resident’s feeding tube to become infested with maggots, records show. Also, Golden Living agreed to pay $750,000 to settle three cases involving patient injuries from falls that occurred after extra oversight ended, court records show.

Last year, Golden Living sold its Pennsylvania homes to Priority Healthcare Group.

Priority is following a common strategy for shedding an unwanted reputation: changing the facility’s name. In California, Parkview — where Fisher slipped out of her wheelchair — is being rebranded too, as Kingston Healthcare Center.

Trump’s Surgeon General Pick Built Name Fighting HIV And Opioids In Indiana

KFF Health News, July 7, 2017

If confirmed, practicing anesthesiologist Jerome Adams, MD, would be the second health official from VP Mike Pence’s home state to join the administration. Seema Verma, who helped shape Indiana’s Medicaid expansion, now heads the Centers for Medicare & Medicaid Services.

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

By Emily Forman, Side Effects Public Media

Several weeks before President Donald Trump nominated Indiana's state health commissioner Jerome Adams to be the next U.S. surgeon general, Adams toured the Salvation Army Harbor Light detox center in Indianapolis, the only treatment facility in the state for people without insurance.

Adams' supporters say the visit is an example of how he has prioritized the opioid epidemic during his tenure as Indiana's top health official. Addiction specialists and advocates say he has led important progress in implementing lifesaving policies. They believe that if confirmed, Adams would use his on-the-ground experience to guide national policy.

"I believe that Dr. Adams understands the value of community grass-roots efforts, that they should be included at the table with decision-makers," said Justin Phillips, founder of the prevention-focused group Overdose Lifeline, who toured the detox center with Adams. "They need to understand what's realistic in the field."

If confirmed by the Senate, Adams would be the second health official from Vice President Mike Pence's home state to join the Trump administration. Seema Verma, who helped shape Indiana's Medicaid expansion, now heads the Centers for Medicare & Medicaid Services.

A practicing anesthesiologist, Adams was appointed Indiana Health Commissioner by then-governor Mike Pence in October 2014. Four months into the job, he announced an HIV outbreak in rural Scott County, Ind., after health workers documented 26 cases of HIV there. By May 2015, the number of confirmed infections had risen to 158, spread almost entirely through injection drug use. Eighty-eight percent of them also tested positive for hepatitis C. Today, the number of confirmed HIV cases has reached 219.

Health workers credit Adams with persuading Pence to allow Indiana counties to create syringe exchanges to contain the spread of the disease. "We wouldn't have syringe exchange if it wasn't for him," said Carrie Lawrence, a public health researcher at Indiana University who helps implement syringe exchange programs throughout the state.

Pence had expressed moral reservations about syringe exchanges — a sentiment that Adams told The New York Times he originally shared. But in March 2015, the governor acted on advice from Adams and the Centers for Disease Control and Prevention and authorized a 30-day emergency syringe exchange, citing a public health emergency. Later that spring, Pence signed a law legalizing syringe exchanges in Indiana.

Beth Meyerson, co-director of Indiana University's Rural Center for AIDS/STD Prevention, worked closely with Adams throughout that period. She said that early on, when it became clear to legislators that a clean-syringe exchange program was needed to reduce the spread of HIV and hepatitis C, Adams was able to bring public health evidence to the table.

"Dr. Adams navigated the very ideological political environment that was created by then-governor Pence," she said. "There's just no doubt the governor wouldn't have listened to me or listened to the leaders in the Legislature, but he would listen to Jerome Adams."

She said she thinks Adams will have sway working with Pence on a national scale, too. "He will navigate [Washington], I suspect, the same way that he did in Indiana, which is to listen to communities, work with several partners across the arena, and bring public health evidence to the table again as an advocate for community health," Meyerson said.

Adams has since supported other state laws aimed at curbing the opioid epidemic, including a bill that increased access to the overdose antidote naloxone, and another that restricts the amount of opioid medication a prescriber may give to adult patients who have not previously taken opioids and to children.

Still, Meyerson said expectations about what Adams might do in Washington have to be tempered by political reality. Even in Indiana, the laws he helped pass haven't been as comprehensive as she and other public health workers would have liked. The original syringe exchange law "was an administrative nightmare," she said. It has since been updated by Indiana Gov. Eric Holcomb, making it easier for counties to start exchanges.

