Following in the steps of Baltimore and Philadelphia, New York City is establishing a committee to review deaths and severe complications related to pregnancy and childbirth, aiming to reduce their toll on expectant and new mothers in the nation’s largest metropolis.
There’s ample room for improvement: The city’s maternal mortality rate is thought to be slightly above average for the U.S., which has the highest such rate in the industrialized world. Of the estimated 700 to 900 deaths related to pregnancy and childbirth nationwide each year, New York City accounts for about 30.
Moreover, the city’s outcomes feature a worsening racial divide. Between 2006 and 2010, black women were 12 times more likely than white women to die from pregnancy-related causes, up from seven times more likely between 2001 and 2005.
The new committee will dig deeper into each maternal death than has previously been possible and, by mining their causes and circumstances, will guide efforts to prevent such tragedies, city health officials said.
“We want to advocate for quality improvement, not just in the city [overall], but in all the hospitals in the community,” said Dr. Lorraine Boyd, medical director of the city health department’s Bureau of Maternal, Infant and Reproductive Health. “We want to be able to say that the rates of maternal mortality, that the [racial] gap is closing and that we’ve put programs in place that are going to lead to that.”
The panel (officially named the Maternal Mortality and Morbidity Review Committee, but already nicknamed M3RC) is scheduled to hold its inaugural meeting in early December and convene four times a year thereafter.
It will have up to 45 members, including not only doctors and nurses, but also doulas, midwives and social workers — “people in the community, who can better reflect how women live their lives,” Boyd observed.
Beyond examining maternal deaths, the panel will also compile and analyze data on severe complications experienced by expectant and new mothers. For every death, experts say there are dozens of cases of such complications, affecting more than 50,000 American women each year.
New York state has had a maternal mortality review committee since 2010 that examined cases statewide, including those in the city; the city has also had its own panel to assess death data in aggregate.
Officials said the city’s new review committee will work hand-in-hand with that of the state, with the city panel reviewing deaths within the five boroughs and the state committee reviewing those outside. The committees will collect a standardized set of data and pool their findings in a statewide report, said Jill Montag, a spokeswoman for the New York State Department of Health.
Beyond its potential to improve outcomes, health officials in New York and beyond said they see the city’s creation of a review committee as a step toward better, more complete data on maternal deaths.
Nationally, such data is so unreliable and incomplete that the United States has not published official annual counts of fatalities or an official maternal mortality rate in a decade.
Unlike the United Kingdom, widely considered the gold standard for maternal mortality data, the U.S. lacks a national system for reviewing pregnancy-related deaths.
Slightly more than half the states and a smattering of cities have active, stable maternal mortality reviews, but many get little or no funding and rely on volunteers to do time-consuming case analyses. Some large states have more deaths to review than one committee can reasonably handle and sometimes skip years or look into subsets of cases rather than reviewing every death.
Adding city committees that can shoulder a portion of the work “makes a lot of sense,” said David Goodman, who oversees maternal health efforts at the Centers for Disease Control and Prevention’s maternal and infant health branch. “The New York City and New York state collaboration is the first we are aware of, and perhaps a model approach for other large states to consider.”
Goodman also leads a privately funded effort to bring together and standardize data from state and local maternal mortality review processes. To do this, the initiative has created a tool, the Maternal Mortality Review Information Application, and New York City and New York state are among 12 jurisdictions nationwide that have begun using it. Another 13 are preparing to do so, Goodman said.
New York City officials said the new committee would be funded partly through a grant but would not specify the funder or the grant amount because the contract isn’t signed yet. Eight staffers at the city health department will work part time on the project, giving it anywhere from 5 percent to 90 percent of their time.
“This is something that we’re committed to, that the city has prioritized, that the health department has committed to fund and to see work,” said Carolina Rodriguez, deputy press secretary for the New York City Department of Health and Mental Hygiene.
Two U.S. senators introduced legislation Tuesday requiring federal agencies to come up with solutions to the waste caused by oversized eyedrops and single-use drug vials, citing a ProPublica story published earlier this month.
The bipartisan effort by Sens. Amy Klobuchar, D-Minn., and Chuck Grassley, R-Iowa, calls for the Food and Drug Administration and the Centers for Medicare and Medicaid Services to come up with a plan to reduce the waste, which is estimated to cost billions of dollars a year.
“With the skyrocketing costs of prescription drugs, American taxpayers shouldn’t be footing the bill for medicine going to waste,” Klobuchar said in a press release announcing the bill, known as the Reducing Drug Waste Act of 2017. Sens. Dick Durbin, D-Ill., and Jeanne Shaheen, D-N.H., are co-sponsors of the legislation.
Grassley called it “common sense” legislation. “It’s no secret that wasteful health care spending is a significant contributor to the rising cost of health care in the United States,” he said in the release.
ProPublica’s story showed how drug companies force patients to pay for expensive liquid medications, such as eyedrops and cancer drugs, which are produced or packaged in ways that lead to waste. Drug companies have known for decades that eyedrops are larger than what the eye can hold — sometimes two or three times too big. As a result, the excess medication overflows the eye and runs down users’ cheeks or is ingested through their eye ducts. This waste causes some patients to run out of medicine before their insurers allow them to refill their prescriptions.
Some of the largest producers of eyedrops — from expensive vials for eye conditions like glaucoma to over-the-counter drops for dry eyes — have done research to show that smaller drops work just as effectively. But they have continued to produce larger drops. Novartis, owner of Alcon, one of the leading eye care companies, said the larger drop size allowed a margin of safety to help patients administer the drops. Other eyedrop makers declined to comment.
ProPublica also examined how the packaging of cancer drugs often results in some of the drug being tossed in the trash. The drug company Genentech, for example, switched earlier this year from sharable vials of its cancer drug Herceptin to single-use vials, causing excessive waste. One California cancer center estimated the change would lead to an average of $1,000 in wasted medicine per patient, per infusion. Patients are billed for such waste.
ProPublica also cited research led by Dr. Peter Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center in New York. Bach’s study, also reported in 2016 in The New York Times, found that single-use cancer vials wasted nearly $3 billion annually in cost increases and medicine that must be thrown away.
“From cancer drugs to expensive eye-drops, many drug companies insist on selling their products in excessively large, one-size-fits-all vials that contain more medicine than the average patient needs,” said Durbin, one of the lawmakers sponsoring the bill. “This is a colossal and completely preventable waste of taxpayer dollars, and it means American patients and hard-working families are paying for medication that gets tossed in the trash.”
Bach’s study proposed making drug companies produce vials in additional sizes, so they could be delivered in a way that’s more efficient, or requiring drug companies to give rebates on unused medicine. He said it’s too early to know what the federal government’s solution would be, but the new bill is a positive step forward.
“This could be legislation that saves Medicare and sick patients a lot of money,” Bach says.
Dr. Alan Robin, a Baltimore ophthalmologist whose research was featured in ProPublica’s story, has been urging drug companies to reduce the size of their eyedrops for decades. When he heard Monday about the senators’ proposed legislation, he started to cry.
“I’m literally crying with joy,” Robin says. “I’m very concerned about both the cost issues associated with waste, the side effects on patients, and also the environmental impact of waste."
An audit released late last week by the New York state comptroller’s office found the state’s Education Department, which regulates nursing, failed to investigate top-priority complaints against nurses in the time allowed by law.
It also found nurses’ backgrounds were not adequately checked and that they were not properly monitored for criminal behavior after licensure.
All of these findings confirm those in a ProPublica investigation into New York’s nursing regulations published in April of 2016.
“The report underscores a problem we already knew existed,” said state Sen. Kemp Hannon, who has co-sponsored two bills — one in 2016 and one in 2017 — aimed at correcting problems identified by ProPublica. In 2016, the bill passed the Senate with a single “no” vote but never received a vote in the Assembly. In 2017, the bill passed the Senate unanimously, but the Assembly never proposed a bill or moved on the Senate bill.
“The roadblock lies squarely at the hands of the Assembly,” Hannon said. “At some point they have to bow to the need for action.”
Assembly member Deborah Glick, who sponsored 2016 legislation similar to the Senate’s, said the Assembly is “working assiduously” towards a bill. She said earlier versions of the legislation did not respect the due process rights of licensed professionals, particularly by allowing regulators to summarily suspend professionals’ licenses before they had a chance to respond in some cases. In other states, regulators have the power to do this when there is an urgent threat to safety.
“We understand the critical importance of protecting the public, but we also understand that licensed professionals are entitled to their due process rights,” she said. She said a solution was almost reached this legislative session, but other initiatives “diverted” the higher education committee’s attention. She said she would make it a priority to pass legislation at the start of the next session, which begins in January 2018.
Mark Johnson, a spokesman for the comptroller’s office, said that while audits of state departments are routine, ProPublica’s reporting was “a factor” in the decision to investigate nursing regulations.
As ProPublica reported, the Education Department relies on nurses to self-disclose misconduct and criminal convictions. In New York, nurses are only required to make these disclosures every three years when they renew their licenses, which the comptroller’s audit noted “[enables] nurses who have been sanctioned to practice in the interim.”
“As a result, the Department cannot be assured that all episodes of misconduct are identified properly and in a timely manner, and that nurses who pose a threat to the public’s health and safety are prevented from practicing in New York State,” the audit said.
Both the 2016 and 2017 Senate bills, sponsored by Sen. Kenneth LaValle and co-sponsored by Hannon, would have fixed the vast majority of the problems identified by ProPublica and the recent audit. Aimed at all 54 professions licensed by the Education Department, both bills would have allowed the department to summarily suspend the licenses of professionals suspected of extreme misconduct. The measures also defined “moral character” requirements for licensed professions, and required professionals to inform the department of criminal convictions within 30 days.
Hannon said he will continue to pursue a solution for the problems referenced in the comptroller’s audit. If the legislature will not act to fix holes in the oversight of all 54 professions licensed by the state, he said he may propose legislation aimed directly at nursing or move to have the regulation of nurses moved from the Education Department to the Health Department, which regulates doctors and physician assistants. New York is the only state in the country that assigns the regulation of nursing to the Education Department.
Under the Education Department’s supervision, New York has continued to allow nurses who have harmed patients to retain active nursing licenses.
ProPublica’s report highlighted the case of Linda Ansa, a Bronx nurse who the New York Health Department found had nearly killed a 99-year-old nursing home resident by administering 50 times the necessary dose of insulin.
Nursing homes in New York are regulated by the Health Department, which penalized Ansa in 2014 before referring her case to the Education Department for action against her license. But more than three years after her case was referred, no action has been taken. Her license remains clear. Neither Ansa nor the attorney who represented her in the Health Department case has responded to requests for comment.
The Education Department declined to comment on Ansa’s case and typically declines to answer questions on specific disciplinary actions. A spokesman for the department, Jonathan Burman, said in a statement that all allegations of misconduct are taken “extremely seriously.” He said that the department has “sought legislation to modernize and enhance our authority over licensed professions” for the past two years.
“We will continue to work with the legislature to get this important public protection bill enacted,” he said.
In a response included in the comptroller’s audit, the Education Department said its budget has not kept pace with its increasing responsibilities. The professions regulated by the Education Department range from nursing to landscape architecture and the number of professions the agency oversees has increased steadily over the decades. According to the audit, receipts from fees collected by the department have risen from $41.5 million in 2010-2011 to $53.5 million in 2016-2017. The department’s appropriation in the state budget, however, has stayed at $45.1 million over the same period. The department also told the comptroller’s office its antiquated computer system made it difficult to efficiently handle its caseload.
The state commissioner of education, MaryEllen Elia, has 90 days to report to the comptroller, the governor and the legislature on what steps the Education Department has taken to implement the comptroller’s recommendations.
The recommendations include streamlining and more closely tracking investigations, strengthening controls over “moral character” requirements for nurses and researching the best practices of other states.