Funding also remains an issue. Indiana ranks 49th in the country in public health spending. "So all of these counties who have tried to move forward for syringe access are doing so with both hands tied behind their backs, because they do not have the resources to make this happen," Meyerson said.

Amount Of Opioids Prescribed In U.S. Has Been Falling Since 2010

KFF Health News, July 7, 2017

A CDC report shows the wide disparities in opioid use across counties in the U.S.: Six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties.

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

By Vickie Connor

Ryan Hampton was prescribed opioids after he broke his ankle, but his doctors provided no plan to wean him off the powerful painkillers. (Courtesy of Chris Hazell)

Ryan Hampton was sitting at his computer at work when he began sweating, feeling sick and unable to concentrate. He went to the bathroom, splashed water on his face and called his friend for help.

That was the day he realized he was addicted to opioids.

Hampton, now 36 and living in Los Angeles, said the prescription for his pain medication had run out and he didn’t realize he would face withdrawal problems.

“I hadn’t made this connection yet because I really didn’t know what was going on with my body,” he recalled of that day in 2004. His doctors, he said, never discussed possible side effects of the drugs they prescribed for him after he broke his ankle the year before, nor did they offer a plan to wean him off the drugs. He described his doctors’ prescribing behavior as “increase, increase, increase.”

Frightened and unable to kick his habit, he turned to heroin before finally getting treatment and dealing with his addiction.

Hampton’s experience is all too familiar for many people prescribed opioids for pain. But federal researchers reported Thursday they are seeing an important change in the trend lines for these potent drugs.

The amount of opioids prescribed in the United States peaked in 2010 and has been declining gradually since then as public health and law enforcement officials raised alarms about growing numbers of overdoses and offered new guidance to doctors about dispensing the drugs, according to a study from the Centers for Disease Control and Prevention.

Still, the amount in 2015 is three times higher than at the turn of the century, they said.

The study analyzed morphine milligram equivalents (MME) per capita and found that the metric — which accounts for differences in opioid drug type and strength — reached 782 MME in 2010 and fell to 640 MME in 2015.

The report, which analyzes prescription data from 2006 to 2015, also shows the wide disparities in opioid use across counties in the U.S.: Six times more opioids per resident were dispensed in the highest-prescribing counties than in the lowest-prescribing counties. The researchers found that the hardest-hit areas were non-urban counties with larger percentages of white residents, high numbers of diabetes and arthritis patients and high unemployment and Medicaid rates.

For instance, a CDC map showing prescription rates per person revealed that rates in California’s more rural and less populated northern counties dwarfed those in almost all other parts of the state.

“The amount of opioids prescribed in the U.S. is still too high, with too many opioid prescriptions for too many days at too high a dosage,” said the CDC’s acting director, Dr. Anne Schuchat.

Researchers said they did not yet have data for 2016 or 2017.

Among the significant findings, researchers said, was that the number of days an opioid prescription was supposed to last increased 33 percent in recent years. In 2006, the average supply was about 13 days, while in 2015 it was nearly 18.

According to the report, the decrease in opioid use may be related to publication of national guidelines in 2008 and 2010 that drew attention to increased dangers of high-dosage opioids. Prescription rates began to drop after that, which “might reflect growing awareness among clinicians and patients of the risks associated with opioids.”

Still, the variations in prescription practices across the country suggest better guidance is needed, the researchers wrote.

While the research shows progress, opioids are still being massively over-prescribed, said Dr. Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University.

“Opioid prescribing has not come down that much,” Kolodny said. “We are just now beginning to see intervention.”

The study pointed out that efforts by Ohio, Kentucky and Florida to more closely regulate opioid prescriptions have helped drive down use.

Nationally, however, overdose death rates continue to climb, the study noted.

“Health care providers have an important role in offering safer and more effective pain management while reducing risks of opioid addiction and overdose.” Schuchat said.

Greg Williams, co-founder of Facing Addiction, agreed. Williams supports making education for providers mandatory, to ensure appropriate prescribing. And he said it is necessary for physicians to talk about addiction as a possible side effect with their patients.