Donna Nickitas is the executive officer of the nursing Ph.D. program at the Graduate Center of the City University of New York. She called the comptroller’s recommendations obvious and said she was “greatly disappointed” that neither the Legislature nor the Education Department had undertaken those improvements over the last year and a half.
“[ProPublica] came to the table so long ago with evidence showing other states were far ahead of us,” she said. “In the private sector, they fire people over this.”
A U.S. senator whose state has been devastated by the opioid epidemic sent letters Tuesday asking two major health insurance companies to remove barriers to non-opioid pain treatments.
The letters from Sen. Joe Manchin, D-W.Va., follow a story by ProPublica and The New York Times, which detailed how insurers have restricted access to pain medications that carry a lower risk of addiction or dependence, even as they provided comparatively easy access to cheaper, generic opioid medications.
“The practices detailed in the article are the exact opposite of what we need and will only serve to worsen the opioid epidemic, putting more people at risk of opioid addiction and overdose death,” Manchin wrote in letters to David S. Wichmann, chief executive of UnitedHealth Group, and Joseph R. Swedish, chief executive of Anthem Inc.
“Specifically, I ask you to reduce or eliminate the barriers that your beneficiaries face to access non-opioid pain medications and physical therapy for pain management. Just as importantly, I urge you to ensure that every beneficiary that you serve that needs substance use disorder treatment, including behavioral health counseling, is able to affordably access it.”
UnitedHealth was cited in the story because it stopped covering Butrans, a painkilling skin patch that contains buprenorphine, an opioid that has a lower risk of abuse and dependence than generic, long-acting opioids. As a result, a patient said she turned to long-acting morphine to control her pain, went to the emergency room because she could not control her pain, and now visits her doctor more often than before.
Anthem denied a request for Lyrica, a non-opioid, brand-name drug, for a patient who had been using it successfully to treat the pain associated with interstitial cystitis, a chronic bladder condition. She cannot afford the roughly $520 monthly retail price of Lyrica, she said, so she takes generic gabapentin, a related, cheaper drug. She said it does not manage the pain as well as Lyrica.
UnitedHealth and Anthem defended their decisions and said they take the opioid crisis seriously. Bothcompanies said they have been able to successfully decrease the number of opioid prescriptions taken by members.
In a statement Tuesday, Anthem said, “We share the Senator’s concerns about overdoses in West Virginia and the entire country, and agree that more needs to be done to address the opioid epidemic. That’s why Anthem is addressing the opioid epidemic through a holistic approach involving prevention, treatment and recovery and deterrence.”
Anthem said a West Virginia affiliate, Unicare Health Plan of West Virginia, is expanding a program to offer substance use treatments as part of primary care, removing the stigma that may be attached to it. The insurer also said it covers non-opioid pain relief drugs “according to best clinical practice guidelines and scientific evidence,” noting that some carry retail prices of $350 to $1,500 per prescription.
UnitedHealth has not yet responded to a request for comment.
Until recently, the role of insurers in fanning — or at least failing to stop — the opioid crisis has not received as much attention as that of other players, including pharmaceutical companies, doctors and drug distributors.
A day after the ProPublica/New York Times story was published, attorneys general for 37 states sent a letter to the health insurance industry’s main trade group, urging its members to reconsider coverage policies that may be fueling the opioid crisis.
“The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable,” the letter said. “We ask that you quickly initiate additional efforts so that you can play an important role in stopping further deaths.”
Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. Moreover, at least two large pharmacy benefit managers, which run insurers’ drug plans, announcedthis year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply.
Manchin’s daughter, Heather Bresch, is the chief executive of Mylan, a major pharmaceutical company. Mylan last month disclosed that it had received a subpoena from the Department of Justice seeking information about its manufacturing and sales of opioids. The company said it was cooperating.
While opioids such as hydrocodone and morphine are often prescribed to relieve pain, they also have been linked to abuse and dependence. Drug overdoses are now the leading cause of death among Americans under 50, and more than 2 million Americans are estimated to misuse opioids.
For our story earlier this month, ProPublica and the Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them.
Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. And even if they do approve coverage, some insurance companies have set a high out-of-pocket cost for Suboxone, rendering it unaffordable for many addicts, a number of pharmacists and doctors said.
In his letters, Manchin asked UnitedHealth and Anthem to share their plans for addressing the crisis. “We have lost too many Americans to the opioid epidemic,” he wrote. “I hope that your company will be a part of the solution.”
In their letter to AHIP, the attorneys general urged insurers to revise their rules "to encourage healthcare providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain."
This article first appeared September 18, 2017 on ProPublica.
Attorneys general for 37 states sent a letter Monday to the health insurance industry’s main trade group, urging its members to reconsider coverage policies that may be fueling the opioid crisis.
The letter is part of an ongoing investigation by the state officials into the causes of the opioid epidemic and the parties that are most responsible. The group is also focusing on the marketing and sales practices of drug makers and the role of drug distributors.
On Sunday, ProPublica and The New York Times reported that many insurance companies limit access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications. The safer drugs are more expensive.
In their letter to America’s Health Insurance Plans, the trade group based in Washington, D.C., the attorneys general urged insurers to revise their rules “to encourage healthcare providers to prioritize non-opioid pain management options over opioid prescriptions for the treatment of chronic, non-cancer pain.”
“The status quo, in which there may be financial incentives to prescribe opioids for pain which they are ill-suited to treat, is unacceptable,” the letter said. “We ask that you quickly initiate additional efforts so that you can play an important role in stopping further deaths.”
The signatories include the attorneys general of California, Florida, New York, Pennsylvania and Michigan.
While opioids, such as hydrocodone and morphine, are often prescribed to relieve pain, they also have been linked to abuse and dependence. Drug overdoses are now the leading cause of death among Americans under 50, and more than 2 million Americans are estimated to misuse opioids. While the crisis has placed the practices of drug makers, pharmaceutical distributors, pharmacies and doctors under scrutiny, the role of insurers in enabling access to cheap, addictive opioids has received less attention.
The Department of Health and Human Services is now studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that insurers are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.
Last week, the New York state attorney general’s office sent letters to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.
In a written statement to ProPublica, Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, said that, “We share the state attorneys general’s commitment to eradicating the opioid epidemic in America.”
“Health plans cover comprehensive, effective approaches to pain management that include evidence-based treatments, more cautious opioid prescribing, and careful patient monitoring,” Donaldson wrote. “Recent research shows that non-opioid medications, even over-the-counter medication like ibuprofen, can provide just as much relief as opioids.”
Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. A number of companies say they have seen marked declines in monthly opioid prescriptions in the past year or so. Moreover, at least two large pharmacy benefit managers, which run insurers’ drug plans, announcedthis year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply.
“Patients and their care providers should talk openly and honestly about pain and how to manage it — from lifestyle changes and exercise to over-the-counter options and clearly understanding the dangers of opioids,” Donaldson said.
Nonetheless, ProPublica and The New York Times found that companies are sometimes refusing to cover less risky drugs prescribed by doctors while putting no such restrictions on opioids.
We analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them.
Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. And even if they do approve coverage, some insurance companies have set a high out-of-pocket cost for Suboxone, rendering it unaffordable for many addicts, a number of pharmacists and doctors said.
“Everyone — including and especially insurance companies — have an obligation to address the opioid epidemic,” New York Attorney General Eric T. Schneiderman said in a press release today. “Insurers must take a hard look at the systemic problems in our healthcare system that result in the over-prescription of opioids and fuel the cycle of addiction.”
At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.
The reason, experts say: Opioid drugs are generally cheap while safer alternatives are often more expensive.
Drugmakers, pharmaceutical distributors, pharmacies and doctors have come under intense scrutiny in recent years, but the role that insurers — and the pharmacy benefit managers that run their drug plans — have played in the opioid crisis has received less attention. That may be changing, however. The New York State attorney general’s office sent letters last week to the three largest pharmacy benefit managers — CVS Caremark, Express Scripts and OptumRx — asking how they were addressing the crisis.
ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.
In contrast, almost every plan covered common opioids and very few required any prior approval.
The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found.
Alisa Erkes lives with stabbing pain in her abdomen that, for more than two years, was made tolerable by Butrans. But in January, her insurer, UnitedHealthcare, stopped covering the drug, which had cost the company $342 for a four-week supply. After unsuccessfully appealing the denial, Erkes and her doctor scrambled to find a replacement that would quiet her excruciating stomach pains. They eventually settled on long-acting morphine, a cheaper opioid that UnitedHealthcare covered with no questions asked. It costs her and her insurer a total of $29 for a month’s supply.
The Drug Enforcement Administration places morphine in a higher category than Butrans for risk of abuse and dependence. Addiction experts say that buprenorphine also carries a lower risk of overdose.
UnitedHealthcare, the nation’s largest health insurer, places morphine on its lowest-cost drug coverage tier with no prior permission required, while in many cases excluding Butrans. And it places Lyrica, a non-opioid, brand-name drug that treats nerve pain, on its most expensive tier, requiring patients to try other drugs first.
Erkes, who is 28 and lives in Smyrna, Georgia, is afraid of becoming addicted and has asked her husband to keep a close watch on her. “Because my Butrans was denied, I have had to jump into addictive drugs,” she said.
UnitedHealthcare said Erkes had not exhausted her appeals, including the right to ask a third party to review her case. It said in a statement, “We will work with her physician to find the best option for her current health status.”
Matthew N. Wiggin, a spokesman for UnitedHealthcare, said that the company was trying to reduce long-term use of opioids. “All opioids are addictive, which is why we work with care providers and members to promote non-opioid treatment options for people suffering from chronic pain,” he said.
Dr. Thomas R. Frieden, who led the Centers for Disease Control and Prevention under President Obama, said that insurance companies, with few exceptions, had “not done what they need to do to address” the opioid epidemic. Right now, he noted, it is easier for most patients to get opioids than treatment for addiction.
Leo Beletsky, an associate professor of law and health sciences at Northeastern University, went further, calling the insurance system “one of the major causes of the crisis” because doctors are given incentives to use less expensive treatments that provide fast relief.
The Department of Health and Human Services is studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that they are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.
Insurers say they have been addressing the issue on many fronts, including monitoring patients’ opioid prescriptions, as well as doctors’ prescribing patterns. “We have a very comprehensive approach toward identifying in advance who might be getting into trouble, and who may be on that trajectory toward becoming dependent on opioids,” said Dr. Mark Friedlander, the chief medical officer of Aetna Behavioral Health who participates on its opioid task force.
Aetna and other insurers say they have seen marked declines in monthly opioid prescriptions in the past year or so. At least two large pharmacy benefit managers announcedthis year that they would limit coverage of new prescriptions for pain pills to a seven- or 10-day supply. And bowing to public pressure — not to mention government investigations — several insurers have removed barriers that had made it difficult to get coverage for drugs that treat addiction, like Suboxone.
Experts in addiction note that the opioid epidemic has been changing and that the problem now appears to be rooted more in the illicit trade of heroin and fentanyl. But the potential for addiction to prescribed opioids is real: 20 percent of patients who receive an initial 10-day prescription for opioids will still be using the drugs after a year, according to a recent analysis by the CDC.
Several patients said in interviews that they were terrified of becoming dependent on opioid medications and were unwilling to take them, despite their pain.
In 2009, Amanda Jantzi weaned herself off opioids by switching to the more expensive Lyrica to treat the pain associated with interstitial cystitis, a chronic bladder condition.
But earlier this year, Jantzi, who is 33 and lives in Virginia, switched jobs and got a new insurer — Anthem — which said it would not cover Lyrica because there was not sufficient evidence to prove that it worked for interstitial cystitis. Jantzi’s appeal was denied. She cannot afford the roughly $520 monthly retail price of Lyrica, she said, so she takes generic gabapentin, a related, cheaper drug. She said it does not manage the pain as well as Lyrica, which she took for eight years. “It’s infuriating,” she said.