This was something never done in Hampton’s case.

“The report is showing us that we have made very little progress,” Kolodny said. “We still have a very long way to go.”

As Seniors Get Sicker, They’re More Likely To Drop Medicare Advantage Plans

KFF Health News, July 6, 2017

Critics argue the plans can prove risky for seniors who need to see specialists, because they often face hurdles getting access. A recent GAO report adds new weight to the criticism.

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

By Fred Schulte

When Sol Shipotow enrolled in a new Medicare Advantage health plan earlier this year, he expected to keep the doctor who treats his serious eye condition.

"That turned out not to be so," said Shipotow, 83, who lives in Bensalem, Pa.

Shipotow said he had to scramble to get back on a health plan he could afford and that his longtime eye specialist would accept. "You have to really understand your policy," he said. "I thought it was the same coverage."

Boosters say that privately run Medicare Advantage plans, which enroll about one-third of all people eligible for Medicare, offer good value. They strive to keep patients healthy by coordinating their medical care through cost-conscious networks of doctors and hospitals.

But some critics argue the plans can prove risky for seniors in poor or declining health, or those like Shipotow who need to see specialists, because they often face hurdles getting access.

A recent report by the Government Accountability Office, the auditing arm of Congress, adds new weight to criticisms that some health plans may leave sicker patients worse off.

The GAO report, released this spring, reviewed 126 Medicare Advantage plans and found that 35 of them had disproportionately high numbers of sicker people dropping out. Patients cited difficulty with access to “preferred doctors and hospitals” or other medical care, as the leading reasons for leaving.

“People who are sicker are much more likely to leave (Medicare Advantage plans) than people who are healthier,” James Cosgrove, director of the GAO's health care analysis, said in explaining the research.

David Lipschutz, an attorney at the Center for Medicare Advocacy, says the GAO findings were alarming and should prompt tighter government oversight.

"A Medicare Advantage plan sponsor does not have an evergreen right to participate in and profit from the Medicare program, particularly if it is providing poor care," Lipschutz says.

The GAO did not name the 35 health plans, though it urged federal health officials to consider a large exodus from a plan as a possible sign of substandard care. Most of the 35 health plans were relatively small, with 15,000 members or fewer, and had received poor scores on other government quality measures, the report said. Two dozen plans saw 1 in 5 patients leave in 2014, much higher turnover than normal, the GAO found.

Medicare Advantage plans now treat more than 19 million patients, and are expected to grow as record numbers of baby boomers reach retirement age.

Kristine Grow, a spokeswoman for America's Health Insurance Plans, an industry trade group, says Medicare Advantage keeps expanding because most people who sign up are satisfied with the care they receive.

She says that patients in the GAO study mostly switched from one health plan to another because they got a better deal, either through cheaper or more inclusive coverage.

Grow says many Medicare Advantage plans offer members extra benefits not covered by standard Medicare, such as fitness club memberships or vision or dental care, and do a better job of coordinating medical care to keep people active and out of hospitals.

"We have to remember these are plans working hard to deliver the best care they can," Grow says. Insurers compete vigorously for business and "want to keep members for the long term," she adds.

Some seniors, wary of problems ahead, are choosing to go with traditional Medicare coverage. Pittsburgh resident Marcy Grupp says she mulled over proposals from Medicare Advantage plans but worried she might need orthopedic or other specialized health care and wanted the freedom to go to any doctor or hospital. She's decided on standard Medicare coverage and paid for a "Medigap" policy to pick up any uncovered charges.

"Everything is already in place," says Grupp, a former administrative assistant who turns 65 this month.

The GAO report on Medicare Advantage comes as federal officials are ramping up fines and other penalties against errant health plans.

In the first two months of this year, for instance, the federal Centers for Medicare & Medicaid Services fined 10 Medicare Advantage health plans a total of more than $4.1 million for alleged misconduct that "delayed or denied access" to covered benefits, mostly prescription drugs.

In some of these cases, health plans charged patients too much for drugs or failed to advise them of their right to appeal denials of medical services, according to government records. Industry watchers predict more penalties are to come.