Jantzi said she wanted to avoid returning to opioids. However, “I could see other people, faced with a similar situation, saying, ‘I can’t live like this, I’m going to need to go back to painkillers,’ ” she said.
In a statement, Anthem said that its members have to meet certain requirements before it will pay for Lyrica. Members can apply for an exception, the insurer said. Jantzi said she did just that and was turned down.
With Butrans, the drug that Erkes was denied, several insurers either do not cover it, require a high out-of-pocket payment, or will pay for it only after a patient has tried other opioids and failed to get relief.
In one case, OptumRx, which is owned by UnitedHealth Group, suggested that a member taking Butrans consider switching to a “lower cost alternative,” such as OxyContin or extended-release morphine, according to a letter provided by the member.
Wiggin, the UnitedHealthcare spokesman, said the company’s rules and preferred drug list “are designed to ensure members have access to drugs they need for acute situations, such as post-surgical care or serious injury, or ongoing cancer treatment and end of life care,” as well as for long-term use after alternatives are tried.
Butrans is sold by Purdue Pharma, which has been accused offueling the opioid epidemic through its aggressive marketing of OxyContin. Butrans is meant for patients for whom other medications, like immediate-release opioids or anti-inflammatory pain drugs, have failed to work, and some scientific analyses say there is not enough evidence to show it works better than other drugs for pain.
Dr. Andrew Kolodny is a critic of widespread opioid prescribing and a co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. Kolodny said he was no fan of Butrans because he did not believe it was effective for chronic pain, but he objected to insurers suggesting that patients instead take a “cheaper, more dangerous opioid.”
“That’s stupid,” he said.
Erkes’s pain specialist, Dr. Jordan Tate, said her patient had been stable on the Butrans patch until January, when UnitedHealthcare stopped covering the product and denied Erkes’s appeal.
Without Butrans, Erkes, who once visited the doctor every two months, was now in Tate’s office much more frequently, and once went to the emergency room because she could not control her pain, thought to be related to an autoimmune disorder, Behcet’s disease.
Tate said she and Erkes reluctantly settled on extended-release morphine, a drug that UnitedHealthcare approved without any prior authorization, even though morphine is considered more addictive than the Butrans patch. She also takes hydrocodone when the pain spikes and Lyrica, which UnitedHealthcare approved after requiring a prior authorization.
Erkes acknowledged that she could have continued with further appeals, but said the process exhausted her and she eventually gave up.
While Tate said Erkes had not shown signs of abusing painkillers, her situation was far from ideal. “She’s in her 20s and she’s on extended-release morphine — it’s just not the pretty story that it was six months ago.”
Many experts who study opioid abuse say they also are concerned about insurers’ limits on addiction treatments. Some state Medicaid programs for the poor, which pay for a large share of addiction treatments, continue to require advance approval before Suboxone can be prescribed or they place time limits on its use, both of which interfere with treatment, said Lindsey Vuolo, associate director of health law and policy at the National Center on Addiction and Substance Abuse. Drugs like Suboxone, or its generic equivalent, are used to wean people off opioids but can also be misused.
The analysis by ProPublica and The Times found that restrictions remain prevalent in Medicare plans, as well. Drug plans covering 33.6 million people include Suboxone, but two-thirds require prior authorization. Even when such requirements do not exist, the out-of-pocket costs of the drugs are often unaffordable, a number of pharmacists and doctors said.
At Dr. Shawn Ryan’s addiction-treatment practice in Cincinnati, called BrightView, staff members often take patients to the pharmacy to fill their prescriptions for addiction medications and then watch them take their first dose. Research has shown that such oversight improves the odds of success. But when it takes hours to gain approval, some patients leave, said Ryan, who is also president of the Ohio Society of Addiction Medicine.
“The guy walks out, and you can’t blame him,” Ryan said. “He’s like, ‘Hey man, I’m here to get help. What’s the deal?’”
Maternity care is disappearing from America’s rural counties, and for the 28 million women of reproductive age living in those areas, pregnancy and childbirth are becoming more complicated — and more dangerous. That’s the upshot of a new report from the Rural Health Research Center at the University of Minnesota that examined obstetric services in the nation’s 1,984 rural counties over a 10-year period. In 2004, 45 percent of rural counties had no hospitals with obstetric services; by 2014, that figure had jumped to 54 percent. The decline was greatest in heavily black counties and in states with the strictest eligibility rules for Medicaid.
The decrease in services has enormous implications for women and families, says Katy B. Kozhimannil, an associate professor in health policy who directs the Minnesota center’s research efforts. Rural areas have higher rates of chronic conditions that make pregnancy more challenging, higher rates of childbirth-related hemorrhages — and higher rates of maternal and infant deaths. And because rural counties tend to be poorer, any efforts to revamp or slash Medicaid could hit rural mothers especially hard. We spoke with Kozhimannil about the new study and the implications for maternal care. (The conversation has been edited and condensed.)
You and your colleagues have been looking at maternal health issues for several years. What’s the most surprising part of this new study?
I was surprised about the findings on race. Being aware of structural racism in U.S. health care, I shouldn’t have been. But we found that hospitals are more likely to close their doors entirely or close their obstetric units in communities that have more black residents. Rural black communities also experience some of the poorest birth outcomes in the country, especially in the Southeast.
I think [the race findings] are new and really important. In all the discussions I've had around maternity care access, I think there's often a false association of “rural” with white communities and with farming, but that doesn't represent the demographic reality of rural America, which is very diverse. There are 10 million people of color in rural America, that’s about 20 percent of all rural Americans.
What has led to the decline in rural obstetric services more broadly over this 10-year period?
We didn’t choose this period because we thought it was particularly unique. We chose it because it was the most recent decade of data we could get. That said, this was a period when there was a substantial shift in the health care delivery system. The debates around Obamacare, the implementation, the threats to repeal — all that really created instability with respect to what hospitals and clinicians were expecting around payments.
And the role of finances is key. If hospitals want to offer obstetric services, they need to be ready for a baby to be born at any time — they need to have a bed available, the equipment available for mom and for baby, clinicians and staff available that have the necessary skills. That's a substantial expense. If a hospital’s revenues are limited because it has a low volume of births — as many rural hospitals do — or if revenues are unpredictable, that creates a really difficult administrative problem.
How does Medicaid play into this?
Medicaid funds about half of all births in the United States, and an even greater percentage of births in rural hospitals. Medicaid funding for births is incredibly important and it’s one factor in hospitals’ decisions around whether to keep obstetric services. We found that rural counties in states with more generous Medicaid programs — with higher income eligibility limits for pregnant women — were less likely to lose hospital-based obstetric services.
Meanwhile, there’s talk of allowing states to impose new rules that could restrict access to Medicaid.
Changes to the financing of Medicaid would likely have big negative effects on the availability of obstetric services in rural areas. Based on our study, the generosity of a state’s Medicaid program seems directly linked to access to maternity care in rural counties. As such, any new reductions or restrictions on Medicaid funding or services may affect rural hospital financing.
What is it like to be pregnant in a rural area that doesn’t have adequate maternity care? What do women do?
For some women, there may be a nearby clinic or their general practitioner may be able to see them for prenatal visits if they have a low-risk pregnancy. But then they need to give birth in a more distant area with a different set of providers.
That may not even be a choice for women who live in communities that don't have any providers that see pregnant patients, or for women that have higher risk complications that require more specialized care.
I remember talking to one woman who lived in rural northern Minnesota and who had a preterm birth with her first pregnancy. For her second pregnancy, she had to drive two hours to the nearest hospital with a high-risk obstetrician. With one child at home already, and a full-time job and a partner who worked, it was almost untenable. It would take a whole day for her to drop her child off at daycare, drive all the way to the hospital, wait for a 15-minute visit that felt rushed, then drive all the way back.
I just heard on the radio this morning that a truck ran into a railroad bridge that goes over the highway that this woman would take to go back and forth to the hospital. So if she was pregnant right now, there's a 27-mile detour on three dirt roads to get around this broken bridge. That adds probably another 45 minutes to an already two-hour drive. Things like that can happen, you know, all the time.
What about giving birth? How does living in a remote area affect the kinds of choices doctors and women make?
In a typical childbirth education class in an urban area, childbirth educators say things like, “Go to the hospital when your contractions are five minutes apart.” None of that makes any sense in a rural context where women give birth far from home.
For rural moms, a lot of the conversation in childbirth education and in prenatal care revolves around logistics and transportation: “Do you know how you’re going to get to your appointment? Do you have access to a car? Is your car reliable? Do you have money for gas? Do you have a backup plan if your car doesn't start? Do you have someone that you can call if you need to go in quickly?”
Anecdotally, I hear a lot about labor induction. The rural physicians I’ve talked to are like, “I can't believe I am trying to talk patients into having an induction.” They believe in letting labor start naturally, but given the long drive, induction is often better for patients clinically. So that if complications come up, someone’s there, monitoring your blood pressure and vital signs. It’s not, you know, your partner or friend desperately driving down dirt roads as fast as they can while you yell in the back seat.
How does all this affect outcomes for babies?
We have good information from Canada that the women who have to drive long distances to give birth have higher rates of the babies being in the neonatal intensive care unit, and even of infant mortality. And so we know that distance is associated with outcomes of care. When rural hospitals close the doors of their maternity units, women have to drive longer distances.
These seem like pretty huge hurdles for rural mothers and babies. Is there any way to address these problems to improve maternity care?
One idea is programs to support pregnant women and families, especially with respect to their housing and transportation needs when they live far away from where they're going to give birth. Alaska has actually done a tremendous job of this.
Another is for states to allow midwives and nurse practitioners to play a greater role in offering prenatal and postpartum care, without having to be under a doctor’s supervision. That would be useful. Our prior research shows that midwives, for example, attend births at about one-third of all rural hospitals, and that hospital administrators would like to expand the role midwives play.
State and federal programs to support the rural maternity workforce are crucial. There ought to be programs to support training in emergency births in rural communities that lose obstetric care, and to support the costs of providing maternity care in communities where there are willing providers.
Medicare patients in Hawaii take fewer opioid painkillers and fewer antibiotics, on average, than those in any other state. Physicians and health policy experts cite demographics as a possible reason why.
This article first appeared August 31, 2017 on ProPublica.
If you think you would be healthier if you lived in Hawaii, you may be right.
People in Hawaii appear to be much less likely to overuse problematic prescription drugs, including opioid pain medications and antibiotics, than people in the mainland United States.
Medicare beneficiaries in Hawaii used fewer opioid pain medications, fewer antibiotics, fewer antipsychotic drugs and fewer drugs labeled as risky for seniors on average than patients in any other state in 2015, according to a ProPublica analysis of data from the Centers for Medicare and Medicaid Services. Medicare’s prescription program covers more than 42 million seniors and disabled people, and pays for more than one in every four prescriptions in the U.S.
These four classes of medications are problematic for a number of reasons. Misuse and abuse of opioid painkillers has been linked to an ever-growing overdose epidemic. Overuse of antibiotics has been linked to the emergence of deadly superbugs that are resistant to drugs. Critics have faulted the use of antipsychotics in the elderly, particularly those with dementia, as a means of chemically restraining them. And the American Geriatrics Society has labeled some medications inappropriate for the elderly because they can increase the risk of falls, confusion and other problems.
Today, ProPublica is updating its Prescriber Checkup tool, which allows people to compare their doctors’ prescribing patterns in Medicare to other providers in the same specialty and state. While it has long been known that patients in the southern and southeastern United States use more medications that are prone to abuse and overuse, there’s been little discussion about why Hawaii fares so well.
“Hawaii is so different,” said Dr. Chien-Wen Tseng, a family physician and health services researcher at the University of Hawaii. “I think there is more of a cultural thing that says we don’t want to overuse medications.”