Last month, CMS officials ended a 16-month ban on enrollment in Cigna Corp.'s Medicare Advantage plans. CMS took the action after citing Cigna for "widespread and systematic failures" to provide necessary medical care and prescription drugs, policies officials called a "serious threat to enrollee health and safety."

A flurry of whistleblower lawsuits have surfaced, too. In late May, Freedom Health, a Florida Medicare Advantage insurer, agreed to pay nearly $32 million to settle allegations that it exaggerated how sick some patients were to boost profits, while getting rid of others who cost a lot to treat.

Freedom Health allegedly kept a list of some "unprofitable" patients that it discouraged from staying in the health plan, while encouraging healthier, "more profitable" members to remain, according to the whistleblower suit. Federal regulations prohibit health plans from discriminating based on a person's health.

Asked by Kaiser Health News for comment, Freedom Health corporate counsel Bijal Patel emailed a statement that read, in part: "We agreed to resolve the case so that we can continue focusing on providing excellent care."

Casey Schwarz, a lawyer with the Medicare Rights Center, a consumer service organization, notes that health plans are required to have a formal process for patients to appeal denials of medical services. She says patients should know their rights and insist on them.

"We want people to vote with their feet and leave plans not serving them," Schwarz says.

McConnell Has About $200B In ‘Candy’ To Make Deals On Obamacare Repeal

KFF Health News, July 5, 2017

Several GOP insiders and a couple of Democrats said it would still be a stretch to get to the 50-vote mark, but none would rule it out.

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

By Michael McAuliff

WASHINGTON — The path to 50 votes for an Obamacare replacement bill seemed to narrow dramatically Thursday as efforts to craft a quick compromise foundered — but Senate Majority Leader Mitch McConnell has $200 billion to build a bridge to victory. His dealmaking may be just beginning.

While many policy experts, lobbyists and senators Kaiser Health News spoke to this week seemed skeptical that the Better Care Reconciliation Act could be saved, they said they could envision a way for McConnell (R-Ky.) to succeed in crafting a bill that would partially replace the Affordable Care Act.

McConnell has significant wiggle room in his repeal bill. Under the budget rules he is using to move the legislation, he needs to reach $133 billion in deficit reduction over 10 years. The Congressional Budget Office estimated that the BCRA would save $321 billion.

That leaves about $200 billion in deficit savings that McConnell can afford to give back and use to make deals with as many as a dozen senators who oppose his draft bill.

“There’s clearly a path to do this,” said Matt Salo, the executive director of the National Association of Medicaid Directors. “McConnell has enough candy to do it, and enough time. It’s still a very real possibility.”

Figuring out exactly how to spread the confectionery around, though, is no simple matter.

The key problem for the bill is very similar to the one that nearly brought down the House version of similar legislation: Conservatives want to repeal more of Obamacare and do it quickly while more centrist Republicans are worried about the damage that would be done by extracting $772 billion from Medicaid and eliminating popular consumer protections for health insurance.

To start with, moderate senators such as Rob Portman (R-Ohio), Shelley Moore Capito (R-W.Va.), Lisa Murkowski (R-Alaska) and Susan Collins (R-Maine) all want the expansion of Medicaid under Obamacare preserved or at least rolled back much more gently than the Senate and House bills propose. And they want to preserve treatment dollars for the opioid crises raging through their states. Two Republican senators up for re-election in tight races next year — Dean Heller in Nevada and Jeff Flake in Arizona — have similar concerns.

“Obviously, anybody who had expanded the Medicaid population wants some kind of softer landing than is outlined. That’s a biggie,” said Flake.

But even a senator from deeply conservative Kansas, Sen. Jerry Moran, opposed the bill’s draconian cuts, which likely would punish the rural hospitals in his state.

All of them need money added back to Medicaid, especially after a new CBO analysis released Thursday said the program’s cuts jump from 25 percent after the first 10 years to a staggering 35 percent in the second decade.

They also have concerns about provisions that would allow states to waive minimum standards in the ACA, including its essential health benefits and protections for people with preexisting conditions.