Other research also has found that people in Hawaii use fewer prescription drugs. Recent figures from the Centers for Disease Control and Prevention show that after the District of Columbia, Hawaii had the lowest rate of opioids dispensed of any state. The state also has among the lowest rates of antibiotic prescribing per capita overall, not just among its Medicare population.
Dr. Lauri Hicks, director of the CDC’s Office of Antibiotic Stewardship, said she can’t definitively explain why some states, including Hawaii, have lower rates of prescribing than others. Some of the variation could be explained by differences in the population and the health status of each state’s residents, she said in a written statement.
That said, Hicks wrote, for conditions that don’t warrant antibiotic use, such as uncomplicated bronchitis and common colds, prescribing rates tend to be highest in the South, “suggesting that there is more inappropriate antibiotic prescribing in that region than in other regions of the country.”
Hawaii doesn’t just have lower rates of prescribing for drugs that carry extra risks. Our analysis shows that among Medicare enrollees who filled at least one prescription, patients in Hawaii filled fewer overall than residents of any other state – an average of 25.7 per person in 2015, compared to 37.2 per person for the country as a whole.
Dr. Scott Miscovich, a family physician in Hawaii who heads a narcotic policy working group for the state, said that while his state has not seen the same opioid epidemic that has been striking the mainland, it is taking steps to prevent it, including rewriting laws to parallel those of other states.
“I wish I could say that I thought it was because we had this magic formula for educating our doctors or educating our public,” he said. “It really isn’t the case. ... We still have pockets of doctors that are probably significantly overprescribing all of these classes of medicine, but I think it’s a far more limited number compared to bigger areas across the United States.”
All of this is not to say that Hawaii has no health concerns. The state is struggling with a persistent methamphetamine problem, far worse than it faces with opioids, Miscovich said. And it has the highest homelessness rate of any state. (Washington, D.C., has a higher rate.) “If you roll the statistics back, it’s not all rosy,” Miscovich said.
States that come closest to matching Hawaii’s low rates of prescribing for risky and misused drugs include New Mexico, Vermont, California, Minnesota and Wyoming.
Our analysis of Medicare’s data also reveals other interesting national trends:
The number of opioid prescriptions has finally started to decline. After peaking at 81.7 million in 2014, the figure dropped to 80.2 million in 2015. The drop is even more pronounced when you consider that enrollment in Medicare’s prescription drug program continued to grow during that time.
The number of antibiotics dispensed kept going up, to 57.3 million in 2015, from 54.2 million in 2014 and 52.4 million in 2013.
The average cost per prescription continues to increase, to $94.84 in 2015 from $85.82 in 2014 and $75.73 in 2013. However, those figures do not include confidential rebates the government receives from drug manufacturers.
A nationwide survey shows that postpartum nurses often fail to warn mothers about potentially life-threatening complications, mainly because they need more education themselves.
This article first appeared August 17, 2017 on ProPublica.
by Nina Martin, ProPublica, and Renee Montagne, NPR
In recent months, mothers who nearly died in the hours and days after giving birth have repeatedly told ProPublica and NPR that their doctors and nurses were often slow to recognize the warning signs that their bodies weren't healing properly. Now, an eye-opening new study substantiates some of these concerns.
The nationwide survey of 372 postpartum nurses, published Tuesday in the MCN/American Journal of Maternal/Child Nursing, found that many of them were ill-informed about the dangers new mothers face. Needing more education themselves, they were unable to fulfill their critical role of educating moms about symptoms like painful swelling, headaches, heavy bleeding and breathing problems that could indicate potentially life-threatening complications.
By failing to alert new mothers to such risks, the peer-reviewed study found, nurses may be missing an opportunity to help reduce the maternal mortality rate in the U.S., the highest among affluent nations. An estimated 700 to 900 women die in the U.S. every year from pregnancy- and childbirth-related causes and 65,000 nearly die, according to the Centers for Disease Control. The rates are highest for black mothers and women in ruralareas. In a recent CDC Foundation analysis of data from four states, nearly 60 percent of maternal deaths were preventable.
Forty-six percent of nurses who responded to the survey were unaware that maternal mortality has risen in the U.S. in recent years, and 19 percent thought maternal deaths had actually declined. "If [nurses] aren't aware that there's been a rise in maternal mortality, then it makes it less urgent to explain to women what the warning signs are," said study co-author Debra Bingham, who heads the Institute for Perinatal Quality Improvement and teaches at the University of Maryland School of Nursing.
Only 12 percent of the respondents knew that the majority of maternal deaths occur in the days and weeks after delivery. Only 24 percent correctly identified heart-related problems as the leading cause of maternal death in the U.S. In fact, cardiovascular disease and heart failure - which, according to recent data, account for more than a quarter of maternal deaths in this country - were "the area that the nurses felt the least confident in teaching about," says Patricia Suplee, an associate professor at the Rutgers University School of Nursing in Camden, New Jersey, and the lead researcher on the study.
Nurses also said they spent very little time instructing new moms about worrisome symptoms - usually 10 minutes or less. Many of the nurses said they were only likely to discuss warning signs of such life-threatening conditions as preeclampsia (pregnancy-related high blood pressure), blood clots in the lungs, or heart problems "if relevant" - even though, as the study noted, "it is impossible to accurately predict which women will suffer from a post-birth complication."
The post-delivery education provided by nurses is particularly important because, once a mother leaves the hospital, she typically doesn't see her own doctor for another four to six weeks. Up to 40 percent of new moms - overwhelmed with caring for an infant, and often lacking in maternity leave, child care, transportation and other kinds of support - never go back for their follow-up appointments at all.
Figuring out the best way to instruct new mothers is all the more crucial, the survey noted, because the first days after giving birth are "exhausting, emotionally charged, and physiologically draining" - hardly an ideal learning environment. But like so many other important aspects of maternal health care, postpartum education has been poorly studied, Bingham said.