On the conservative side, the pressure has been on to cut taxes established by the health law, and to roll back insurance regulations, so that states could craft whatever rules they want. The House repeal bill would let states get waivers for the 10 essential benefits in Obamacare. Sen. Ted Cruz (R-Texas) sponsored an amendment that goes further and would let insurers directly offer plans that don’t comply with the ACA standards as long as they also offered one plan that did in the affected state.

These competing interests would seem to be diametrically opposed. But McConnell’s ability to tap that $200 billion could go a long way to ease the friction, and Sen. Mike Rounds (R-S.D.) stepped forward Wednesday and Thursday to suggest which tax cut to forgo — a politically toxic one that primarily benefits the rich. That’s the 3.8 percent net investment tax on families that earn more than $250,000.

Not only would this provide McConnell with an additional $172 billion for his dealmaking, it would mute Democrats’ criticism of the bill as a mechanism to reward rich Republican donors while depriving poorer Americans of health care.

How McConnell doles out that largesse is another part of the puzzle. Capito and Portman had asked for $45 billion to fight the opioid crisis that is so critical to Ohio, West Virginia and other states, and aides speaking on background say they are likely to get it.

Senators like Flake, Moran and Heller could certainly be tempted by easing the blow to Medicaid and, in spite of long styling themselves fiscal conservatives, could keep a tax hike in place.

“That’s not the issue Nevada’s worried about,” said Heller, referring to the taxes. “It’s insurance for poor people.”

Even Sen. Ron Johnson (R-Wis.), who initially aligned himself against the Senate bill with Cruz and Sens. Rand Paul (R-Ky.) and Mike Lee (R-Utah), sounded open to Rounds’ idea.

“We’re $20 trillion in debt, so I think we should seriously consider retaining some of the tax revenue that funds the subsidies,” Johnson told reporters as he fast-walked to a closed-door meeting of the GOP caucus with Vice President Mike Pence on Thursday.

On the conservative side, even Lee suggested he was sensitive to the charge that Republicans were cutting taxes for the rich to stiff the poor. But Cruz hasn’t said he would be willing to keep the taxes in place. Pressed by reporters Thursday on whether the tax was a deal killer for him, he strolled onto an elevator and stayed deliberately silent as he waited for the doors to close.

There are some other levers McConnell has, but they are issues unrelated to the health bill. McConnell and senators would have to act as if it is not quid pro quo. For instance, Murkowski might be swayed by an offer of an unrelated bill to open the Arctic National Wildlife Refuge to oil drilling. (She laughed when a reporter made that suggestion earlier this year but didn’t say she’d turn it down.) Heller is locked in a battle with the administration to ensure that the Yucca Mountain nuclear waste storage facility never opens in his state. McConnell’s support keeping it closed would appeal to him, although it would be hard for him to brag about it later in connection to the health bill.

One Republican health care lobbyist and former Capitol Hill aide said the behavior of the conservatives showed that if the bill is to pass, they will have to cave.

“The conservatives are going to have to capitulate a long way, but when they do that, are they getting anything in return?” the lobbyist said.

What they could get in return is some version of Cruz’s amendment, but the lobbyist and others noted it could not be as extreme, since essential health benefits and protections for people with preexisting conditions were among the top concerns for Senate moderates when the House passed its bill.

Several GOP insiders and a couple of Democrats said it would still be a stretch to get to the 50-vote mark, but none would rule it out.

Speaking privately so they could be candid, aides from both parties saw similar political downsides for Republicans. One senior Democratic aide summed it up succinctly.

“We suffered for a few cycles over health care, but at least we had people who could talk about it who were helped,” the aide said. “They won’t have that.”

Still, the GOP remains committed to trying to fulfill the pledge they’ve made for seven years, and even vulnerable senators like Flake were not giving up.

“We’ve still got a long way to go, I think,” Flake said. “In some ways, we’re going around in circles, but I think we’re getting closer on some elements.”

Flake said the lawmakers were sending various amendments that contain those elements to the CBO and expected to have numbers back next week while the Senate is on recess. Those numbers will be crucial.

“We’re just trying to get to 50 votes,” Rounds said. “We’ve got a lot of work to do yet. We just want to make it the best we can.”

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