The respondents, of whom nearly one-third had master's or doctorate degrees, were members of the Association of Women's Health, Obstetric and Neonatal Nurses, the leading professional organization for nurses specializing in maternal and infant care. AWHONN began looking at the education issue in 2014, when Bingham was the association's vice president of nursing research and education. "We had to start really from the ground up, because we didn't know exactly what women were being taught," she said.
In focus groups conducted in New Jersey and Georgia, two states with especially high rates of maternal mortality, researchers discovered that postpartum nurses spent most of their time educating moms about how to care for their new babies, not themselves. The information mothers did receive about their own health risks was wildly inconsistent, and sometimes incorrect, Bingham said. The written materials women took home often weren't much better.
Some nurses were uncomfortable discussing the possibility that complications could be life-threatening. "We had some nurses come out and say, 'Well you know what, I don't want to scare the woman. This is supposed to be a happy time. I don't want to seem like all I want to talk about is death,'" Bingham said.
But the researchers also found that nurses could be quickly educated with short, targeted information. Using insights from the focus groups, an expert panel developed two standardized tools - a checklist and script that nurses could follow when instructing new mothers and a one-page handout of post-birth warning signs that mothers could refer to after they returned home, with clear-cut instructions for when to see a doctor or call 911. Those tools were tested in four hospitals in 2015. "Very quickly we started hearing from the nurses that women were coming back to the hospital with the handout, saying, 'I have this symptom,'" Bingham said.
One of them was a Georgia mom named Sarah Duckett, who had just given birth to her second child. A week later, she recognized the warning signs of what turned out to be a blood clot in her lung - an often fatal postpartum complication. "Those were anecdotes, but they were very powerful anecdotes," Bingham said. "I've led multiple projects over the years and rarely do I get such immediate feedback that something is working."
The shortcomings documented by the national survey could foster wider use of these tools, suggested Mary-Ann Etiebet, executive director of Merck for Mothers, which funded the study as part of a 10-year, $500 million initiative to improve maternal health around the world. "Something as simple as creating educational and training programs for nurses...can have a real impact," she said.
Reversing course, federal health officials have withdrawn a proposal that would have required private accrediting organizations to publicly release reports of problems they found in health care facilities.
This article first appeared August 03, 2017 on ProPublica.
Federal health officials have backed down from a controversial proposal that would have required private accreditors to publicly release reports about errors, mishaps and mix-ups in the nation's hospitals and health care facilities.
The Centers for Medicare and Medicaid Services had proposed in April that accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by these accreditors, not the government.
But in a notice released Wednesday afternoon, the government withdrew the proposal. CMS said that federal law prohibits the agency from disclosing the results of inspections performed by the accrediting organizations and that the proposal - though it required accreditors, not the agency, to release the reports - "may appear as if CMS was attempting to circumvent" the law.
"CMS is committed to ensuring that patients have the ability to review the findings used to determine that a facility meets the health and safety standards required for Medicare participation," the agency said in a fact sheet. "However, we believe further review, consideration, and refinement of this proposal is necessary to ensure that CMS establishes requirements, consistent with our statutory authority, that will inform patients and continue to support high quality care."
The government's proposal, and subsequent about face, comes as federal officials have grown increasingly concerned that private accreditors aren't picking up on serious problems at health facilities.
Health care facilities that receive federal funding are required to comply with Medicare's requirements and thus are subject to government oversight. But the law allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight instead.
Every year, CMS and state health agencies inspect a sample of hospitals and other health care facilities accredited by private organizations, in order to validate the work of the groups. In a report to Congress last month, CMS noted that its reviews in fiscal year 2015 found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.
Leah Binder, president and CEO of The Leapfrog Group, a coalition of employers that advocates for quality and transparency in health care, criticized the CMS decision to back down.
"This is disgraceful, unfair to patients as well as employers and other purchasers of health care," she said in an email. "The public deserves full transparency on how the health care industry performs. Instead, transparency has been sacrificed to accommodate special interests that lobby to avoid disclosing embarrassing information about health care quality."
The government's proposal to make accreditors' reports public was strongly protested by accreditors and the hospitals that pay them for their services. Some questioned its legality; all challenged its wisdom. The Joint Commission, for instance, said the proposal would increase costs and decrease patient safety. "The provision will adversely affect the collaborative efforts of accrediting bodies and healthcare organizations to improve patient safety and engage in continuous quality improvement," the commission said in a June letter. "Ultimately, there will be increased patient harm and lower quality."
Another accreditor, the Center for Improvement in Healthcare Quality, raised similar concerns. "Knowing that survey [inspection] reports are public knowledge will only incentivize hospitals and other healthcare entities to go back to the days of 'hiding' quality of care issues from accreditors, rather than working with us to improve the quality and safety of care rendered to patients."
But consumer groups, business alliances and a group representing health care journalists were supportive, saying consumers deserve more information about the quality of hospitals. The Medicare Payment Advisory Commission, an independent agency that advises Congress on Medicare policy, had urged CMS to implement the requirement as soon as possible, saying it would "enable Medicare beneficiaries to make more informed decisions" about where to seek health care.
Consumer Reports and its publisher, Consumers Union, likewise supported the proposal. "Such survey [inspection] results provide insight into hospital quality that is not now transparent. …Consumers have a right to know this critical information that is used to determine if facilities are in compliance with health and safety requirements for Medicare patients, and thus, all patients."
Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,010 hospitals listed on The Joint Commission's website, more than 99 percent have full accreditation and only eight are on track to lose their "gold seal of approval."
On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information on inspection findings, even when hospitals are described as receiving a "preliminary denial of accreditation." For one hospital, the explanation is: "Existence at time of survey of a condition, which in The Joint Commission's view, poses a threat to patients or other individuals served." The threat itself is not specified.
Other smaller accrediting organizations provide even less information.
Disclosure: Ornstein was previously president of the Association of Health Care Journalists. While he served in that position, AHCJ called for The Joint Commission to make its inspection reports public. The Joint Commission declined to do so.